Understanding Mental Health Systems and Services in Texas 3Rd Edition – 2016 Acknowledgement

A Guide to Understanding Mental Health Systems and Services in Texas 3rd Edition – 2016 Acknowledgement

The foundation would like to acknowledge Senior Student Associate Rachel Gandy, Graduate Research Assistants Matti Hautala, Megan Randall, and Lindsey Zischkale, along with Policy Fellow Alison Boleware for the many hours of research, writing and editing needed to update this guide. Their commitment to developing a quality product illustrates their commendable work ethic and professionalism. Hogg Foundation for Mental Health

The Hogg Foundation for Mental Health has been promoting mental health in Texas since 1940, when the children of former Texas Governor James S. Hogg established the foundation at The University of Texas at Austin.

Over the years, the foundation has awarded millions of dollars in grants to continue the Hogg family’s legacy of public service and dedication to improving mental health in Texas. Other donors have established smaller endowments at the foundation to support its mission. Today the foundation continues to support mental health services, research, policy analysis, and public education projects in Texas. The foundation focuses its grant making on key strategic areas in mental health and awards grants through a competitive proposal process.

The foundation is part of the Division of Diversity and Community Engagement at The University of Texas at Austin. For more information, visit www.hogg.utexas.edu. Language Usage

Behavioral health is the term typically used when referring to mental health and substance use. The foundation acknowledges the ongoing discussions and differing perspectives about utilizing the terms “behavioral health” and “mental health.” In this document, the Hogg Foundation uses the term “behavioral health” when referring to both mental health and substance use services and supports. Our belief is that the priority goal of behavioral health policy must be recovery.

First Edition: November 2012 Second Edition: November 2014 About the Guide

Suggested Citation: Hogg Foundation for Mental Health. (November 2016). A guide to understanding mental health systems and services in Texas. Retrieved from www.hogg.utexas.edu

The Hogg Foundation has made every effort to ensure the accuracy of the information and citations in this report. The foundation encourages and appreciates comments and corrections as well as ideas for improving this guide. Specific comments should reference the applicable section and page number(s). Please include citations for all factual corrections or additional information. All comments and recommendations should be emailed to [email protected].

The online version of this resource guide is available at: www.hogg.utexas.edu

2 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Contents

Introduction and Overview 13

Texas Environment 17

Select Committee on Mental Health 17 Office of Mental Health Coordination 18 Statewide Behavioral Health Coordinating Council 18 Mental Health Workforce in Texas 20 Contributing Factors to the Workforce Challenges 21 Loan Repayment Program for Mental Health Professionals 23 Peer Support Services/Peer Re-entry Pilot 23 Mental Health and Substance Use Parity 26 Lawsuit Against the Department of Family Protective Services on Behalf of Long-Term Foster Youth 27 Behavioral Health Integration Advisory Committee (BHIAC) 29 Boarding Homes and Housing Choices 29 Services for Individuals with Intellectual/Developmental Disabilities Experiencing Co-occurring Mental Health Conditions 30 Health and Human Services System Transformation 32 HHS Transformation 32 Highlights 33 Discontinuation of NorthSTAR 34 HHS Advisory Committee Reorganization 35 Austin State Hospital (ASH) - Austin State Supported Living Center (AuSSLC) Location Feasibility Study 36 Behavioral Health Advisory Committee 36 1115 Waiver: Texas Health Care Transformation and Quality Improvement Program 37 The Uncompensated Care (UC) Pool 37 The Delivery System Reform Incentive Payments (DSRIP) Pool 38 Funding for Texas’ 1115 Waiver 40 Cost Savings and Outcomes of DSRIP Projects Under the 1115 Waiver 41 Telemedicine and Telehealth Services 42 Benefits ofTelemedicine and Telehealth Services 43 Teladoc Lawsuit Against Texas Medical Board 44 Texas Dual Eligible Integrated Care Project 44 Children’s Services: YES Waiver, STAR Kids, and STAR Health 45 YES Waiver 46 STAR Kids 46 STAR Health 47

National Context 55

SAMHSA 55 The Helping Families in Mental Health Crisis Act – H.R. 2646 55

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 3 The Cassidy-Murphy Mental Health Reform Act of 2015 — S. 1945 56 The Mental Health Reform Act of 2016 — S. 2680 57 Updates on the Implementation of the Patient Protection and Affordable Care Act (ACA) 58 Medicaid Expansion Under the ACA 58 Rule Changes to CMS Managed Care 60 Mental Health Parity and Addiction Equity Act (MHPAEA) 61 Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) 62

Public Behavioral Health Services in Texas 67 Texas Health and Human Services System 69 Policy Concerns 72 Fast Facts 72 Organization Chart 72 Changing Environment 74 HHS Transformation: SB 200 (84th, Nelson/Price) Highlights 75 Highlights 75 Discontinuation of NorthSTAR: SB 200 (84th, Nelson/Price) 77 HHS Advisory Committee Reorganization: SB 200 (84th, Nelson/Price) and SB 277 (84th, Schwertner/Sheffield) 77 Network Adequacy in Medicaid Managed Care: SB 760 (84th, Schwertner/Price) and HHSC Rider 81, HB 1, 78 Article II (84th, Otto/Nelson) Evaluation of Substance Use Treatment Benefit in Medicaid: HHSC Rider 44, HB 1, Article II (84th, Otto/Nelson) 79 Integration of Behavioral Health Services with Medicaid Managed Care: SB 58 (83rd, Nelson/Zerwas) 79 Programs Transferring from DARS to HHSC and TWC 80 Programs Transferring from DADS to HHSC 81 HHSC Funding 82

MEDICAL AND SOCIAL SERVICES DIVISION 85 Officeof Mental Health Coordination 86 Medicaid & CHIP Services 89 Medicaid 89 State Medicaid Agency 90 Medicaid Managed Care 91 Medicaid Funding 94 Medicaid Eligibility and Services 95 Demographics of Medicaid Recipients 98 Children’s Health Insurance Program 98 CHIP Eligibility 98 CHIP Funding 99 Enrollment 99

COMMUNITY SERVICES 103

INTELLECTUAL AND DEVELOPMENTAL DISABILITIES & BEHAVIORAL HEALTH SERVICES 105 Behavioral Health Services (formerly provided through the Department of State Health Services) 106 Policy Concerns 106 Fast Facts 106 Background 107 Sunset and Transformation Highlights 108 Changing Environment 108 Discontinuation of the NorthSTAR Program 108

4 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Forensic Director Position 109 Ongoing Jail-based Competency Restoration Pilot Program 110 Continued Expansion of Peer Support Services 111 Implementation of the Statewide Expansion of the YES Waiver 112 Improvement of Client Outcome and Performance Measures 113 Rider 58 114 Rider 82 115 Behavior Health Funding 116 Service Providers 118 Medicaid Managed Care Providers 118 Local Mental Health Authorities 119 NorthSTAR 122 Federally Qualified Health Centers (FQHCs) and Other Community Providers 122 Community Mental Health Services 123 Texas Resilience and Recovery Framework 123 Medicaid 128 Individuals Considered Medically Indigent 129 Priority Populations 130 System Utilization (Community Mental Health Services) 131 Waitlists for Community-Based Mental Health Services 134 Crisis Services 136 Inpatient Mental Health Hospital Services 138 Introduction to Inpatient Services and the Admissions Process 138 Civil Commitments 139 Forensic Commitments 139 Maximum vs. Non-Maximum Security Placements 140 Types of Inpatient Settings 140 State Hospitals 140 Staffingand Functional Capacity of State Hospitals 142 Funding for Inpatient Care 143 Institutions for Mental Diseases (IMD) Exclusion 143 Inpatient Services at State Hospitals: Utilization and Costs 144 State-Funded Community and Private Hospitals 146 Continuing Issues 148 Addressing the Shortage of Publicly-Funded Inpatient Beds 148 Improvements to Aging State Hospital Infrastructure 150 Other Issues Associated with Inpatient Services 152 Reducing the Use of Seclusions and Restraints 152 Increasing Access to Timely Competency Restoration Services 152 Inpatient Competency Restoration 154 Jail-Based Competency Restoration 154 Outpatient Competency Restoration 154 Substance Use Services 156 Access to Substance Use Services 158 Funding for Substance Use Services 159 Eligibility for Substance Use Services 159 Priority Populations 160 Co-occurring Mental Health and Substance Use Disorders 160 Substance Use Services: Utilization and Costs 161 Substance Use Services: Quality of Care Measures 162 Systems of Care and The Texas Recovery Initiative 163

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 5 Intellectual and Developmental Disability Services Department 165 Policy Concerns 165 Fast Facts 165 Mental Health Needs of Individuals with Intellectual/Developmental Disabilities 165 Prevalence of Mental Health Conditions for People with Disabilities 166 Mental Health Needs of Aging Texans 167 Changing Environment 167 Funding 170 Programs and Services for People with Disabilities Who Have Co-occurring Behavioral Health Conditions 171 Community Long-Term Services and Supports 171 Medicaid 1915(c) Waiver Services 171 Role of Local Intellectual and Developmental Disability Authorities (LIDDA) in Connecting People to Waiver Services 173 Institutional Long-Term Services and Supports 174 Skilled Nursing Facilities 174 Community Intermediate Care Facilities 174 State Supported Living Centers 175

HEALTH, DEVELOPMENTAL, AND INDEPENDENCE SERVICES 179 Rehabilitative and Social Services Unit 179 Independent Living Services Program 179 Services for Individuals Living with Blindness and Visual Impairments 180 Comprehensive Rehabilitation Services 181 Guardianship Program 181 Health and Developmental Services 182 Early Childhood Intervention (ECI) Services 182 Children’s Autism Program 184 Additional Programs for People with Disabilities and Aging Texans 185 Non-Medicaid Services 185 Additional Federally Funded Programs 186 Promoting Independence Initiative 186 Money Follows the Person Program 186 Achieving a Better Life Experience (ABLE) Program 187 Additional HHS System Partners and Programs 187 Federally Qualified Health Centers 187 Medicaid Buy-In Programs 188 Texas Health Insurance Premium Payment Program 188 Texas Medicaid and Healthcare Partnership 188 Texas Wellness Incentives and Navigation Project 189 Veteran Services Division 189

ACCESS AND ELIGIBILITY SERVICES 191 Disability Determination Services (DDS) 191 Social Security Disability Insurance (SSDI) 191 Supplemental Security Income (SSI) 192 Eligibility 193 Utilization 194 Texas Department of State Health Services 213 Organizational Charts 213 Inpatient Mental Health Hospital Services 215 Introduction to Inpatient Services and the Admissions Process 216 Civil Commitments 216 Forensic Commitments 217 6 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Maximum vs. Non-Maximum Security Placements 217 Types of Inpatient Settings 217 State Hospitals 217 Quality of Care Measures 219 Crisis Services: Utilization and Costs 219 Inpatient Services at State Hospitals: Utilization and Costs 220 Department of Aging and Disability Services 225 DADS Organization Chart (September 1, 2016 – August 31, 2017) 225 DADS Transformation Recap 227 State Supported Living Centers 228 Office of the Independent Ombudsman for SSLCs 231 Regulatory Services 231 Texas Department of Family and Protective Services 233 Policy Concerns 233 Fast Facts 234 Organizational Charts 234 Sunset and Transformation Highlights 236 Changing Environment 237 Parental Relinquishment of Custody to Obtain Mental Health Services 237 Senate Bill 125: Mandatory Screenings for Youth Entering Foster Care 239 Lawsuit Against DFPS/CPS 240 Foster Care Redesign 241 CPS “Transformation” Plan: Reduce Caseworker Turnover and Child Fatalities 243 Increased Focus on Normalization in Mental Health Treatments and Interventions 245 Funding 245 Statewide Intake (SWI) 248 Child Protective Services (CPS) 249 Child Abuse/Neglect and CPS Investigations 250 Alternative Response System 251 Accessing Mental Health Services 252 Superior Health System (STAR Health) 252 Former Foster Care Children Program (FFCC) and Medicaid for Transitioning Foster Care Youth (MTFCY) 253 Institutional Residential Services 254 Continuing Issues 255 Child Fatalities in the CPS System 255 Disproportionality and Diversity of Children and Youth in CPS 257 Psychotropic Medications in Foster Care 260 Trauma-Informed Care 261 Prevention and Early Intervention (PEI) 263 Adult Protective Services (APS) 264 Child Care Licensing (CCL) 266 Texas Workforce Commission 277 Policy Concerns 277 Fast Facts 277 Organization Chart 278 Funding 280 Changing Environment 282 Sunset Highlights 283 Programs Transferred from DARS per Sunset Legislation 284

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 7 Vocational Rehabilitation for Persons with Disabilities (VR) 284 Vocational Rehabilitation Program for Individuals with Visual Impairments 285 Integrating the Vocational Rehabilitation Programs 286 The Criss Cole Rehabilitation Center 286 The Business Enterprises of Texas program 287 Independent Living Services Program for Older Individuals Who Are Blind 287 Overview of Texas Workforce Commission (TWC) Programs 288 Skills Development 288 Veterans Specific Services 288 Other TWC Programs 289 Texas Department of Criminal Justice and 293 Local Criminal Justice Agencies Policy Concerns 293 Fast Facts 294 Organizational Chart 294 Changing Environment 296 Major Legislation from the 84th Texas Legislature 297 Relevant Riders 299 Sandra Bland and Jail Safety Concerns 299 Overview of the Texas Criminal Justice System 300 The Texas Department of Criminal Justice 301 Cost and Funding Summary 301 TDCJ Facilities and Housing Issues 303 Administrative Segregation 303 Sexual Assault and Prison Rape Elimination Act (PREA) Investigations 304 Behavioral Health Services and Programs in the State Criminal Justice System 305 Access to Services 306 Behavioral Health Services 306 Post-Incarceration Community-Based Services 308 Medically Recommended Intensive Supervision 309 Release on Parole Special Programs 309 Special Concerns for Incarcerated Females 310 Local Criminal Justice Systems 311 Texas Commission on Jail Standards 312 Suicide in Local Jails 313 Incarceration Prevention and Diversion Programs 314 Community Examples of Jail Diversion Strategies 316 Specialty Courts 317 Mental Health Public Defender Offices 319 Reentry Peer Support 320 The Texas Juvenile Justice Department and 327 Local Juvenile Justice Agencies Policy Concerns 328 Fast Facts 328 Organizational Chart 328 The Texas Juvenile Justice Department and Local Juvenile Justice Agencies 329 Juvenile Justice and Mental Health 329 Changing Environment 331 Major Legislation from the 84th Legislature 331 The Closing of Three TJJD Facilities 335

8 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Trauma-Focused Cognitive Behavioral Therapy Pilot 336 The Texas Juvenile Justice System 336 Cost and Funding Summary 339 TJJD Funding 339 Local Juvenile Probation Department Funding 340 How Juveniles Move through TJJD 341 Juvenile Arrests 341 Juvenile Courts, Sentences, and Placements 342 Release Review Panel and Parole 343 Discharge from TJJD 343 Disproportionality in the Texas Juvenile Justice System 344 The Office of the Independent Ombudsman 345 Behavioral Health Services in the Juvenile Justice System 346 Behavioral Health Services in State Secure Facilities 347 Intake, Orientation, and Placement 347 Rehabilitation and Specialized Treatment Programs 348 Behavioral Health Services in County-Level Secure Facilities 350 Behavioral Health Services for Youth on Parole 351 Community-Based Behavioral Health Services Offered by Juvenile Probation Departments 351 State-Funded Programs Available to Local Juvenile Probation Departments with Behavioral Health Service Components 354 Diversion Programs for Youth with Behavioral Health Conditions 357 The Front-End Diversion Initiative 357 Specialty Juvenile Courts 358 The Special Needs Diversionary Program 359 Texas Education Agency and Local School Districts 369 Policy Concerns 370 Fast Facts 370 Organizational Chart 371 Overview of Texas Education Agency and Local School Districts 371 Changing Environment 372 Mental Health First Aid (MHFA) Training in Texas Schools 372 Suicide Prevention and Programs that Promote Healthy Behavior 373 Funding 376 Efforts to Reduce and Decriminalize Truancy 377 Delivery of Mental Health Services in Schools 378 Special Education Services in Texas 379 Special Education for Early Childhood and Youth Transitioning to Adulthood 380 Eligibility for Special Education Services 381 Funding for Special Education Services 383 Special Education Funding: Individuals with Disabilities Education Act (IDEA) 383 Special Education Funding: Medicaid 384 Mental Health Support Systems for Schools 385 Education Service Centers (ECSs) 385 Coordinated School Health Model 386 Communities In Schools (CIS) and Dropout Prevention 387 Exclusionary Discipline in Schools 387 In-School Suspensions (ISS) and Out-of-School Suspensions (OSS) 389 Expulsions to Disciplinary Alternative Education Programs (DAEPs) 389 Expulsions to Juvenile Justice Alternative Education Programs (JJAEPs) & Expulsions Without Placement 390 School Ticketing and Class C Misdemeanors 393

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 9 Corporal Punishment and the Use of Force in Schools 394 Holistic Approaches to Discipline and Student Mental Health 395 Positive Behavioral Interventions and Supports (PBIS) 396 Social and Emotional Learning (SEL) 397 Trauma-Informed Care (TIC) 398 Restorative Justice Framework 398 Efforts to Reduce Bullying 399 Texas Department of Housing and Community Affairs 409 Policy Concerns 410 Fast Facts 410 Organizational Chart 410 Changing Environment 415 National Housing Trust Fund 415 Limiting Source of Income Protections (SB 267, 84th, Perry/Huberty) 415 Inclusive Communities and the Low Income Housing Tax Credit Program 416 Application for Homebuyer Assistance Funds (HB 1428, 84th, Raymond/Zaffirini) 417 Landlord Liability for Individuals with a Criminal Justice Record (HB 1510, 84th, Thompson/Garcia) 417 Funding 418 Affordable Housing 421 Permanent Supportive Housing 423 Housing First 423 Housing Programs for People with Disabilities or Mental Health Conditions 424 Section 8 Housing Choice Voucher Program 424 Project Access 424 Low Income Housing Tax Credit Program 425 HOME Investments Partnerships Program 426 Persons with Disabilities (PWD) Set-aside 426 Homebuyer Assistance Program 426 Tenant-Based Rental Assistance 426 Section 811 Supportive Housing for People with Disabilities 427 Section 811 Project Rental Assistance 427 Amy Young Barrier Removal Program 427 Poverty and Homeless Prevention Programs 428 Emergency Solutions Grants Program 428 Homeless Housing and Services Program 428 Community Services Block Grant Program 428 Related Services and Programs - Other State Agencies 428 Model Boarding Home Standards and Housing Referral Network 428 Home and Community Based Services - Adult Mental Health 429 Supportive Housing Rent and Utility Assistance Program 429 Housing and Services Partnership Academy 429 Housing and Services for Persons with Disabilities Clearinghouse Website 430 Impediments to Fair Housing Choice 430 Texas Veterans Commission 437 Policy Concerns 437 Fast Facts 437 Organizational Chart 438 Introduction 439 Changing Environment 440 SB 55 – The Texas Veterans + Family Alliance program 440

10 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas HB 3404 – Study on Veterans with Post-Traumatic Stress Disorder (PTSD) 440 SB 1304- Mental Health Intervention Programs for Female Veterans 441 SB 1305- Mental Health Intervention Programs for Veterans Living in Rural Areas 441 SB 169- Interest and Wait Lists of HHS Programs for Active Duty Service Members 441 Funding 442 Claims Representation and Counseling Program 443 Eligibility for VA Benefits 443 VA Behavioral Health Services 444 TVC Employment Services 445 Fund for Veterans’ Assistance (FVA) 445 Veterans Mental Health Program (VMHP) and Other Supports 446 Military Veteran Peer Network 446 Other VMHP Services 447 Specialty Courts 447 Texas Veterans Portal (TVP) 448 Women Veterans 448

Appendices 451

List of Figures 453 List of Acronyms 457 Additional Resources 461 Agency Websites 461 Certified eerP Specialists and Certified Recovery Coaches 461 Child Welfare/Children’s Mental Health 462 Civil Rights 462 Consumer and Family Organizations 463 Criminal/Juvenile Justice and Mental Health 463 Cultural and Linguistic Competency 463 Early Childhood and Mental Health 464 General Information on Mental Health and Substance Use 464 Housing 464 Integrated Physical and Mental Health Care 465 Intellectual Disability with Co-occurring Mental Health Conditions 465 Mental Health in Schools 466 Mental Health Workforce Development 466 Promotores(as) 466 Recovery and Wellness 467 Suicide Prevention 467 Telemedicine and Telehealth 467 Veterans Services 468 Glossary: Common Behavioral Health Terms 469 Advisory Committees 481 Texas Health and Human Services Commission (HHSC) 481 Texas Department of Family and Protective Services 489

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 11 12 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Introduction Introduction and Overview and Overview

Mental health, as defined by the World Health Organization (WHO), is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”1 Mental health and well-being are essential to an individual’s ability to properly think, interact and have a quality life. Therefore, mental health inevitably has a direct impact on economic productivity, educational attainment, and public health and safety. Ultimately, the promotion of mental Recovery is a process of health should be prioritized for individuals, communities and change through which societies throughout the world. individuals improve their health and wellness, live a Meeting the mental health care needs of Texans requires self-directed life, and strive critical policy analysis and decision-making to ensure a coordi- to reach their full potential. nated system of supports and services that are effective, appro- — Substance Abuse and priate and fiscally responsible. The maze of behavioral health Mental Health Services services in Texas is complex, making it difficult to understand Administration and, consequently, difficult to improve.

Behavioral health is the term typically used when referring to mental health and substance use conditions. The goal of behavioral health policy should be recovery. Recovery from mental illness and substance use is possible. Recovery is not synonymous with a cure. It is an ongoing process that enables individuals experiencing mental health challenges to become empowered to manage their illness and take control of their lives. Recovery does not happen in isolation but requires holistic support from peers, family, friends and other stakeholders in the healthcare system, especially mental health professionals and the supports provided through the public mental health systems.

Although the recovery journey will look different for each individual, effective supports, interventions and evidence-based treatments are widely recognized as beneficial in the recovery process. While crisis intervention often relies heavily on the support of mental health professionals, long-term recovery focuses on personal responsibility, peer and family support, and self-direction of services and treatment. Psychosocial supports such as assertive community treatment, peer support and Wellness and Recovery Action Planning (WRAP®) often provide long- term stabilization and increased quality of life beyond the short-term impact of medical interventions.

Public behavioral health services in Texas are dispersed among many programs and

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 13 agencies. Individuals needing treatment may receive care through a variety and combination of state agencies, including:

· Health and Human Services Commission · Department of State Health Services · Department of Family and Protective Services · Department of Aging and Disability Services (to be eliminated 9/1/17) · Texas Department of Criminal Justice · Texas Department of Juvenile Justice · Texas Education Agency · Texas Department of Housing and Community Affairs · Texas Veterans Commission · Texas Workforce Commission

A discussion of behavioral health supports available at each agency is provided in Section IV. Public Behavioral Health Services in Texas.

In addition to state entities, behavioral health services are provided at the local level in jails, hospital emergency departments, schools, local mental health authorities, various nonprofit agencies, public health clinics and other settings, with people frequently moving between service systems. While the Harris County Jail is often referred to as the “largest mental health facility in Texas,” this is not the case. The Har- ris County Jail is a correctional facility that offers minimal mental health services often limited to pharmacological treatment. This is not mental health and substance use care and does not aid an individual in working toward their recovery.

Insufficient access to mental health treatment, supports and services remains one of the most pressing policy issues in Texas. Many Texans are unable to obtain services due to lack of access to private or public insurance coverage and insufficient public mental health safety net services. Over time, these shortages have led to persons receiving services through a confusing, uncoordinated and inefficient system of state and local agencies, often resulting in poorer health outcomes at greater expense.

Fortunately, the current Texas policy environment offers new options for expanding and improving the delivery of behavioral health services in Texas, providing opportunities to develop a system that is less fragmented and more accessible to consumers of behavioral health services. The federal Patient Protection and Affordable Care Act (ACA), Texas Healthcare Transformation and Quality Improvement Program Medicaid 1115 Waiver, the expansion of Medicaid managed care, and the recent increases in behavioral health appropriations all could lead to the development of a more comprehensive, integrated, and coordinated approach to the delivery of behavioral health services. With multiple initiatives in play, the potential for improvement is significant.

Behavioral health services in Texas are provided through a complex maze of programs that vary widely across the state. The range of available services may be different depending on an individual’s location, age, individual and family income, access to private or public insurance, type of symptoms, severity of condition, and the availability of health care providers who can provide the needed care within a reasonable distance. Navigating this system is often frustrating even for the most informed providers and clinicians who support individuals on a daily basis. For policymakers, family members

14 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas and individuals receiving mental health services, especially those with little experience or knowledge of this system of care, understanding the complexities of the patchwork Introduction and Overview of behavioral health care services can be particularly challenging.

The purpose of the guide is to provide a general overview of the behavioral health care delivery system and the services provided under various state agencies that are funded in full or in part with state appropriations. To ensure this document is a useful reference tool, it does not provide significant detail on the various programs but instead focuses on the general infrastructure, funding and services provided. This guide is designed to provide the reader with a basic understanding of how behavioral health services are provided, the populations that are served, and the challenges of meeting the growing and often unmet needs of Texans with mental health or substance use conditions. For policymakers, advocates and other stakeholders who struggle with many complex matters and decisions, we hope this report will be a useful guide, providing practical and accurate information on mental health services in Texas.

The report is divided into the following four categories:

· The Texas Environment: A discussion of current issues and recent developments at the state level, including a description of new programs and organizational approaches to care, some of which are being implemented and others of which may require further legislative action during the 2015 session of the Texas Legislature. · National Context: A basic overview of national activities and initiatives related to behavioral health care services, including a discussion of federal requirements that impact the types of benefits provided and the populations served under the Patient Protection and Affordable Care Act (ACA). · Public Behavioral Health Services in Texas: An overview of the multiple Texas state agencies and programs that provide a wide range of behavioral health services for clients, including programs provided by Health and Human Services agencies and services administered by juvenile and criminal justice agencies, school districts and the Texas Education Agency, the Texas Department of Housing and Community Affairs, Texas Workforce Commission and the Texas Veterans Commission. · Appendices

This third edition of the guide was somewhat more challenging to develop due to the major transformations taking place in the Health and Human Services System. We have attempted to include organizational structure and program alignment in place as of October 1, 2016, but are fully aware of the fact that changes will continue for the next several years.

Included in the Appendices of the report is a list of figures, a list of acronyms, additional resources, advisory committees, and a glossary of commonly used behavioral health terms. Some programs are subject to very specific, technical definitions in state or federal statutes that may vary from the more commonly used definitions included in this report. For that reason, readers may want to refer to additional resources noted throughout this document for more comprehensive information about a specific program.

The Hogg Foundation wants to emphasize that this report focuses primarily on state

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 15 programs for treating behavioral health care needs in Texas. Many communities and providers throughout the state are equally engaged in the development, implementation and oversight of locally operated (and often locally funded) programs and services that are more specifically designed to serve the needs of local residents. Due to the variations in programs and the lack of a central database that identifies these various resources, this report generally does not include programs created at the local level unless funded by the state. However, we recognize that there are many valuable and effective programs that provide critical services that supplement the programs described in this report. Introduction and Overview Introduction

The Hogg Foundation offers this guide to help policymakers in Texas understand the array of behavioral health services currently available, the multiple access portals and the numerous funding streams. We want to reiterate that this area of health care is extremely complex and constantly evolving. While the information in this report is the best available at the time, new innovations in health care, and new legislation and programs, are continually changing the landscape of behavioral health care services in Texas. We hope that this report serves as a useful introduction, reference and guidebook illustrating the critical need for a long-term, coordinated, sufficiently funded approach to providing effective behavioral health care services.

Endnote 1 World Health Organization. Strengthening Mental Health Promotion. Geneva, World Health Organization (Fact sheet no. 220), 2001.

16 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Texas Environment

The Texas legislature, advocates, and other stakeholders continue to recognize the importance of improving mental health and substance use services and supports Texas Environment within the state. The past legislative session yielded both successes and lost opportunities for individuals with mental health and substance use conditions. Overall, the 2016-17 state budget appropriated $2.7 billion in General Revenue- Related Funds ($3.6 billion in All Funds) for behavioral health and substance use services.1 The Department of State Health Services (DSHS) behavioral health budget increased by approximately $87 million over the prior biennium.2 Further, mental health spending is not concentrated in one or two state agencies. In 2015, the Office of Mental Health Coordination recognized 54 cross-agency mental health initiatives spanning a total of 18 state agencies.3 In this section, important areas of Texas behavioral health systems are highlighted.

Select Committee on Mental Health

On November 9, 2015, House Speaker Joe Straus announced the creation of a select committee on mental health to take a comprehensive look at Texas’s current behavioral health system.4 The committee was charged to review and make recommendations on issues including substance use, care for veterans, prevention of mental illnesses, and improving the delivery of mental health care. Speaker Straus appointed the following legislators to serve on the committee:

· Rep. Four Price (Chair) · Rep. Joe Moody (Vice Chair) · Rep. Greg Bonnen · Rep. Garnet F. Coleman · Rep. Sarah Davis · Rep. Rick Galindo · Rep. Sergio Muñoz, Jr. · Rep. Andrew Murr · Rep. Toni Rose · Rep. Kenneth Sheets · Rep. Senfronia Thompson · Rep. Chris Turner · Rep. James White

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 17 The first committee hearing was held in February 2016. Topics covered by the committee include: children’s mental health, veterans’ issues, insurance and parity, homelessness, substance use conditions, and the state hospital system. The committee continued to meet through September 2016 and will release a report with recommendations to the legislature before the start of the 85th legislative session in January 2017. More information on the committee, including archived recordings of the hearings, is available here: http://www.house.state.tx.us/committees/ committee/?committee=382

Office of Mental Health Coordination

In recent years, mental health and substance use have become major topics of national dialogue. Recognizing the need to be more strategic in behavioral health service delivery and funding, the Texas Legislature took steps to increase and improve cross-agency planning, coordination, and collaboration. In 2013 the legislature created the Office of Mental Health Coordination, which it tasked with providing broad oversight for state mental health policy as well as managing cross- agency coordination of behavioral health programs and services.5 The office is housed within HHSC with a vision “to ensure that Texas has a unified approach to the delivery of behavioral health services that allows Texans to have access to care at the right time and place.”6 Under the new organizational structure, this office reports to the deputy executive commissioner of the Medical and Social Services Division. The office has developed a website to provide consumers, families and providers up-to-date information on mental health and wellness. According to the site, it was “developed with the goal of providing information, resources, and direction to Texas residents who may have mental health related needs or who want to support someone who does”. The website can be found at http://www.mentalhealthtx.org.

In 2015, the office documented 54 cross-agency mental health initiatives spanning a total of 18 state agencies.7 The report on these cross agency behavioral health initiatives can be found at: https://hhs.texas.gov/sites/hhs/files//documents/about- hhs/cabhi.pdf

Statewide Behavioral Health Coordinating Council

Also in 2015, as part of the state’s ongoing efforts to coordinate services across agencies and departments (including those outside of the HHS enterprise), the legislature established the Behavioral Health Coordinating Council, which it tasked with establishing a statewide strategic plan for mental health programs and services. The HHSC assistant commissioner in the Office of Mental Health Coordination at HHSC served as chair of the council.8 Eighteen agencies and departments worked together under the direction of the Office of Mental Health Coordination to develop the goals and strategies included in the plan. The plan can be found at http://www. hhsc.state.tx.us/reports/2016/050216-statewide-behavioral-health-strategic-plan.pdf.9

18 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas In addition to development of the behavioral health strategic plan, the Behavioral Health Coordinating Council was directed to develop a “coordinated statewide expenditure proposal” for mental health services for FY 2017. The legislative directive required approval of the proposal by the HHSC executive commissioner and the Legislative Budget Board. FY 2017 appropriations could not be expended until the budget was developed and the required approvals were obtained.

As a result of the legislative directive, the Behavioral Health Coordinating Council developed the Coordinated Statewide Behavioral Health Expenditure Proposal, Fiscal Year 2017. Figure 1 below summarizes the proposed budget. The full proposal can be found at https://hhs.texas.gov/sites/hhs/files//fy-2017-csbh-expenditure- proposal.pdf. Texas Environment Figure 1. Coordinated Statewide Behavioral Health Expenditures Proposal for FY 2017

Source: Health and Human Services Commission, (July 2016). Coordinated Statewide Behavioral Health Expenditure Proposal for FY 2017. Retrieved from https://hhs.texas.gov/sites/hhs/files//fy-2017-csbh-expenditure-proposal.pdf

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 19 Mental Health Workforce in Texas

Mental health workforce challenges are not new to Texas or to the nation. Challenges include insufficient reimbursement rates, lack of residency slots and internship sites, an aging mental health workforce, and inadequate mental health training for primary care providers. A number of factors make it difficult to address these challenges including the diverse Texas population, the lack of cultural and linguistic competency among providers, the lack of license reciprocity, and the unwillingness of providers to accept patients with Medicaid.10

The federal government’s measure of healthcare workforce shortages is known as Health Professional Shortage Areas (HPSA). The federal government uses a ratio of 1 psychiatrist for every 30,000 individuals in the general population as the threshold for designating a Mental Health HPSA, and this ratio is considered a valid measure of mental health workforce adequacy.11 Texas’ growing population, and widespread rural geography have created an environment where mental health professional

Texas Environment Texas shortage areas far outnumber areas of adequate access. The maldistribution of mental health providers across Texas demands unique strategies.

As of July 2015, 206 out of 254 (81.1%) Texas counties were designated as full or partial Mental Health HPSAs. Partial HPSA designations typically occur in large metropolitan areas, like Harris County and Travis County, where there is disproportionate access to mental health services in different parts of the city.12 In 2011, twenty-five counties that were not previously designated as Mental Health HPSAs now hold the designation, and 181 other counties that were Mental Health HPSAs in 2010 still held that designation in 2015.13 Further, 185 Texas counties did not have a single psychiatrist in 2015, which left over three million Texans in counties without access to a psychiatrist.14 The rates are better for psychologists and social workers, but still far below what is needed. In 2015 there were 149 counties without a single licensed psychologist, while 40 counties did not have a licensed social worker.15,16 Figure 2 below details the Mental Health HPSAs by county as of July 2015.

Figure 2. Federally Designated Mental Health Professional Shortage Areas as of July 2015

Source: U.S. Department of Health and Human Services, “Health Professional Shortage Area Data Download.” Health Resources and Services Administration Data Warehouse. (2015). Data by Geography - Texas. Retrieved from https://datawarehouse.hrsa.gov/Tools/DataByGeographyResults.aspx?geoTyp=State&geoCd=48

20 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Considering only psychiatrists, the graph below shows the drastic difference in the number of psychiatrists available in urban versus rural communities. This graph also highlights the reality that, due to the fact that urban areas have the vast majority of Texas’ population, focusing only on statewide data can hide the true severity of the problem in rural counties. Figure 3 below details the distribution of psychiatrists across the state from 2006 to 2015.

Figure 3. Mental Health Professional Shortages: Distribution of Psychiatrists in Texas, 2006-2015

Texas Environment

Texas has not adequately invested in developing a strong mental health workforce, and the consequences are increasingly evident. Critical shortages will likely continue unless Texas prioritizes the mental health workforce shortage and develops a comprehensive plan to address capacity problems. Contributing Factors to the Workforce Challenges

Many variables converge to create mental health workforce challenges, including an aging mental health workforce, inadequate reimbursement rates, the unwillingness of mental health providers to accept patients with Medicaid, insufficient internship sites and residency slots, insufficient retention and recruitment practices, outdated education and training practices, linguistic and cultural barriers, and more. These issues will need to be addressed collectively in order to make a significant impact.

The percentage of mental health providers accepting Medicaid continues to decline, making it difficult for managed care organizations to build adequate networks of providers. In 2014, 76 percent of psychiatrists in Texas reported not accepting new clients who are recipients of Medicaid. 17 To increase the number of practicing mental health care providers willing to provide services to consumers with Medicaid, reimbursement rates should be evaluated and improved. While reimbursement rates are not the only incentive available to attract Medicaid providers, low rates are the most frequently identified barrier to expanding network participation.18

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 21 Additionally, the state is experiencing a massive shift in the mental health workforce as a large number of skilled mental health providers reach retirement age.19 The median ages for mental health professionals range from Licensed Clinical Social Workers (45 years old) to Licensed Marriage and Family Therapists (59 years old).20 At the same time, educational institutions are not producing enough graduates in mental health fields to meet the predicted demand.21

Figure 4. The Aging Mental Health Workforce in Texas Texas Environment Texas

Source: Statewide Health Coordinating Council. “2015-1016 Update to the State Health Plan”. (2015). Retrieved from: https://www.dshs. state.tx.us/chs/shcc/SHPUpdate2015.pdf

The composition of our psychiatric workforce does not mirror the Texas population. It is important that the state builds a diverse workforce to meet the needs of Texans by promoting more of a shared experiential base. Only 9.8 percent of psychiatrists in Texas are Hispanic/Latino and 5.7 percent are African American. However, Hispanic/Latinos make up 39.5 percent of the Texas population and African Americans make up 11.5 percent.22 There is evidence that health care consumers who share a culture and race with a provider develop a stronger therapeutic alliance and have higher treatment retention rates.23 One way to prioritize culturally relevant care is to assist mental health providers in developing a sensitivity to cultural differences in perceptions about illness, treatment, and recovery, as well as their ability to adapt care to the personal goals, cultural beliefs, and primary language of each consumer.24

Texas’ mental health workforce challenges are very real. The solutions are not always easy to implement and they often require additional resources. However, the cost of ignoring the problem will be great. The growing Texas population coupled with the aging mental health workforce will continue to strain the behavioral health workforce.

22 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Loan Repayment Program for Mental Health Professionals

The number of counties in Texas with an insufficient number of mental health providers remains a concern. In 2013, the Texas Legislature passed HB 1023 (83rd, Burkett/Nelson), requiring DSHS to conduct a study and develop a legislative report on the mental health workforce. The HB 1023 report, published in 2014, confirmed the critical workforce environment and offered recommendations. Additionally, both the Texas House and Senate were assigned interim charges targeting the mental health workforce. Texas Environment Despite considerable discussion about the mental health workforce during the previous interim, little legislative action took place during the 84th legislative session. One notable action was SB 239 (Schwertner/Zerwas), which created a student loan repayment program to encourage mental health professionals to work in rural and underserved areas of Texas. SB 239’s loan repayment program aims to address mental health professional shortage areas where there are gaps in services due to lack of providers.25

The funding for SB 239’s loan repayment program is currently available through the 2016-17 biennium. The program serves eligible mental health professionals such as licensed clinical social workers, psychiatrists, psychologists, licensed professional counselors, psychiatric mental health advanced practice nurses who work in rural and underserved areas where there are significant workforce gaps.26 The program, coordinated by the Texas Higher Education Coordinating Board (THECB), requires that these professionals assist only people enrolled in Medicaid or Children’s Health Insurance Program (CHIP).27

THECB reported they had received 497 applications by the May 31, 2016 deadline.28

Peer Support Services/Peer Re-entry Pilot

According to the Centers for Medicare and Medicaid Services (CMS), “peer support services are an evidence-based mental health model of care which consists of a qualified peer support provider who assists individuals with recovery from mental illness and substance use disorders.”29 According to research sponsored by SAMHSA to assess evidence-based services, “peers are individuals with histories of successfully living with serious mental illness who, in turn support others with serious mental illness.”30 Certified peer specialists have both the lived experience and have achieved the education and examination requirements for certification. Peer support services generally fall into three categories:

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 23 1) A distinct set of activities or a curriculum that includes education and the development of coping and problem-solving strategies to facilitate self- management of a person’s mental illness and reinforce daily living skills (for example, rehabilitative services); 2) Activities that are delivered as part of a [recovery] team that may include non-peers (for example, an assertive community treatment team); and 3) Traditional activities that are delivered in a way that is informed by a peer’s personal recovery experience.31

Peer specialists assist individuals experiencing mental illness by helping them focus on recovery, wellness, self-direction, personal responsibility and independent living. While peer services are not intended to supplant other existing mental health/ substance use services, the frequency of other services can be reduced when an individual is supported by a peer, often resulting in lower costs and better outcomes.32 The behavioral health service array is not complete unless these services are included. Peer and recovery specialists play a critical role in supporting individuals experiencing mental health/substance use conditions who are working toward recovery.

Texas Environment Texas Research shows that recovery-oriented peer support services produce positive outcomes. For example, peer support may increase feelings of personal empowerment and reduce negative clinical symptoms among behavioral health consumers.33 Recent randomized controlled trials also demonstrate that peer service delivery can decrease hospitalizations and improve treatment engagement among participants.34

In Texas, certified peer providers serve individuals with behavioral health conditions in a variety of settings, including state hospitals, halfway houses, and all 39 local mental health authorities (LMHAs) located across the state. A peer provider may work as a mental health peer specialist or a substance use recovery coach to directly engage with others who are navigating the recovery process. In FY 2014, the top five services provided by peer providers in Texas included:

· One-on-one support · Helping people advocate for themselves · Goal setting · Connecting people to community resources · Facilitating support groups.35

To perform the services listed above, peers require more than lived experience within the behavioral health system. Mental health peer specialists and family partners must also complete a training and certification process during which they learn about the nature of serious mental illness and acquire rehabilitative practice skills.36 In Texas, the nonprofit Via Hope operates a statewide peer specialist and family partners training program.37 The trainings consist of interactive classroom courses, as well as a written certification exam. To maintain this certification, mental health peer specialists and family partners must earn 20 continuing education units (CEUs) every two years.38 Additionally, peers and family partners may participate in endorsement trainings in which they develop specialized skills in areas such as trauma-informed care, intentional peer support, special education, and co-occurring disorders.39 In FY 2016, Via Hope certified 115 individuals as peer specialists and 26 individuals as family partners. At the end of FY 2016, there were 560 individuals in

24 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Texas with active peer specialist certifications and 121 individuals with active family partner certifications.40

DSHS and the Texas Certification Board of Addiction Professionals (TCBAP) provide similar training and certification opportunities for substance use recovery coaches. DSHS manages a 46-hour training curriculum for recovery coaches, which includes skills-based activities such as motivational interviewing and role clarity workshops.41 If individuals wish to be certified through TCBAP, they must provide documentation that they have completed 46 hours of training across five specific domains (including advocacy, mentoring, education, recovery support, and ethics), as well as undergo 500 hours of supervision.42 Between 2013 and 2016, over 1,450 individuals completed training as recovery coaches in Texas.43 In FY 2016, DSHS used $4.4 million in block grants to fund 22 agencies that provide recovery coach services, including 14 substance use treatment providers, six community-based Texas Environment programs, and two stand-alone, peer-run centers.44 Currently, there is no Medicaid reimbursement option for recovery coach services.

In 2015, the Texas Legislature approved a pilot program to reduce individuals involved in the criminal justice system from returning to jail or prison through the use of peer support. Research shows that reentry challenges are amplified for people with mental illness, who experience higher rates of disrupted treatments, homelessness, unemployment, and criminal activity upon release from incarceration.45

This peer pilot program aimed to address some of these issues with a $1 million budget rider. Rider 73 to the DSHS budget created a reentry peer support pilot to connect incarcerated persons with mental illness to peers with similar life experiences. Peers with dual mental health and criminal justice experience were recruited to help design and serve within the pilot program because they are particularly well-placed to assist formerly incarcerated persons through the recovery and reentry processes. Stakeholders in Texas developed the pilot after researching a similar program in Pennsylvania, where participants reported a three- year re-incarceration rate of 24%, compared to a 46% rate among other formerly incarcerated individuals in the state.46

DSHS selected three LMHAs to administer the pilot program: the Harris Center for Mental Health and IDD (which serves Harris County), MHMR Tarrant (which serves Tarrant County), and Tropical Texas Behavioral Health (which serves Cameron, Hidalgo, and Willacy counties). Hogg Foundation for Mental Health is funding an evaluation of the pilot program.

Also in 2015, during the 84th legislative session, Rep. Burkett filed HB 1541 hoping to expand access to peer provided services. The legislation passed the House, but did not get through the Senate. The legislation directed the Health and Human Services Commission to develop and adopt:

1) rules that establish training requirements for peer specialists so that they are able to provide services to persons with mental illness and services to persons with substance use conditions; 2) rules that establish certification and supervision requirements for peer specialists;

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 25 3) rules that define the scope of services that peer specialists may provide; 4) rules that distinguish peer services from other services that a person must hold a license to provide; 5) any other rules necessary to protect the health and safety of persons receiving peer services; and 6) rule to allow services provided under the medical assistance program (Medicaid) to include peer services provided by certified peer specialists to the extent permitted by federal law.

This legislation would have allowed more Medicaid recipients to use peer support services in a variety of settings.

Mental Health and Substance Use Parity

Per federal regulations in the Mental Health Parity and Addiction Equity Act (MHPAEA), all health plans that offer mental health or substance use benefits must Texas Environment Texas provide those benefits at the same level (“parity”) as surgical and medical benefits. To read more about the federal legislation requiring parity, please refer to the National Context section of this guide.

In 2011, the Texas Department of Insurance (TDI) adopted rules in response to MHPAEA. TDI’s rules detail that mental health and substance use benefits must be offered at a comparable level to medical and surgical benefits. The rules do not address certain federal parity rules, including non-quantitative treatment limitations (NQTLs). While quantitative treatment limitations are numerical, like the number of visits per year or the number of days covered for inpatient treatment, NQTLs include “non-numerical limitations” like step-therapy or preauthorization. A MHPAEA rule issued in 2013 requires parity in NQTLs, but TDI rules do not reflect this federal update. TDI’s rules prohibit financial requirements and treatment limits from being more restrictive than the requirements or limits applied to medical and surgical benefits offered by the plan. TDI’s rules also require out-of-network benefits for mental health and substance use conditions if the plan also covers out-of-network benefits for medical and surgical procedures.47 Further, TDI’s parity rules mandate coverage for necessary care and treatment of substance use conditions for employers of over 250 employees.

Parity is enforced by different agencies (both state and federal, including the federal Departments of Health and Human Services, Labor, and the Treasury) depending on the type of plan, which can make parity enforcement and oversight complex. TDI only has the regulatory control to enforce parity for “fully insured” individual and employer health insurance plans and HMOs. “Self-funded” employer plans are regulated by the Department of Labor. TDI has considered their parity enforcement as “responsive” rather than “proactive”.

TDI’s parity regulation is a dual approach. TDI reviews group health policy forms for compliance with Texas requirements (including coverage for serious mental illnesses (SMI) and quantitative parity).48 TDI also reviews plans for network adequacy, which is meant to ensure that all covered services are accessible and available with an adequate number of providers.49 Federal regulators review

26 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas individual and small group policies (which TDI does not regulate) for compliance with ACA’s essential health benefits. Federal regulators also enforce parity consistent with rules that address quantitative and non-quantitative treatment limitations.50

Although Texas has its own parity rules and regulations, many consumers continue to struggle with their health plans to receive needed mental health and substance use services. National reports have indicated that the nation has serious barriers to true mental health parity. For example, a 2015 NAMI report found that people report being denied mental health care nearly twice as often as they report being denied general medical care.51 Consumers face parity-related barriers including denials based on medical necessity, lack of access to an adequate provider base, and prescription cost and accessibility.52 Parity is meant to ensure the equal treatment of mental health and substance use condition benefits to medical and surgical Texas Environment benefits, but consumers continue to report issues in accessing services. However, TDI reported that the agency only received seven total complaints related to parity in 2014 and ten complaints through June 2016.53 This could be due to individuals reporting parity complaints to the Department of Labor or not labeling a complaint as a violation of parity. More work is needed to ensure that individuals with mental health and substance use conditions can access needed services at parity with medical and surgical benefits.

Lawsuit Against the Department of Family Protective Services on Behalf of Long-Term Foster Youth

In 2011, a class-action lawsuit was filed against the Department of Family Protective Services (DFPS) on behalf of all Texas children in foster care on a long-term basis. The case was originally brought forth by two advocacy groups — Children’s Rights and A Better Childhood — but over a dozen other advocacy organizations have since joined as plaintiffs in the case.54 The lawsuit addressed how the Child Protective Services (CPS) division of DFPS treats children in the state’s Permanent Managing Conservatorship (PMC) program, which serves children who have been unable to find a permanent placement within a year of their initial removal from their home.55 The advocacy groups amended complaint stated that children in PMC’s rights were violated, including their right not to be harmed while in state custody and their right to familial association.56 The lawsuit against CPS increased public attention to the quality of care provided to the roughly 28,000 children who are under the care of the state at any given time.57 In 2011, when the lawsuit was first brought against CPS, there were approximately:

· 12,000 children in Permanent Managing Conservatorship (PMC), · 6,400 children in PMC for three or more years, · 500 children in PMC for more than 10 years, and · More than 1/3 of children in PMC experiencing five or more placements. 58

Since the lawsuit against DFPS began, the 84th Texas Legislature made some initial

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 27 reforms to DFPS’ foster care system and increased CPS funding by $231 million.59 However, a lack of available foster care homes that fit children’s specific needs has continued to make it difficult to quickly find children in foster care a permanent placement — especially a placement that is close to the child’s home community.60 This shortage was further exacerbated by a series of increased caregiver eligibility requirements that were put into place at the beginning of 2015, making it more difficult for children to be placed in kinship placements (i.e. with extended family members). After these stricter safety-screening standards were put into place, CPS removals of children from their homes grew by 37 percent and short-term informal kinship placements fell by 56 percent during the same time. 61

U.S. Federal District Judge Janis Graham Jack of Corpus Christi issued a ruling on the CPS case in December 2015. Judge Graham ruled against CPS, finding that the state had systematically violated the Fourteenth Amendment rights of children in the PMC foster care program to be free from an unreasonable risk of harm while in state custody.62 In her decision, Judge Jack described the foster care system run by DFPS as one where:

Texas Environment Texas “…Foster children often age out of care more damaged than when they entered… Years of abuse, neglect and shuttling between inappropriate placements across the state has created a population that cannot contribute to society, and proves a continued strain on the government through welfare, incarceration or otherwise. Although some foster children are able to overcome these obstacles, they should not have to.” 63

The state appealed Judge Jack’s ruling but as of October 2016 those appeals have been unsuccessful. The implementation of several of the ruling’s reforms to improve the PMC program began in early 2016.64 Most importantly, Judge Jack appointed two special masters in March 2016 to help guide and oversee changes to DFPS’ foster care system — mediator and specialist attorney Francis McGovern and Kevin Ryan, former Commissioner of Children and Families for New Jersey.65 At an estimated cost of $3 to $4 million per year, the co-transition special masters will create a plan for addressing capacity and workforce issues in CPS (e.g. defining “manageable” caseload sizes and addressing the amount of time children spend in PMC).66 Judge Jack also addressed immediate concerns of child safety in foster care placements by prohibiting the placement of children in foster group homes without 24-hour awake supervision.67 While that order is in place, the co-transition special masters will make a recommendation about whether group homes should continue to operate at all, depending on their determination as to whether group homes cause “an unreasonable risk of harm” to foster children.68

The main mission of the co-transition special masters is to help DFPS and CPS define a reasonable caseload size and improve caseworker turnover and overall conditions.69,70 CPS caseworker turnover and high caseloads make it difficult for cases to be processed quickly and in some cases thoroughly, which leaves children in the foster care system longer and at greater risk of experiencing instability in their placements. 71, 72 Average CPS caseload sizes in Texas have fallen some in recent years — from 31 cases in 2014 to 28 in 2015 — but that still far exceeds the maximum number of cases (17) recommended in national best practices.73 ,74 Caseworker turnover also remained high throughout 2015, with workers citing management concerns and overwhelming demands of the job in addition to low pay as reasons for leaving.75

28 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas In an effort to expand the caseworker applicant pool and reduce turnover, DFPS reduced hiring requirements for caseworker positions in June 2016. The new requirements allow individuals with relevant work experience and an associate’s degrees (or two years of a bachelor’s degree completed) to be eligible for employment as a CPS caseworker. Prior to this change only individuals with bachelor’s degrees or higher were eligible for these positions.76 Texas Speaker of the House Joe Strauss also declared that fixing the foster care system will be one of his top priorities for the 85th Legislature.

Behavioral Health Integration Advisory

Committee (BHIAC) Texas Environment

People with mental health and substance use conditions may have poorer health outcomes than the average person.77 This is mostly from untreated and preventable chronic physical conditions like hypertension, diabetes, obesity, and cardiovascular disease that can be aggravated by poor health habits such as lack of physical activity, poor nutrition, smoking, and substance abuse.78 Fragmentation of mental and physical health care services is one of the primary barriers to realizing optimal health outcomes for individuals with mental illness. Integrated behavioral health care seeks to eliminate fragmentation through the systematic coordination of mental health and substance use services with general healthcare.79 This care may address health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.80

In recent years, Texas has taken steps to coordinate mental and behavioral health services across the various HHS agencies in order to improve service delivery for Texans with mental illness. The Behavioral Health Integration Advisory Committee (BHIAC) was created by SB 58 (Nelson/Zerwas) in the 83rd Legislative Session. The BHIAC was charged with addressing planning and development needs to integrate Medicaid mental health and substance use services, including targeted case management, mental health rehabilitative services and physical health services. Further, the committee was directed to seek input from consumers and providers within the behavioral health committee on the issues and provide formal recommendations to HHSC on how to best accomplish integrating behavioral health and physical health within Medicaid managed care.

BHIAC’s presentations and reports are available at https://hhs.texas.gov/about-hhs/ leadership/advisory-committees/behavioral-health-integration-advisory-committee.

Boarding Homes and Housing Choices

In 2009, the Texas Legislature directed the Health and Human Services Commission (HHSC) to establish model boarding home standards with HB 216 (81st, Menendez/ Shapleigh). The legislation gave local governments the option to adopt the model standards, as well as to require boarding home permitting, fees, and inspections.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 29 HHSC released its model standards in 2010.81 The state does not require localities to adopt the model or permitting standards, but those who do must submit a report to HHSC with the number of homes in their jurisdiction.82 DADS has had responsibility for compiling those reports and has published them biennially. Only a few local governments have adopted the HHSC standards for boarding homes in their jurisdiction. In 2014, DADS reported that only four municipalities had adopted the standards: Brenham, Dallas, El Paso, and San Antonio. Advocates have expressed concern that few municipalities are adopting the standards and that boarding homes in most cities continue to be unregulated and unsupervised. In November 2015, the House Committee on Human Services and House Committee on Urban Affairs received a joint interim charge to investigate the operation and regulation of boarding homes and identify communities that have adopted local standards.83 The Mental Health America - Greater Dallas website on boarding home regulations is available: http://boardinghome.org/.

In 2013, the Legislature passed HB 1191 (83rd, Burkett/Zaffirini), which added Texas Environment Texas housing resources specifically for people with mental health conditions to the online Texas Information and Referral Network (TIRN, also known as 2-1-1). Information about housing options for individuals with mental illness is currently available on the 2-1-1 website http://www.211texas.org/housing-choices-finding-a-place-to-live/.

Services for Individuals with Intellectual/Developmental Disabilities Experiencing Co-occurring Mental Health Conditions

Individuals with intellectual and other developmental disabilities (IDD) often experience mental health conditions as well as the harmful consequences of trauma. Analysis of recent data from the National Core Indicators suggests that approximately 34% of adults living with IDD also have a co-occurring mental health condition.84 People with IDD experience abuse, neglect, exploitation, isolation, institutionalization, bullying, restraint, seclusion, violence, and other forms of trauma, yet rarely are IDD or special education systems and policies built on recovery and trauma-informed principles. Goals and objectives of these systems rarely address mental wellness. While we know that recovery from mental illness and trauma is possible, the developmental disabilities too often overshadow attention to possible mental health conditions or any consideration of the impact of past trauma.

Depression and anxiety seem to be two of the most frequently identified mental health conditions in people with IDD but are certainly not the only ones.85 Research has also indicated an over-representation of schizophrenia in people with IDD compared to the general population. Post-traumatic stress disorder (PTSD) has also been identified as a significant cause of mental health concerns in people living with IDD.86 Studies indicate that individuals with reduced developmental levels are more

30 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas at risk for experiencing PTSD and that their PTSD symptoms can be more severe.87

There can be challenges associated with assessing and treating individuals with IDD who experience mental health conditions such as communication differences, time required for assessment, lack of mental health providers who understand the IDD population, limited resources, professional biases, overuse of pharmacology, and the lack of consideration of people with IDD when developing state mental health policies. The challenges, however, are not insurmountable and both the state and national dialogue indicate a recognition of the need to take action.

Texas is beginning to understand the current gap in our systems of supports and services for individuals with IDD living with co-occurring mental health conditions. HB 2789 (84th, Raymond/Zaffirini) required web-based trauma-informed care training for new employees hired at state supported living centers and intermediate Texas Environment care facilities for people with intellectual disabilities. As a result of the legislation, the Department of Aging and Disability Services and the Department of State Health Services developed a series of web-based training modules designed to help families and providers consider the mental health and wellness support needs of individuals with IDD as opposed to limiting their efforts to managing “challenging behaviors.” Efforts have also been made in Texas to address the need for crisis intervention services for individuals with IDD experiencing a mental health crisis. This is a start, but does not address the inability of individuals with IDD to access quality mental health treatment and supports that could prevent a crisis.

As a result of Sunset legislation passed during the 84th Texas Legislative Session, the health and human services system is being re-structured and one of the changes combines IDD and mental health services in one division. Additionally, new HHS divisions will have units devoted to cross-division coordination. This offers opportunities to more comprehensively address the needs of the IDD population. At the same time, the state continues to expand the scope of health services included in the publicly-funded managed care system. The resulting integration of services will also offer opportunities for more holistic supports for individuals with IDD.

Recently the Hogg Foundation for Mental Health partnered with the National Child Traumatic Stress Network (NCTSN) to develop a training toolkit, Road to Recovery: Supporting Children with Intellectual and Developmental Disabilities Who Have Experienced Trauma. The toolkit was developed over two years with the guidance of national mental health experts and IDD experts. The toolkit is designed to be a two-day train-the-trainer resource and is available free of charge at http://nctsn. org/products/children-intellectual-and-developmental-disabilities-who-have- experienced-trauma

The dearth of mental health services and supports for individuals with IDD requires ongoing efforts at the national, state, and local levels. Efforts to increase awareness, build capacity, and increase access to quality mental health services should be part of the state’s overall mental health plan.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 31 Health and Human Services System Transformation

The Health and Human Services Commission and the HHS system are currently undergoing significant reorganization. Prior to the 84th session, the Texas Sunset Advisory Commission performed a comprehensive review of the system and recommended that the legislature consolidate agencies in order to improve efficiency and service delivery.88 The 2014 Sunset Commission recommended further consolidation as a step toward achieving the state’s 2003 vision for efficient, streamlined health and human services. According to the 2014 Sunset Commission, further system reorganization was also necessitated by recent developments in Texas healthcare, such as the transition to Medicaid managed care, the integration of behavioral health services into managed care, and the implementation of the federal Affordable Care Act (ACA).89

Texas Environment Texas Informed by the commission’s recommendations, the 84 Legislature directed the transfer of behavioral health and regulatory functions previously administered by DSHS and DFPS to HHSC, as well as a complete transfer of services and the ultimate elimination of DADS and DARS as separate entities.90 The 84th Texas Legislature directed a reorganization of the entire HHS system, requiring that many programs and services transfer to HHSC from the other four HHS agencies. Implementation began in 2015 and will continue over the course of several years, although the majority of the structural reorganization is expected to be complete by September 1, 2017.

In addition to the transformation, HHSC is implementing many legislative directives passed during the 84th Legislative Session that address a number of policy and program areas such as the Medicaid substance use benefit, network adequacy in Medicaid managed care, and the discontinuation of the NorthSTAR managed care program. The commission also continues to implement directives from the 83rd Legislative Session, such as integrating behavioral health services with Medicaid managed care.

Finally, as part of the transformation plan for health and human services, SB 200 (84th, Nelson/Price) created the new Division of Transformation, Policy and Performance within HHSC. Among other duties, the Policy and Performance Office is responsible for:

· Evaluating current HHSC (and DSHS) performance measures, · Developing “new and refined” measures, and · Establishing targeted system-level measures that evaluate and communicate overall system performance.91 HHS Transformation

During the 84th Legislative Session, the legislature adopted the Texas Sunset Commission’s recommendation to reorganize the HHS enterprise (SB 200, 84th, Nelson/Price). The HHSC Sunset legislation requires the five HHS agencies to consolidate into three, discontinuing DARS and DADS and maintaining DSHS and DFPS as separate agencies until further legislative review in 2018.

32 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Highlights

· SB 200 (84th, Nelson/Price) directed the state to transfer many of the programs and functions currently housed across the four other HHS agencies over to HHSC. · Phase one of the transformation focused on reforming the enterprise’s broader organizational structure, with major changes effective on September 1, 2016 and continuing through September 1, 2017. · Behavioral health programs at DSHS and DADS, as well as select client services at DARS, were transferred to HHSC; DARS was discontinued as a separate agency on September 1, 2016. · DARS general vocational rehabilitation services, vocational rehabilitation for individuals who are blind, Independent Living Services for older individuals who

are blind, and Business Enterprises of Texas program was transferred to the Texas Texas Environment Workforce Commission on September 1, 2016. · Phase two will focus on reforming program operations within the new HHS structure. · Regulatory functions at DSHS, DADS, and DFPS, as well as operation of the state supported living centers (SSLCs) and the state hospitals, will transfer to HHSC by September 1, 2017. · DADS will be discontinued on September 1, 2017. · DSHS and DFPS will continue to operate as separate agencies, maintaining their public health and child protective services functions, until further legislative review in 2018.92

In July 2016, the commission published a revised version of Health and Human Services System Transition Plan, outlining its plan for carrying out the transformation directives in SB 200. The timeline for the anticipated changes is shown in Figure 5.

Figure 5. Proposed Health and Human Services Transformation Timeline

Date Proposed Changes By September 1, 2016 (Phase One) DADS: All client services transfer to HHSC (social and medical) Regulatory, licensure and SSLC operations remain at agency DARS: Vocational Rehabilitation Programs transfer to Texas Workforce Commission (TWC) Remaining programs and functions transfer to HHSC Agency is discontinued DFPS: Prevention and Early Intervention programs transfer from HHSC to DFPS Protective services and regulatory functions remain at agency DSHS: All client services transfer to HHSC (social and medical) Public health and regulatory functions remain at agency

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 33 Date Proposed Changes By September 1, 2017 (Phase Two) DADS: Regulatory, licensure and SSLC functions transfer to HHSC Agency is discontinued

DFPS: Childcare placement licensure functions transfer to HHSC Protective services functions remain at agency

DSHS: Regulatory and licensure functions transfer to HHSC Agency maintains public health functions HHSC: Begin organizational review of within-division and within-program operations By September 1, 2018 (Continuing) HHSC: Submit study and recommendations to the Transition Legislative Oversight Committee on whether to continue DSHS and DFPS as separate agencies

Source: Texas Health and Human Services Commission. (2016). Health and Human Services system transition plan. Retrieved from

Texas Environment Texas http://www.hhsc.state.tx.us/hhs-transformation/

The reorganization of the HHS enterprise is occurring in two phases:

· Phase One: Implemented on September 1, 2016, this phase focused on implementing broad structural changes to the HHS system. During this phase, HHSC facilitated the transfer of the majority of social and medical services into one HHSC division. The goal has been to transfer programs to HHSC in their entirety before attempting intra-program or intra-division organizational reform. · Phase Two: During this phase, the agency plans to transfer remaining regulatory and facility operations to HHSC. The transfer of programs and functions to HHSC is expected to be complete by September 1, 2017. During this phase, the agency will begin to pursue reorganization within core functional divisions or specific programs, as necessary.93

The two-phase reorganization process is designed to minimize interruptions to client services during the transformation process.94 While the majority of the structural changes are expected to be complete by September 1, 2017, the agency expects that reorganization within divisions and programs will occur over the course of several years.

By September 1, 2018, the agency must, additionally, submit a report to the Texas Legislative Oversight Committee providing recommendations as to whether DSHS and DFPS should continue to operate as separate agencies or be merged into HHSC. For more information, see the Health and Human Services Transition Plan at http:// www.hhsc.state.tx.us/hhs-transformation/transition-plan.shtml

DISCONTINUATION OF NORTHSTAR

The HHSC Sunset legislation also requires the state to discontinue the NorthSTAR behavioral health demonstration project on December 31, 2016. Since 1999, the NorthSTAR program has provided behavioral health and substance use services to Medicaid-eligible clients in the Dallas area through a capitated payment system to

34 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas one managed behavioral health care organization.95

In 2014, the Sunset Commission found that NorthSTAR’s behavioral health delivery system was outdated and inconsistent with Texas’ systemwide efforts to integrate behavioral healthcare with other basic physical health services and Medicaid managed care.96 In its analysis of Senate Bill 200 (84th, Nelson/Price), the Texas House Research Organization reported that dismantling NorthSTAR would:

· Produce cost-savings · Facilitate behavioral health integration efforts · Enhance access to federal funding97

SB 200 adopted the Sunset Commission’s recommendations, removing reference to the NorthSTAR program from statute. Medicaid-eligible NorthSTAR clients Texas Environment will receive their behavioral health care services through the same managed care organization that provides their physical health care.98 DSHS has established two Behavioral Health Authorities (BHAs) that will provide an alternative model for indigent care (mental health services for those not eligible for Medicaid).99 LifePath Systems and the North Texas Behavioral Health Authority (NTBHA) have been selected as the two BHAs in the region.100 These transitions become effective January, 1 2017.101 See the HHSC section for more information about NorthSTAR.

HHS ADVISORY COMMITTEE REORGANIZATION

The HHSC Sunset legislation also directed important changes to the advisory committee structure in the HHS enterprise, eliminating 36 existing advisory committees from state statute while enabling the HHSC Executive Commissioner to establish new advisory committees in rule.102 Advisory committees play an important role in the HHS enterprise, providing the agency with feedback from clients, families and other stakeholders on specific issues.

In 2015, a cross-agency workgroup evaluated the 133 existing HHS advisory committees. Following a public input process, the workgroup submitted recommendations to the HHS Executive Commissioner on which advisory committees to keep, consolidate or dismantle. A list of the recreated advisory committees can be found at https://hhs.texas.gov/about-hhs/leadership/advisory- committees.

The HHSC Sunset legislation expressly directed HHSC to establish an advisory committee that would address behavioral health issues, and the Behavioral Health Advisory Committee held its inaugural meeting in January 2016. Its role is to provide recommendations to the HHS Executive Commissioner on how to promote cross-agency coordination, ensure access to and integration of services, and promote behavioral health wellness and recovery.103

For a full listing of the Commissioner’s final advisory committee recommendations, please see the Health and Human Services Transition Plan at https://hhs.texas.gov/ transition-plan.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 35 AUSTIN STATE HOSPITAL (ASH) - AUSTIN STATE SUPPORTED LIVING CENTER (AUSSLC) LOCATION FEASIBILITY STUDY

The legislature continues to discuss the future of the Austin State Hospital (ASH) and Austin State Supported Living Center (AuSSLC). Both facilities have been recognized to have outdated infrastructure that can create unsafe conditions for residents and staff. As of October 11, 2016, 345 people were on the forensic waiting list for a state hospital bed, including 270 individuals on the maximum security wait list.104 State hospital bed availability has simply not kept pace with the growing population and need. Austin State Hospital (ASH) covers 30 counties, has 299 beds, and admits about 1600 people a year.105 Senate Bill 200 required HHSC to conduct a study to determine the feasibility, costs, and benefits of transferring operation of ASH from its current facilities to a new facility at a new location. Rep. Workman requested the inclusion of Austin State Supported Living Center (AuSSLC) in the study, which will examine the following options:

· Consolidated ASH/AuSSLC facility at the existing ASH campus · Consolidated ASH/AuSSLC facility at the existing AuSSLC campus · Replacement ASH facility on other State-owned land Texas Environment Texas · Replacement ASH facility on the existing ASH campus · Replacement ASH facility on a site not currently owned by the State · Replacement ASH and AuSSLC facilities on a site not currently owned by the State.106

The final report was submitted to the Legislature in September 2016. It stated more research needs to be done before moving forward with a decision.

BEHAVIORAL HEALTH ADVISORY COMMITTEE

The Behavioral Health Advisory Committee (BHAC) was created as a result of the HHSC review of all advisory committees. According to the advisory committee webpage, the BHAC is charged with providing “input to the health and human services system in the form of recommendations regarding the allocation and adequacy of behavioral health services and programs within the State of Texas.” The recommendations of the committee are given to the executive commissioner for his consideration. The scope of the recommendations include:

· The promotion of cross-agency coordination, state/local and public/private partnerships in the funding and delivery of behavioral health services; · The promotion of data-driven decision-making; · The prevention of behavioral health issues and the promotion of behavioral health wellness and recovery; · The integration of mental health and substance use disorder services in prevention, intervention, treatment, and recovery services and supports; · The integration of behavioral health services and supports with physical health service delivery; · Access to services and supports in urban, rural, and frontier areas of the state; · Access to services and supports to special populations; · Rules, policies, programs, initiatives, and grant proposals/awards for behavioral health services; and · The five-yearbehavioral health strategic plan and coordinating expenditure plan.107

36 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 1115 Waiver: Texas Health Care Transformation and Quality Improvement Program

In December 2011, Texas was approved by the Centers for Medicare & Medicaid Services (CMS) for a waiver of certain federal Medicaid regulations under section 1115 of the Social Security Act.108 These waivers were designed to improve managed care delivery and access to services while maintaining supplemental payments to assist hospitals in covering the costs of uninsured patients during the initial implementation of the Affordable Care Act (ACA). Several parts of the 1115 waiver aim to improve Texas Environment primary healthcare services and coverage more generally (e.g. improving access to primary care physicians and chronic care management), but this section focuses specifically on the 1115 waiver’s impact on improving behavioral health services.109

The Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver – commonly known as the “1115 Waiver” — has five main objectives:

· Expand Medicaid managed care statewide · Develop and maintain a coordinated care delivery system · Improve health outcomes while containing costs · Leverage federal Medicaid match dollars with local and state funding · Transition health services to innovative, quality-based payment systems.110

The Texas 1115 Waiver accomplishes these goals through the statewide expansion of Medicaid managed care through the STAR, STAR Kids and STAR+PLUS programs, and through the creation and utilization of two unique funding sources:

· The Uncompensated Care (UC) pool, which replaces the Upper Payment Limit (UPL) program for reimbursing physicians and hospitals for Medicaid shortfalls and care provided to individuals who do not have third party coverage (i.e. health insurance). · The Delivery System Reform Incentive Payment (DSRIP) pool, which provides incentive payments to fund infrastructure improvements and test innovative models of healthcare delivery for Medicaid recipients and low-income, uninsured individuals.111

The initial demonstration period for Texas’ 1115 waiver was from September 2011 until September 2016. In September 2015, HHSC requested to extend the 1115 waiver for five years but that extension was denied by CMS.112 Then in May 2016, CMS authorized HHSC’s request for a 15-month extension of the 1115 waiver, which will continue the program through December 2017.113 The Uncompensated Care (UC) Pool

The UC Pool replaces Upper Payment Limit (UPL) funding for hospitals and physicians and allows them to receive payments for uncompensated care for low- income Medicaid eligible patients and others who are uninsured. While payments through the 1115 waiver UC pool initially helped Texas cover gaps in healthcare

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 37 coverage that resulted from the state’s decision not to expand Medicaid under the Affordable Care Act, a policy passed by CMS in 2015 no longer allows for federal Medicaid funds to cover uncompensated care for individuals who would have been covered by statewide Medicaid expansion or a coverage waiver.114

As of June 2015, Texas has paid out an estimated $11 billion in payments from the UC pool — $6.3 billion for private hospitals, $4.1 billion for public hospitals, $294.3 million for physician groups and $263 million for ambulances and groups of dental providers.115 With the 15-month extension of the 1115 waiver, roughly $2 billion of the funds received by hospitals from the UC pool will be from federal match dollars in 2016.116 The Delivery System Reform Incentive Payments (DSRIP) Pool

The goal of the DSRIP pool is to transform healthcare delivery systems, improve individual and population health, and lower overall healthcare costs through efficiencies and innovations.117 The DSRIP pool incentivizes innovation by freeing providers from the constraints of traditional fee-for-service payments and Texas Environment Texas reimbursing providers based on the quality of their services and their patient outcomes. In order to receive funding from the DSRIP pool, projects must meet their project-specific performance metrics.118 Metrics should demonstrate improved patient outcomes, quality improvement, and the development of project infrastructures through the expansion of space, hours, and staff. Providers report on these performance metrics twice per year in order to earn DSRIP payments.119

The improvement of healthcare delivery systems through the DSRIP pool in Texas relies heavily on the 20 Regional Healthcare Partnerships (RHPs) across the state. RHPs are local collaborations that help to identify community needs and fund the state’s portion of all waiver payments.120 The goal of RHPs is to address specific regional concerns through individualized DSRIP projects while providing an overarching framework that allows for improved coordination and resource sharing across regions. The counties and other local entities providing the state share of funds determine how their funds are used in the RHP, consistent with waiver requirements.

Figure 6 below shows a map of the 20 RHPs in charge of Texas’ DSRIP programs.

38 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Figure 6. Map of Regional Healthcare Partnerships (RHPs) and Managed Care Service Delivery Areas (SRAs) in Texas: January 2016 Texas Environment

Source: Texas Health and Human Services Commission. (January 6, 2016). Texas: Regional Healthcare Partnerships (RHP) and Manages Care SDAs. Retrieved from http://www.hhsc.state.tx.us/1115-docs/081816/TX_RHP_and_SDAs_Regions_010616_Update.pdf

In order to be meet the requirements of the 1115 waiver, RHPs must choose DSRIP projects that make improvements within at least one of the following four categories:

· Category 1: Infrastructure Development. “Lays the foundation for delivery system transformation through investments in technology, tools, and human resources that strengthen the ability of providers to serve populations and continuously improve services.” · Category 2: Program Innovation and Redesign. “Includes the piloting, testing, and replicating of innovative care models, such as telemedicine, patient-centered medical home, and innovations in health promotion and disease prevention.” · Category 3: Quality Improvements. “Assess the effectiveness of Category 1 and 2 interventions for improving outcomes in the Texas healthcare delivery system. Each project [in] Categories 1 and 2 has one or more associated outcome measures from Category 3.” · Category 4: Population-Focused Improvements. “A series of reporting measures for a hospital to track the community-wide impact of delivery system reform investments. Required reporting includes data related to potentially preventable admissions, readmissions, and complications, patient-centered health care and emergency department utilization, with optional reporting of core healthcare quality measures for children and adults.”121

As of May 2015, there were 1,458 active DSRIP programs in Texas operated by 298 distinct providers across the state’s 20 RHPs.122 Local mental health authorities (LMHAs) are the most common type of providers for DSRIP services, operating 340 different DSRIP projects, but hospitals, physician groups and local health departments also serve as providers for many DSRIP projects. 123,124 As of April 2016, DSRIP programs in Texas have received approximately $7.1 billion in total payments

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 39 as a result of meeting their pre-determined, program-specific success metrics.125

Behavioral health services have been targeted for significant expansion under the 1115 waiver. Texas prioritized behavioral health for its 1115 waiver by reserving 10 percent of DSRIP funds for community mental health centers (LMHAs) and including several behavioral health projects in the DSRIP menu.126 DSRIP 1115 waiver projects related to behavioral health account for approximately one third (472) of all DSRIPs, with 46 of those projects focused specifically on providing children and adolescents with improved behavioral health DSRIP 1115 waiver projects services.127 The 1115 waiver also creates the option for local related to behavioral communities to expand behavioral health services without health account for conforming to the narrow eligibility requirements that exist for approximately one third state-funded LMHA services. (472) of all DSRIPs, with 46 of those projects focused Examples of current behavioral health DSRIP projects include: specifically on providing children and adolescents · Improved and expanded crisis intervention (e.g. rapid with improved behavioral response teams, psychiatric extended observation and stabilization Texas Environment Texas health services.127 units, and trainings for mental health deputies) · Integration of behavioral health services with primary care (e.g. including behavioral health in obstetrics outpatient services to treat postpartum depression) · Expansion of peer support services and early intervention programs · Expanding community treatment options so that individuals experiencing a psychiatric crisis are not unnecessarily put into emergency rooms, state hospitals, prisons or jails · Improved recovery programs that provide supportive services to increase compliance and success (e.g. transportation and meals to help individuals at a homeless shelter stay engaged and involved in their recovery) · Expansion of providing behavioral health services through telemedicine/telehealth · Implementation of the Family Preservation Program to provide continuity of care services for children at risk for out-of-home placements or who are returning to the community after a stay at an inpatient psychiatric hospital. 128,129

FUNDING FOR TEXAS’ 1115 WAIVER

For the first five years of the 1115 waiver, funds totaled $29 billion ($17.6 billion from the UC pool and $11.4 billion from the DSRIP pool).130 The UC and DSRIP pools in the Texas 1115 waiver have an annual budget of roughly $6 billion, including $4 billion a year in federal matching funds and $2 billion from Intergovernmental Transfers (IGT) and other local sources, such as taxpayer money.131,132

As a result of DSHS Rider 59 in the 2016-2017 General Appropriations Act (and Rider 79 in the previous legislative session), community mental health centers (LMHAs) are now required to use GR funds appropriated by the state to draw down federal funds through the DSRIP pool whenever possible.133 In FY 2014 and 2015, LMHAs leveraged roughly $219 million in GR appropriations and $55.5 million in local funds to draw down $385.1 million in federal funding for behavioral health services provided through the DSRIP pool.134

The 15-month extension of the 1115 waiver kept the same funding structure of the

40 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas initial five-year demonstration in place, with $3.1 billion available for each pool (i.e. DSRIP and UC) in the first 12 months of the extension. Both pools will receive a prorated amount for the final three months at the end of the extension.135,136 However, CMS clearly stated in their approval of Texas’ extension that the UC pool cannot be used to cover services that would have been covered had Texas expanded Medicaid under the ACA. CMS also stated that HHSC must work with the agency during the extension to develop a viable long-term plan.137

COST SAVINGS AND OUTCOMES OF DSRIP PROJECTS UNDER THE 1115 WAIVER

While there is some initial data available on the effectiveness and impact of DSRIP projects, more will be known about the efficacy and success of these projects as the initial demonstration period comes to a close in 2017. Examples of performance metrics for behavioral health projects include: Texas Environment

· Reductions in admissions and readmissions into the criminal justice system · Reductions in emergency department visits · Improved quality of life and overall functioning.138

While program-wide outcomes data is still forthcoming, there is some qualitative data available about the impact that DSRIP projects are having on the lives of individuals who are enrolled in services. One DSRIP project in Austin-Travis County that expands access to mobile psychiatric crisis units has successfully diverted roughly 90 percent of the individuals they have served from entering into the criminal justice system.139 In another DSRIP project One DSRIP project in Austin- focused on integrating behavioral health services with Travis County that expands access primary care in RHP 1, one primary care physician to mobile psychiatric crisis units expressed that the program has helped them to better has successfully diverted roughly recognize their clients’ behavioral health needs — “[I’d] 90 percent of the individuals they been treating this patient for years and never knew he was have served from entering into depressed. Because of our integration project, I learned the criminal justice system.139 he was suicidal and was able to get him treatment. DSRIP has changed how I practice medicine.”140

Because reimbursements for DSRIP projects are tied to achieving specific patient- centered metrics, the financial success of these projects also signals improvements at the individual level. For example, behavioral health-related DSRIP projects earned roughly $1.7 billion in incentive payments as of January 2016 and are expected to earn an additional $1 billion in incentive payments by 2017.141 These incentive payments come from meeting project-specific benchmarks, for instance successfully reducing the number of psychiatric hospital readmissions within 30 days of discharge or reductions in the use of emergency rooms for treating psychiatric needs. In the initial five-year demonstration of the 1115 waiver, Texas yielded an overall expected costs savings of $8.65 billion, coming from things such as reductions in pre-term births, diverting individuals from incarceration or unnecessary emergency room visits. 142

In terms of expanding access to care, funds from the 1115 waiver provided behavioral health services for 50,350 new clients and enhanced services for 23,728 clients in year three of the waiver demonstration (October 2013 to September 2014).143 In that

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 41 same time period, DSRIP projects altogether provided more than 2 million separate patient encounters that were not being provided before the 1115 waiver began.144

At the systems level, DSRIP projects have improved collaboration between different RHPs and DSRIP providers, allowing them to increase efficiency by sharing information on best practices and barriers to implementation. As a result of the 1115 waiver’s DSRIP projects, there has been a 25 percent increase in the number of “collaborative inter-organization relationships” across the state’s 20 RHPs.145 The 400+ behavior health-related DSRIPs have increased collaboration and resource sharing between LMHAs, hospitals, and other community providers. 146 DSRIP projects have improved the mental health outcomes of thousands of Texans and laid the foundation for developing important community partnerships. However, as the 1115 extension approval letter from CMS explains, the 1115 waiver is not a permanent solution to Texas’ shortcomings in providing behavioral health services and more long-term plans for coverage must be made.147

Texas Environment Texas Telemedicine and Telehealth Services

Telemedicine and telehealth services generally refer to medical services or treatments that are provided to distant locations using advanced telecommunication technologies (e.g. interactive digital video conferencing programs like Skype) to remotely connect a patient with a doctor or other health professional.148 According to Texas statutes, telemedicine services are provided by physicians or other health professionals acting under a physician’s delegation while telehealth services can be delivered by a number of different licensed or certified health professionals acting within the scope of their license or certification (e.g. Licensed Professional Counselors (LPC), Licensed Clinical Social Workers (LCWS), or Psychologists). 149,150

In Texas, behavioral health services provided via telemedicine/telehealth include:

· Psychiatric diagnostic evaluations · Psychotherapy (with an individual and/or their family) · Office visits · Other outpatient visits including counseling, coordination of care with other physicians and decision-making · Inpatient consultation, pharmacologic management and medication review 151

The legislative push for the approval of telemedicine medical services in Texas began in 1995.152 Interest in telemedicine services waned in the early 2000s but in recent years, legislators have shown a renewed interest in funding and expanding telemedicine and telehealth options. The following telemedicine/telehealth bills were passed in 2015:

· HB 1878 (84th, Laubenberg/Taylor) — ensures reimbursement for physicians providing telemedicine services to children in primary or secondary school-based settings.153 · SB 200 (84th, Nelson/Price) — abolished the telemedicine and telehealth advisory committee and transferred all duties within DADS and DARS to HHSC (as part of the larger Health and Human Services Transformation).154

42 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas · HB 2641 (84th, Zerwas/Schwertner) — extends Medicaid reimbursement for home telemonitoring services (e.g. remote monitoring to determine compliance with psychotropic medications) until September 1, 2019. HB 2641 also adds patients with “mental illness or serious emotional disturbance” as eligible for telemonitoring services.155

Both Medicaid and Medicare now view telemedicine and telehealth services as cost- effective alternatives to traditional face-to-face appointments in a doctor’s office.156 As Figure 7 shows, telemedicine and telehealth services have become increasingly popular in Texas over the last eight to ten years.

Figure 7. The Growth of Telemedicine/Telehealth Services in Texas: 2005 - 2013

Texas Environment

Source: Texas Health and Human Services Commission. (December 1, 2014). Telemedicine, Telehealth and Home Telemonitoring Texas Medicaid Services. Pages C1-C3. Retrieved from http://www.hhsc.state.tx.us/reports/2015/telemedicine-telehealth-home-monitoring.pdf

Benefits of Telemedicine and Telehealth Services

Research indicates four main ways in which telemedicine and telehealth can help improve behavioral health treatment and increase access to care:

· Quicker and easier access to a wider array of healthcare services and mental health specialists · Improved and expanded televideo mental health trainings for providers in rural areas · More equitable geographic distribution of healthcare workforce and specialist skills · Cost savings for patients, private health insurers, and public health programs such as Medicaid through increased efficiencies, fewer redundancies, and earlier interventions during (or before) mental health crises.157,158

Telemedicine is increasingly being pursued as a solution to help alleviate access to care challenges experienced by certain marginalized groups. For instance, there is a national shortage of geriatric mental health care providers, and geriatric consumers traditionally have difficulties with transportation to and from medical appointments. Telemedicine can help geriatric consumers in rural areas better connect with the few geriatric specialists that exist. Telemedicine is also being used as a method to help solve some of the transportation and access to quality care issues experienced by individuals living in rural areas or for individuals who have mobility issues or visual impairments.159 While

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 43 expanding access to telemedicine and telehealth services does not add any new mental health workers to the field, it can help to more equitably and efficiently redistribute the specialist skillsets that are currently available in the workforce.160 Teladoc Lawsuit Against Texas Medical Board

The Texas Medical Board (TMB) recently adopted an “emergency” rule requiring physicians to meet with a patient face-to-face before providing any prescriptions or telemedicine/telehealth services.161 The telemedicine company Teladoc has since filed an anti-trust lawsuit against the TMB, alleging that the new rules restrict Teladoc’s ability to establish initial patient-client relationship via telephone and compete with other healthcare providers on the price and quality of their services.162 On September 9, 2016, the Federal Trade Commission sent a letter to the U.S. 5th Circuit Court, criticizing the Texas Medical Board for allegedly “misinterpreting case law”.163 According to the Texas Tribune, the state has asked the appeals court to throw out Teladoc’s lawsuit, and federal regulators urged the court not to on September 9, 2016. 164 The federal regulators stated that the Texas Medical Board “failed to show that any disinterested state official ever substantially reviewed the telemedicine rules to Texas Environment Texas determine whether the rules promote a clearly articulated state policy to displace competition rather than the private interests of active market participants”.165

Texas Dual Eligible Integrated Care Project

In an effort to address the concerns of the fragmented system that people who qualify for Medicaid and Medicare (also known as “dual eligibles”) have to navigate, the Centers for Medicare & Medicaid Services (CMS) worked with states to test models focused on aligning the financing of the two systems and integrating primary, acute, behavioral health, and long-term services and supports for dual eligible individuals. Texas was one of thirteen states that offered this demonstration project to dual eligible individuals.166

On May 23, 2014, Texas and CMS entered a partnership to test a new model intended to better coordinate and provide a more person-centered care experience for dual eligible individuals, called “Texas Dual Eligibles Integrated Care Demonstration.” Texas and CMS contracted with managed care organizations to work toward the goal of more enhanced, coordinated system for fully dual eligible individuals who reside in specific parts of the state. The demonstration project began on April 1, 2015 and served individuals from the following counties: Bexar, Dallas, El Paso, Harris, Hidalgo, and Tarrant.167 Individuals in six demonstration counties were passively enrolled into a Medicare-Medicaid plan, following a notification process. Individuals received a letter that explained the project and identified which plans the individual would be enrolled in if there was no action was taken (known as “passive enrollment”). Each plan within the demonstration project provides the individual the full array of both Medicaid and Medicare services, including the integration of both acute care and long term services and supports.168 Figure 8 details the participating counties, with the number of individuals served and the health plans available in each county.

44 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Figure 8. Demonstration Project: County, Number Served, and Health Plans

County Number of Individuals Served Health Plans Bexar 26,452 Amerigroup, Molina, Superior Dallas 27,941 Molina, Superior El Paso 19,645 Amerigroup, Molina Harris 47,160 Amerigroup, Molina, United Hidalgo 27,090 Cigna-HealthSpring, Molina, Superior Tarrant 16,986 Amerigroup

Source: Texas Health and Human Services Commission. (2016). Texas Dual Eligible Integrated Care Project. Retrieved from https://hhs. texas.gov/services/health/medicaid-and-chip/provider-information/texas-dual-eligible-integrated-care-project Texas Environment

HHSC identified the following objectives for the project:

· Make it easier for individuals served to get care. · Promote independence in the community. · Eliminate cost shifting between Medicare and Medicaid. · Achieve cost savings for the state and federal government through improvements in care and coordination.169

Starting early 2017, the program will make a few changes related to passive enrollment and rapid re-enrollment. HHSC has announced that the program will restart monthly passive enrollment (rather than yearly enrollment) in early 2017. HHSC also announced that the program will begin rapid re-enrollment providing the option to rapidly re-enroll an individual back into their health plan if they regain Medicaid eligibility within sixty days from the effect date of disenrollment. This change allows an eligible individual who loses Medicaid, but regains eligibility quickly (no more than sixty days from the effective date of disenrollment) to be rapidly re-enrolled back into their original health plan. HHSC stated that this option would promote continuity of care for the individual and limit how many times the individual would be moved from one plan to the other.170

In September of 2015, HHSC sent a letter of intent to CMS asking to extend the demonstration for an additional two years. The original end date of the demonstration project was December 2018 but is now extended to 2020. The most up-to-date information on the Dual Eligible Integrated Care Project is available on the HHSC website at: https://hhs.texas.gov/services/health/medicaid-and-chip/ provider-information/texas-dual-eligible-integrated-care-project

Children’s Services: YES Waiver, Star-Kids, and Star-Health

Children in Texas receive a range of behavioral health services in various settings, from behavioral skills training in school classrooms and juvenile detention centers to psychiatric counseling in community-based clinics or in psychiatric hospitals. While the chapters throughout this guide will give in-depth descriptions of all the behavioral health programs and services within Texas’ state agencies, this section

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 45 will discuss three specific child mental health initiatives that are being implemented across the state:

· Youth Empowerment Services (YES) Waiver · STAR Health · STAR Kids YES Waiver

Youth Empowerment Services (YES) is a Medicaid 1915(c) home and community- based waiver program for children ages 3 to 19 years old. The goal of the YES Waiver is to reduce Medicaid psychiatric hospital expenses, voluntary parental relinquishments to obtain care, and out-of-home placement for children with serious emotional disturbance by providing a full range of Medicaid services, non-traditional services and family supports. The YES waiver program offers an alternative to inpatient treatment by providing individualized and coordinated community-based care for youth with particularly complex or severe behavioral health needs, regardless of family incomes.171 YES Waiver services are particularly effective for youth who do not respond well to Texas Environment Texas traditional outpatient services and might have better success through innovative treatments, such as intensive in-home support or specialized therapies.172

HHSC contracts with local mental health authorities (LMHAs) and other community service providers to ensure all required YES waiver services are available (e.g. case management, respite service and non-medical transportation).173 The YES Waiver program was approved for statewide expansion during the 84th legislative session (Rider 60) and as of September 2015, every LMHA in Texas is providing YES Waiver services to individuals across the state. 174,175 HHSC is currently in the process of applying a YES Waiver amendment (Amendment #9) that would make children who are in state conservatorship eligible to receive YES Waiver services. 176 Up-to-date information on the status of YES Waiver amendments can be found at https://www. dshs.texas.gov/mhsa/yes/

For more in-depth information on the YES Waiver, see the HHSC chapter in this guide. STAR Kids

STAR Kids is a new Medicaid managed care program designed specifically for children and young adults under the age of 21 who have disabilities.177 STAR Kids provides a range of services for enrollees, including acute and community-based services as well as long-term services and supports (LTSS). An essential component of the STAR Kids program is that everyone receives a standard screening assessment during enrollment and has their individualized care plan monitored and updated based on their needs and ongoing response to treatment.178 Eligibility for specific services within STAR Kids is dependent upon other services the individual receives:

· Individuals will receive basic health services and limited LTSS services through STAR Kids if they already receive Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiples Disabilities (DBMD), Home and Community-based Services (HCS), Texas Home Living (TxHml), or YES Waiver services.

46 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas · Individuals will receive basic health services and all of their LTSS services through STAR Kids if they are enrolled in the Medically Dependent Children Program (MDCP) or if they receive Social Security Income (SSI).179,180

Because it is a managed care program, STAR Kids members have the option to pick their health plan provider based on what services and providers are included in each health plan. The STAR Kids program began enrollment in Summer 2016 and started providing services to consumers on November 1, 2016. 181 STAR Health

The STAR Health program was created in 2008 to provide children in foster care with primary care and behavioral health services using a managed care delivery model.182 STAR Health requires that each child in foster care has access to Texas Environment primary care physicians, behavioral health clinicians, specialists, dentists, vision services, pharmaceuticals, and more.183 STAR Health is designed to provide more comprehensive and coordinated services by improving the continuity of care through streamlined eligibility and accessibility.

Another benefit of the STAR Health program is the “Health Passport”, which allows medical providers and certain family members to access medical and dental records for a child in foster care through one central location — https://www.fostercaretx. com/. Historically, the lack of a central medical records system for children in DFPS care created serious problems such as the over-prescription of medications or the sudden discontinuation of medications when a child’s placement changed. 184 The Health Passport follows children wherever they go so that every caregiver, DFPS staff member and medical professional working with a child has a full understanding of his or her past and current treatments and can access that information in one central, easy-to-find location. While the Health Passport is not a full and complete medical record, it provides claims data on pharmacy, dental, vision, physical, and behavioral health services provided to each child.185

Superior Health Plan contracted with the state to run STAR Health and has been operating the program since its inception.186 In FY 2014, 30,732 children were enrolled in STAR Health (including those in kinship care, foster youth up to age 22, and former foster youth receiving transitional Medicaid services).187

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 47 Endnotes 1 Legislative Budget Board. (2016). Statewide Behavioral Health Strategic Plan and Coordinated Expenditures – Overview and Funding. Retrieved from http://www.lbb.state.tx.us/Documents/Publications/Presentation/ SFC_LBB_BH_Presentation_12616.pdf 2 Hogg Foundation for Mental Health. (2015). Texas 84th Legislative Session Summary for Mental Health-Related Legislation and Sunset Recommendation Legislation. Retrieved from http://hogg.utexas.edu/public-policy/ texas-84th-legislative-session-summary 3 Texas Health and Human Services Commission, Statewide Behavioral Health Coordinating Council. (2016). Texas Statewide Behavioral Health Strategic Plan, Fiscal Years 2017-2021. Retrieved from https://hhs.texas.gov/ sites/hhs/files/050216-statewide-behavioral-health-strategic-plan.pdf 4 Silver, J. (November 9, 2015). Straus Forms Select Committee on Mental Health. The Texas Tribune. Retrieved from https://www.texastribune.org/2015/11/09/straus-forms-select-committee-mental-health/ 5 Texas Health and Human Services Commission. (n.d.). The Office of Mental Health Coordination. Retrieved from http://www.hhsc.state.tx.us/hhsc_projects/omh/index.shtml 6 Gaines, S., & Kirch, L. (February, 2016). Presentation to House Select Committee on Mental Health - Texas Health and Human Services Commission. Retrieved from http://www.hhsc.state.tx.us/news/presentations/2016/house- select-committee-mental-health-21816.pdf 7 Texas Health and Human Services Commission, Office ofental M Health Coordination. (2015). Cross-agency behavioral health initiatives. Retrieved from https://hhs.texas.gov/sites/hhs/files//documents/about-hhs/ cabhi.pdf 8 Ibid. 9 Texas Legislature Online. (2015). General Appropriations Act, House Bill 1, Conference Committee Report. Retrieved from http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017.pdf 10 Hogg Foundation for Mental Health. (2016). The Texas Mental Health Workforce: Continuing Challenges Texas Environment Texas and Sensible Strategies. Retrieved from http://hogg.utexas.edu/project/the-texas-mental-health-worforce- continuing-challenges-and-sensible-strategies 11 U.S. Department of Health and Human Services, Health Resources and Services Administration. (2015). Shortage Designation: Health Professional Shortage Areas & Medically Underserved Areas/Populations. Retrieved from http://www.hrsa.gov/shortage/ 12 U.S. Department of Health and Human Services, Health Resources and Services Administration. (2015). Health Professional Shortage Area Data Download. Retrieved from http://datawarehouse.hrsa.gov/data/datadownload/ hpsaDownload.aspx 13 Ibid. 14 North Texas Regional Extension Center. (2015). The Physician Workforce in Texas. Retrieved from http:// www.merritthawkins.com/UploadedFiles/MerrittHawkings/Surveys/Merritt_Hawkins_NTREC_Physician_ Workforce_Survey.pdf 15 Center for Health Statistics. (2015). Social Workers by County of Practice, 2015. Retrieved from http://www.dshs. state.tx.us/chs/hprc/tables/2015/15SW.aspx 16 Center for Health Statistics. (2015). Licensed Psychologists by County, 2015. Retrieved from http://www.dshs. state.tx.us/chs/hprc/tables/2015/15LP.aspx 17 Texas Medical Association. TMA 2014 Physician Survey Research Findings [Power Point Slides]. 18 Glans, M. (2014) Research and Commentary: Reimbursement Flaws in Medicaid and the ACA. The Heartland Institute. Retrieved from https://www.heartland.org/policy-documents/research-commentary- reimbursement-flaws-medicaid-and-aca 19 Statewide Health Coordinating Council. (2015). 2015-1016 Update to the State Health Plan. Retrieved from https://www.dshs.state.tx.us/chs/shcc/SHPUpdate2015.pdf 20 Ibid. 21 Ibid. 22 Statewide Health Coordinating Council. (2015). 2015-1016 Update to the State Health Plan. Retrieved from https://www.dshs.state.tx.us/chs/shcc/SHPUpdate2015.pdf 23 Hoge, M. A., Stuart, G. W., Morris, J., et al. (2013). Mental Health and Addiction Workforce Development: Federal Leadership is Needed to Address the Growing Crisis. Health Affairs. 32(11), 2005-2012. 24 Ibid. 25 Boleware, A. (2016). New Loan Repayment Program Can Help with Workforce Shortage in Texas. Retrieved from: http://hogg.utexas.edu/new-loan-repayment-program-can-help-with-workforce-shortage-in-texas 26 Nelson, K. (2016). TX Starts Loan Repayment for Mental Health Pros. Retrieved from: http://www.nbcdfw.com/ news/local/TX-Starts-Student-Loan-Repayment-for-Mental-Health-Pros-368113651.html 27 Texas Higher Education Coordinating Board. (2016). Loan Repayment Program for Mental Health Professionals. Retrieved from: http://www.hhloans.com/index.cfm?objectid=EC6C1C10-8982-11E5-A0840050560100A9 28 National Association of Social Workers – Texas Chapter. (2016, October 11) Personal communication: THECB Loan Repayment Program. 29 U.S. Department of Health & Human Services Centers for Medicare and Medicaid Services (August 2007). State Medicaid Director Letter #07-011. 30 Chinman, M., et al. (2013). Peer support services for individuals with serious mental illness: Assessing the evidence. 31 Chinman, M., et al. (2013). Peer support services for individuals with serious mental illness: Assessing the evidence. 32 Velicer,C. (2013). Mental health peer support: effectiveness and cost-effectiveness. American Academy of Family Physicians Foundation. Retrieved at http://peersforprogress.org/pfp_idea_exchange/mental-health-peer-

48 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas support-effective-and-cost-effective 33 Missouri Institute of Mental Health. (2009). Federal Multisite Study Finds Consumer-Operated Service Programs Are Evidence-Based Practices. 7. Retrieved from http://cosp.mimhtraining.com/2010/12/federal-multi-site- study-finds-consumer-operated-service-programs-are-evidence-based-practices/ 34 Chinman, M., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Swift, A., & Delphinn-Rittmon, M. E. (2014). Peer Support Services for Individuals with Serious Mental Illness: Assessing the Evidence. Psychiatric Services. 65(4), 429-441. Retrieved from http://ps.psychiatryonline.org/article.aspx?articleID=1832833 35 Texas Institute for Excellence in Mental Health, University of Texas Center for Social Work Research. (2015). Survey of Peer Specialist Workforce in Texas. Pg. 17. 36 Department of State Health Services. (2015). Mental Health and Substance Abuse Peer Specialists, Recovery Coaches and Recovery Oriented Programming: A Brief Overview. Pg. 14. 37 Via Hope. (n.d.). Peer Specialist Training and Certification. Retrieved from http://www.viahope.org/programs/ peer-specialist-training-and-certification/ 38 Ibid. 39 Via Hope. (2016, July). Personal communication: Peer support certification and endorsement trainings. 40 Via Hope. (2016, September 23). Personal communication: number of peer support specialists and recovery coaches. 41 Department of State Health Services. (2016, July 25). Personal communication: Recovery coach training Texas Environment curriculum. 42 Ibid. 43 Ibid. 44 Ibid. 45 Urban Institute Justice Policy Center. (2008). Health and Prisoner Re-Entry: How Physical, Mental, and Substance Abuse Conditions Shape the Process of Reintegration. Pg. 34-43. Retrieved from http://www.urban.org/ sites/default/files/alfresco/publication-pdfs/411617-Health-and-Prisoner-Reentry.PDF 46 Center for Public Policy Priorities. (2014, August). From Recidivism to Recovery: The Case for Peer Support in Texas Correctional Facilities. Pg. 13. Retrieved from http://forabettertexas.org/images/HC_2014_07_RE_ PeerSupport.pdf 47 Texas Department of Insurance. (2016). House Select Committee on Mental Health Hearing, June 2, 2016. [PowerPoint slides]. Slide 20. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/ C3822016060210001/33e37642-44b1-4640-9896-e43f8e1c8be2.PDF 48 Texas Department of Insurance. (2016). House Select Committee on Mental Health Hearing, June 2, 2016. [PowerPoint slides]. Slide 25. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/ C3822016060210001/33e37642-44b1-4640-9896-e43f8e1c8be2.PDF 49 Texas Department of Insurance. (2016). House Select Committee on Mental Health Hearing, June 2, 2016. [PowerPoint slides]. Slide 26. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/ C3822016060210001/33e37642-44b1-4640-9896-e43f8e1c8be2.PDF 50 Ibid. 51 National Alliance on Mental Illness. (2015). A Long Road Ahead- Achieving True Parity in Mental Health and Substance Use Care. Retrieved from https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy- Reports/A-Long-Road-Ahead/2015-ALongRoadAhead.pdf 52 Ibid. 53 Texas Department of Insurance. (2016). House Select Committee on Mental Health Hearing, June 2, 2016. [PowerPoint slides]. Slide 10. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/ C3822016060210001/33e37642-44b1-4640-9896-e43f8e1c8be2.PDF 54 Garrett, R. T. (March 21, 2016). Federal judge picks ‘best of the best’ to help her overhaul Texas foster care. Dallas Morning News. Retrieved from http://trailblazersblog.dallasnews.com/2016/03/federal-judge-picks- best-of-the-best-to-help-her-overhaul-texas-foster-care.html/ 55 Kelly, J. (December 18, 2015). Texas Loses Child Welfare Lawsuit to Children’s Rights. Chronicle of Social Change. Retrieved from https://chronicleofsocialchange.org/featured/texas-loses-child-welfare-lawsuit-to- childrens-rights/14892 56 Children’s Rights. (n.d.) Class Actions, TX – M.D. v. Abbott. Retrieved from http://www.childrensrights.org/ class_action/texas/ 57 Ibid. 58 Kelly, J. (December 18, 2015). Texas Loses Child Welfare Lawsuit to Children’s Rights. Chronicle of Social Change. Retrieved from https://chronicleofsocialchange.org/featured/texas-loses-child-welfare-lawsuit-to- childrens-rights/14892 59 Tinsley, A. M. (April 12, 2016). More must be done to protect Texas children, lawmakers demand. The Fort Worth Star Telegram. Retrieved from http://www.star-telegram.com/news/politics-government/state-politics/ article71413677.html 60 Walters, E. (2016). Texas’ Foster Care System Faces $40M Shortfall. The Texas Tribune. Retrieved from http:// www.governing.com/topics/health-human-services/tt-texas-foster-care-system-faces-40-million-shortfall. html 61 Walters, E. (March 17, 2016). More Kids Sleeping in State Offices Amid Foster Shortage. The Texas Tribune. Retrieved from https://www.texastribune.org/2016/03/17/more-kids-sleeping-cps-offices-amid-placement- shor/ 62 Texas Tribune. (2015). Civil Action No. 2:11-CV-84. Pg. 243. Retrieved from https://static.texastribune.org/

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 49 media/documents/2015.12.17_Opinion.pdf 63 Texas Tribune. (2015). Civil Action No. 2:11-CV-84. Pg. 244. Retrieved from https://static.texastribune.org/ media/documents/2015.12.17_Opinion.pdf 64 Garrett, R. T. (March 21, 2016). Federal judge picks ‘best of the best’ to help her overhaul Texas foster care. Dallas Morning News. Retrieved from http://trailblazersblog.dallasnews.com/2016/03/federal-judge-picks-best-of- the-best-to-help-her-overhaul-texas-foster-care.html/ 65 Garrett, R. T. (March 21, 2016). Federal judge picks ‘best of the best’ to help her overhaul Texas foster care. Dallas Morning News. Retrieved from http://trailblazersblog.dallasnews.com/2016/03/federal-judge-picks-best-of- the-best-to-help-her-overhaul-texas-foster-care.html/ 66 Garrett, R. T. (March 21, 2016). Federal judge picks ‘best of the best’ to help her overhaul Texas foster care. Dallas Morning News. Retrieved from http://trailblazersblog.dallasnews.com/2016/03/federal-judge-picks-best-of- the-best-to-help-her-overhaul-texas-foster-care.html/ 67 Garrett, R. T. (April 12, 2016). As more CPS bigwigs quit, Texas house speaker Joe Straus vows to better protect abused kids. Dallas Morning News. Retrieved from http://trailblazersblog.dallasnews.com/2016/04/as-more- cps-bigwigs-quit-texas-house-speaker-joe-straus-vows-to-better-protect-abused-kids.html/ 68 Walters, E. & Ramshaw, E. (December 17, 2015). Judge: Foster Care System Violates Children’s Rights. The Texas Tribune. Retrieved from https://www.texastribune.org/2015/12/17/judge-foster-care-system-violates- childrens-rights/ 69 Walters, E. & Ramshaw, E. (December 17, 2015). Judge: Foster Care System Violates Children’s Rights. The Texas Tribune. Retrieved from https://www.texastribune.org/2015/12/17/judge-foster-care-system-violates- childrens-rights/ 70 Walters, E. & Ramshaw, E. (December 17, 2015). Judge: Foster Care System Violates Children’s Rights. The Texas Tribune. Retrieved from https://www.texastribune.org/2015/12/17/judge-foster-care-system-violates- childrens-rights/ Texas Environment Texas 71 Social Work Policy Institute. (2010). High caseloads: How do they impact delivery of health and human services? Retrieved from http://www.socialworkpolicy.org/wp-content/uploads/2010/02/r2p-cw-caseload-swpi-1-10.pdf 72 Keel, J. (2013). An audit report on caseload and staffing analysis for Child Protective Services at the Department of Family and Protective Services (State Auditor’s Office Report No. 13-036). Retrieved from http://www.sao.state. tx.us/reports/main/13-036.pdf 73 Walters, E. (March 9, 2016). Texas Caseworkers Call For Foster Care Reforms. The Texas Tribune. Retrieved from https://www.texastribune.org/2016/03/09/texas-caseworkers-call-foster-care-reforms/ 74 Eiserer, T. (June 7, 2016). CPS workers share what drove them to leave their jobs. KHOU. Retrieved from http:// www.khou.com/news/local/texas/cps-workers-share-what-drove-them-to-leave-their-jobs/235365971 75 Eiserer, T. (June 7, 2016). CPS workers share what drove them to leave their jobs. KHOU. Retrieved from http:// www.khou.com/news/local/texas/cps-workers-share-what-drove-them-to-leave-their-jobs/235365971 76 Garrett, R. T. (May 27, 2016). CPS clarifies rule: New caseworkers in Texas must have at least 2-year degree. Dallas Morning News. Retrieved from http://trailblazersblog.dallasnews.com/2016/05/cps-clarifies-rule-new- caseworkers-in-texas-must-have-at-least-two-year-degree.html/ 77 Substance Abuse and Mental Health Services Administration. (n.d.) What is Integrated Care? Retrieved from http://www.integration.samhsa.gov/about-us/what-is-integrated-care 78 Ibid. 79 Ibid. 80 Agency for Healthcare Research and Quality. (n.d.) The Definition of Integrated Behavioral Health Care. Retrieved from https://integrationacademy.ahrq.gov/resources/ibhc-measures-atlas/what-integrated- behavioral-health-care-ibhc 81 Texas Health and Human Services Commission. (2010). Texas Boarding House Model Standards. Retrieved from http://www.hhsc.state.tx.us/boardinghousemodelstandards.pdf. 82 Texas Department of Aging and Disability Services. (2014). Boarding Home Facilities: Report to the Texas Legislature. Retrieved from http://www.dads.state.tx.us/news_info/publications/legislative/ boardinghomefaciliities-dec2014.pdf. 83 Texas House of Representatives. (2015). Interim committee charges, 31, 59. Retrieved from http://www.house. state.tx.us/_media/pdf/interim-charges-84th.pdf. 84 National Association of State Directors of Developmental Disability Services (NASDDDS), Human Services Research Institute (HSRI). (2015). National Core Indicators, 2015. 85 Davis, E., Saeed, S., and Antonacci, D. (2008). Anxiety disorders in persons with developmental disabilities: Empirically informed diagnosis and treatment. Psychiatric Quarterly, 79 249-263. 86 Cooper, S.A., et al. (2007). Mental ill-health in adults with intellectual disabilities: prevalence and associated factors. The British Journal of Psychiatry. 2007, 190(1): p. 27-35. 87 Mevissen, L., deJongh, A. (2010). PTSD and its treatment in people with intellectual disabilities: A review of the literature. Clinical Psychology Review, 30 (2010) 308-316. 88 Texas Sunset Advisory Commission. (2015). Report to the 84th Legislature. Retrieved from https://www.sunset. texas.gov/public/uploads/u64/Report%20to%20the%2084th%20Legislature.pdf 89 Ibid. 90 Texas Legislature Online. (2015). Senate Bill 200. Retrieved from http://www.capitol.state.tx.us/BillLookup/ History.aspx?LegSess=84R&Bill=SB200 91 Ibid. 92 Texas Health and Human Services Commission. (2016). Health and Human Services system transition

50 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas plan. Retrieved from https://hhs.texas.gov/sites/hhs/files/documents/about-hhs/transformation/final- transformation-plan.pdf 93 Texas Health and Human Services Commission. (2016). Health and Human Services system transition plan, 1-2. Retrieved from https://hhs.texas.gov/sites/hhs/files/documents/about-hhs/transformation/final- transformation-plan.pdf 94 Ibid. 95 Texas Health and Human Services Commission. (2015). Texas Medicaid and CHIP in perspective tenth edition, 7-11 to 7-13. Retrieved from http://www.hhsc.state.tx.us/medicaid/about/PB/PinkBook.pdf 96 Sunset Advisory Commission. (2015). Report to the 84th Legislature, 17-18. Retrieved from https://www.sunset. texas.gov/public/uploads/u64/Report%20to%20the%2084th%20Legislature.pdf 97 Texas House Research Organization. (2015). Bill analysis: SB 200, Nelson et al. (Price et al.). Retrieved at http:// www.hro.house.state.tx.us/pdf/ba84R/SB0200.pdf 98 Sunset Advisory Commission. (2015). Report to the 84th Legislature. Pg. 122-123. Retrieved from https://www. sunset.texas.gov/public/uploads/u64/Report%20to%20the%2084th%20Legislature.pdf; Texas Health and Human Services Commission. (2016). Personal communication. 99 Texas Health and Human Services Commission. (2016). Personal communication. 100 Texas Health and Human Services Commission. (2016). Personal communication; North Texas Behavioral Health Authority. (2016). Local plan for indigent behavioral health services. Retrieved from http://www.ntbha. Texas Environment org/docs/NTBHA_IBH_Revised_Plan_Submission_1-15-16.pdf; Collin County, Texas & LifePath Systems. (2015). Local plan for indigent behavioral health services. Retrieved from http://www.lifepathsystems.org/wp- content/uploads/2016/04/CollinCo_FinalLocalPlan_NStransition_9-30-15-Complete.pdf 101 Texas Health and Human Services Commission. (September, 2015). Status update on the reorganization of the Health and Human Services system. Retrieved from http://www.hhsc.state.tx.us/news/meetings/2015/ mcac/091815/5.pdf 102 Texas Health and Human Services Commission. (2016). Health and Human Services system transition plan. Pg. 53. Retrieved from http://www.hhsc.state.tx.us/hhs-transformation/ 103 Texas Health and Human Services Commission. (2016). Behavioral Health Advisory Committee. Retrieved from http://www.hhsc.state.tx.us/about_hhsc/AdvisoryCommittees/bhac/index.shtml. 104 Texas Department of State Health Services. (2016, October 11). Personal Communication: Forensic Waitlist. 105 Legislative Budget Board. (2016). State Hospitals: Mental Health Facilities in Texas. Retrieved from http://www. lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospitals-Mental_Health_Facilities_in_Texas_ Diehl.pdf 106 Texas Legislature Online. (2015). Senate Bill 200. Retrieved from http://www.capitol.state.tx.us/BillLookup/ History.aspx?LegSess=84R&Bill=SB200 107 Health and Human Services Commission, Behavioral Health Advisory Committee, Retrieved from https://hhs. texas.gov/about-hhs/leadership/advisory-committees/behavioral-health-advisory-committee 108 Texas Health and Human Services Commission. (September 30, 2015). Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver Extension Application. Page 4. Retrieved from: https://hhs.texas.gov/sites/hhs/files//documents/laws-regulations/policies-rules/1115-docs/101415/TX%20 1115_ExtApp2015_AttachD_corrected.pdf 109 Texas Health and Human Services Commission. (August 27, 2015). Texas DSRIP Program Learning Together Today and Looking Forward. Retrieved from http://www.hhsc.state.tx.us/1115-docs/082615/DSRIP_Progress. pdf 110 Texas Health and Human Services Commission. (September 30, 2015). Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver Extension Application. Page 4. Retrieved from: https://hhs.texas.gov/sites/hhs/files//documents/laws-regulations/policies-rules/1115-docs/101415/TX%20 1115_ExtApp2015_AttachD_corrected.pdf 111 Traylor, C. (May 16, 2016). Presentation to the House County Affairs Committee: Texas 1115 Transformation Waiver Extension Update [PowerPoint slides]. Texas Health and Human Services Commission. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/C2102016051610001/9715550e-bc29-46c4-99d8- 15d4a1a54150.PDF 112 Traylor, C. (May 16, 2016). Presentation to the House County Affairs Committee: Texas 1115 Transformation Waiver Extension Update [PowerPoint slides]. Texas Health and Human Services Commission. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/C2102016051610001/9715550e-bc29-46c4-99d8- 15d4a1a54150.PDF 113 Center for Medicare & Medicaid Services. (May 1, 2016). Texas 1115 Waiver Approval Letter. Retrieved from http://www.hhsc.state.tx.us/1115-docs/050216/TX-Waiver-Approval-Letter_%2020160501.pdf 114 Sorrel, A. L. (October 2015). 1115 Medicaid Waiver Up for Renewal: Lack of Medicaid Expansion and Physician Involvement Poses Stumbling Blocks. Texas Medical Association. Retrieved from https://www.texmed.org/ MedicaidWaiverUpForRenewal/ 115 Texas Health and Human Services Commission. (September 30, 2015). Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver Extension Application. Page 30. Retrieved from: https://hhs.texas.gov/sites/hhs/files//documents/laws-regulations/policies-rules/1115-docs/101415/ TX%201115_ExtApp2015_AttachD_corrected.pdf 116 Center for Public Policy Priorities. (March 14, 2016). Numerous Groups tell Federal Officials that Texas Needs to Close the Health Care Coverage Gap: Analysis of public comments on the Texas Medicaid ‘1115’ waiver shows strong demand for expanded health care. Retrieved from http://forabettertexas.org/images/HW_2016_

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 51 Comments_1115Waiver.pdf 117 Traylor, C. (May 16, 2016). Presentation to the House County Affairs Committee: Texas 1115 Transformation Waiver Extension Update [PowerPoint slides]. Texas Health and Human Services Commission. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/C2102016051610001/9715550e-bc29-46c4-99d8- 15d4a1a54150.PDF 118 Traylor, C. (May 16, 2016). Presentation to the House County Affairs Committee: Texas 1115 Transformation Waiver Extension Update [PowerPoint slides]. Texas Health and Human Services Commission. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/C2102016051610001/9715550e-bc29-46c4-99d8- 15d4a1a54150.PDF 119 Texas Health and Human Services Commission. (September 2015). Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver Extension Application. Pages 20, 49-50. Retrieved from: https://hhs.texas.gov/sites/hhs/files//documents/laws-regulations/policies-rules/1115- docs/101415/TX%201115_ExtApp2015_AttachD_corrected.pdf 120 Texas Health and Human Services Commission. (September 2015). Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver Extension Application. Page 17. Retrieved from: https://hhs.texas.gov/sites/hhs/files//documents/laws-regulations/policies-rules/1115-docs/101415/ TX%201115_ExtApp2015_AttachD_corrected.pdf 121 Texas Health and Human Services Commission. (September 2015). Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver Extension Application. Pages 17-18. Retrieved from: https://hhs.texas.gov/sites/hhs/files//documents/laws-regulations/policies-rules/1115-docs/101415/ TX%201115_ExtApp2015_AttachD_corrected.pdf 122 Texas Health and Human Services Commission. (September 2015). Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver Extension Application. Page 18. Retrieved from: https://hhs.texas.gov/sites/hhs/files//documents/laws-regulations/policies-rules/1115-docs/101415/ Texas Environment Texas TX%201115_ExtApp2015_AttachD_corrected.pdf 123 Texas Health and Human Services Commission. (May 2016). Texas Statewide Behavioral Health Strategic Plan: Fiscal Years 2017-2021. Pages 18-19. Retrieved from http://www.hhsc.state.tx.us/reports/2016/050216- statewide-behavioral-health-strategic-plan.pdf 124 Texas Department of State Health Services and Texas Health and Human Services Commission. (March 2016). Children’s Mental Health Services: Presentation to the House Select Committee on Mental Health. Retrieved from http://webcache.googleusercontent.com/search?q=cache:RFfWQw0TrBwJ:www.dshs.state.tx.us/legislative/ docs/House_Select_Committee_on_Mental_Health_%25203-22.pdf+&cd=1&hl=en&ct=clnk&gl=us 125 Texas Health and Human Services Commission. (April 27, 2016). Presentation to the House Select Committee on Mental Health: Medicaid 1115 Transformation Waiver [PowerPoint slides]. Retrieved from http://www.legis. state.tx.us/tlodocs/84R/handouts/C3822016042710001/d4ecf5cd-6e2a-43ed-9e21-2d5909a6c2a6.PDF 126 Kirsch, L. & Lacefield Lewis, L. (June 16, 2014). Presentation to the House Appropriations Article II Subcommittee: Behavioral Healthcare Projects in the 1115 Waiver [PowerPoint slides]. Retrieved from http:// www.hhsc.state.tx.us/news/presentations/2014/House-Appropriations-Committe-DSRIP-BH.pdf 127 Lacefield Lewis, L. & Jessee, G. (March 22, 2016). Presentation to the House Select Committee on Mental Health: Children’s Mental Health Services [PowerPoint slides]. Texas Department of State Health Services and Texas Health and Human Services Commission. Retrieved from https://dshs.texas.gov/WorkArea/linkit. aspx?LinkIdentifier=id&ItemID=8590006580 128 Lacefield Lewis, L. & Jessee, G. (March 22, 2016). Presentation to the House Select Committee on Mental Health: Children’s Mental Health Services [PowerPoint slides]. Texas Department of State Health Services and Texas Health and Human Services Commission. Retrieved from: https://dshs.texas.gov/WorkArea/linkit. aspx?LinkIdentifier=id&ItemID=8590006580 129 Texas Department of State Health Services. (January 2016). Mental Health Appropriations and the 1115 Texas Medicaid Transformation Waiver. Retrieved from http://www.dshs.state.tx.us/legislative/ docs/2016reports/Mental%20Health%20Appropriations%20and%20the%201115%20Texas%20Medicaid%20 Transformation%20Waiver.pdf 130 Khalsa, A. (April 17, 2016). Presentation to the House Select Committee on Mental Health: Medicaid 1115 Transformation Waiver [PowerPoint slides]. Texas Health and Human Services Commission. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016042710001/d4ecf5cd-6e2a-43ed-9e21- 2d5909a6c2a6.PDF 131 Center for Public Policy Priorities. (July 2015). Made for Each Other: A Coverage Plan is Texas’ Best Bet to Maximize Medicaid 1115 Waiver Renewal. Retrieved from http://forabettertexas.org/images/HW_2015_07_ MedicaidWaiver.pdf 132 Center for Public Policy Priorities. (March 14, 2016). Detailed Updates on the Texas Medicaid 1115 Waiver Renewal and the Health Care Coverage Gap. Retrieved from http://forabettertexas.org/images/HW_2016_ PP_1115WaiverAndtheCoverageGap.pdf 133 Texas Department of State Health Services. (January 2016). Mental Health Appropriations and the 1115 Texas Medicaid Transformation Waiver. Retrieved from http://www.dshs.state.tx.us/legislative/ docs/2016reports/Mental%20Health%20Appropriations%20and%20the%201115%20Texas%20Medicaid%20 Transformation%20Waiver.pdf 134 Texas Legislative Budget Board. (January 2016). Overview of Texas Healthcare Transformation Waiver [PowerPoint slides]. Retrieved from http://www.lbb.state.tx.us/Documents/Publications/Presentation/LBB_ Supplemental_info_DSHS_1115_Waiver.pdf

52 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 135 Texas Health and Human Services Commission. (April 7, 2016). Initial 1115 Extension Request to CMS. Retrieved from http://www.hhsc.state.tx.us/1115-docs/041516/Initial-1115-Extension-Request-to-CMS.pdf 136 Traylor, C. (May 16, 2016). Presentation to the House County Affairs Committee: Texas 1115 Transformation Waiver Extension Update [PowerPoint slides]. Texas Health and Human Services Commission. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/C2102016051610001/9715550e-bc29-46c4-99d8- 15d4a1a54150.PDF 137 Center for Medicare & Medicaid Services. (May 1, 2016). Texas 1115 Waiver Approval Letter. Retrieved from http://www.hhsc.state.tx.us/1115-docs/050216/TX-Waiver-Approval-Letter_%2020160501.pdf 138 Kirsch, L. & Lacefield Lewis, L. (June 16, 2014). Presentation to the House Appropriations Article II Subcommittee: Behavioral Healthcare Projects in the 1115 Waiver [PowerPoint slides]. Retrieved from http:// www.hhsc.state.tx.us/news/presentations/2014/House-Appropriations-Committe-DSRIP-BH.pdf 139 Texas Health and Human Services Commission. (September 30, 2015). Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver Extension Application. Page 57. Retrieved from: http://www.hhsc.state.tx.us/1115-docs/101415/TX%201115_ExtApp2015_AttachD_corrected.pdf 140 Texas Health and Human Services Commission and the Statewide Learning Collaborative. (2014). 20 Regional Healthcare Partnerships: Collaboration and Innovation [PowerPoint slides]. Retrieved from http://www.hhsc. state.tx.us/1115-docs/RHP-Snapshot-HHSC-SLC-2014.pdf 141 Texas Health and Human Services Commission. (May 2016). Texas Statewide Behavioral Health Strategic Texas Environment Plan: Fiscal Years 2017-2021. Pages 15-16. Retrieved from http://www.hhsc.state.tx.us/reports/2016/050216- statewide-behavioral-health-strategic-plan.pdf 142 Traylor, C. (May 16, 2016). Presentation to the House County Affairs Committee: Texas 1115 Transformation Waiver Extension Update [PowerPoint slides]. Texas Health and Human Services Commission. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/C2102016051610001/9715550e-bc29-46c4-99d8- 15d4a1a54150.PDF 143 Texas Council of Community Centers. (February 18, 2016). Presentation to the Select Committee on Mental Health [PowerPoint slides]. Retrieved from http://www.legis.state.tx.us/tlodocs/84R/handouts/ C3822016021810001/3ea17faa-4c5b-4a15-9b2d-5af88e9cd4a9.PDF 144 Texas Health and Human Services Commission. (September 30, 2015). Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver Extension Application. Pg 7. Retrieved from http://www.hhsc.state.tx.us/1115-docs/101415/TX%201115_ExtApp2015_AttachD_corrected.pdf 145 Texas Health and Human Services Commission. (September 30, 2015). Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver Extension Application. Pg. 49-50. Retrieved from http://www.hhsc.state.tx.us/1115-docs/101415/TX%201115_ExtApp2015_AttachD_corrected.pdf 146 Texas Health and Human Services Commission. (September 30, 2015). Texas Healthcare Transformation and Quality Improvement Program Section 1115 Demonstration Waiver Extension Application. Pg. 49-50. Retrieved from http://www.hhsc.state.tx.us/1115-docs/101415/TX%201115_ExtApp2015_AttachD_corrected.pdf 147 Center for Medicare & Medicaid Services. (May 1, 2016). Texas 1115 Waiver Approval Letter. Retrieved from http://www.hhsc.state.tx.us/1115-docs/050216/TX-Waiver-Approval-Letter_%2020160501.pdf 148 Telligen Health Information Technology Regional Extension Center and Great Plains Telehealth Resource and Assistance Center. (2014). Telehealth Start-Up and Resource Guide Version 1.1. Retrieved from http://healthit. gov/sites/default/files/telehealthguide_final_0.pdf. 149 Texas Medicaid and Healthcare Partnership. (2015). Texas Medicaid Provider Procedures Manual Volume 2: Provider Telecommunications Service Handbook. Retrieved from http://www.tmhp.com/tmppm/tmppm_living_ manual_current/Vol2_Telecommunication_Services_Handbook.pdf 150 Texas Government Code, Title 4, Subtitle I, Chapter 531: Health and Human Services Commission, Subchapter A, Section 531.001: Definitions. (2015). Retrieved from http://www.statutes.legis.state.tx.us/Docs/GV/htm/ GV.531.htm 151 Texas Medicaid and Healthcare Partnership. (2015). Texas Medicaid Provider Procedures Manual Volume 2: Provider Telecommunications Service Handbook. 152 Texas Legislature Online. (1995). Senate Bill 673. Retrieved from http://www.capitol.state.tx.us/BillLookup/ History.aspx?LegSess=74R&Bill=SB673. 153 Texas Legislature Online. (2015). House Bill 1878. Retrieved from http://www.capitol.state.tx.us/BillLookup/ History.aspx?LegSess=84R&Bill=HB1878 154 Texas Legislature Online. (2015). Senate Bill 200. Retrieved from http://www.capitol.state.tx.us/BillLookup/ History.aspx?LegSess=84R&Bill=SB200 155 Texas Legislature Online. (2015). House Bill 2641. Retrieved from http://www.capitol.state.tx.us/BillLookup/ History.aspx?LegSess=84R&Bill=HB2641 156 Centers for Medicare and Medicaid Services. (2015). Telemedicine. Retrieved from http://www.medicaid.gov/ Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html. 157 American Academy of Pediatrics. (2015). The Use of Telemedicine to Address Access and Physician Workforce Shortages. Retrieved from http://pediatrics.aappublications.org/content/early/2015/06/23/peds.2015-1253 158 Anouk L. Grubaugh, Gregory D. Cain, Jon D. Elhai, Sarah L. Patrick, and B. Christopher Frueh. (2008). Attitudes toward medical and mental health care delivered via telehealth applications among rural and urban primary care patients. The Journal of Nervous and Mental Disease, 196, no. 2. Retrieved from http://goo.gl/4krjxk. 159 Wilson, J. A. B. and Schild, S. (2014). Provision of mental health care services to deaf individuals using telehealth. Professional Psychology: Research and Practice 45, no. 5. Retrieved from http://goo.gl/c3YFTD. 160 Rimsza, M. E., Hotaling, A. J., Keown, M. E., Marcin J. P., Moskowitz, W. B., Sigrest, T. D., and Simon, H. K. (2015).

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 53 The Use of Telemedicine to Address Access and Physician Workforce Shortages. Pediatrics 136, no. 1. Pg. 202-209. Retrieved from http://pediatrics.aappublications.org/content/pediatrics/136/1/202.full.pdf. 161 Terry, K. (2015). Federal Judge Blocks Texas Rule Restricting Telemedicine. Medscape Medical News. Retrieved from http://www.medscape.com/viewarticle/845772. 162 Schencker, L. (2015). Judge allows Teladoc lawsuit against Texas Medical Board to proceed. Modern Healthcare. Retrieved from http://www.modernhealthcare.com/article/20151214/NEWS/151219924. 163 Walter, E. (September 10, 2016). Federal Regulators Take Teladoc’s Side in Medical Board Suit. Texas Tribune. Retrieved from https://www.texastribune.org/2016/09/10/federal-regulators-take-teladocs-side-medical- boar/?utm_source=Texas+Tribune+Master&utm_campaign=bbd6154f03-trib-newsletters-rss&utm_ medium=email&utm_term=0_d9a68d8efc-bbd6154f03-101186413&mc_cid=bbd6154f03&mc_eid=9b6cbca62b 164 Ibid. 165 Ibid. 166 Texas Health and Human Services Commission. (2016, September 16). Personal Communication: Texas Dual Eligible Integrated Care Project. 167 Texas Health and Human Services Commission. (2016). Texas Dual Eligible Integrated Care Project. Retrieved from https://hhs.texas.gov/services/health/medicaid-and-chip/provider-information/texas-dual-eligible- integrated-care-project 168 Ibid. 169 Ibid. 170 Texas Health and Human Services Commission. (2016, September 16). Personal Communication: Texas Dual Eligible Integrated Care Project. 171 Texas Health and Human Services Commission. (July 8, 2010). Youth Empowerment Services: A Medicaid Waiver Program for Children with Severe Emotional Disturbance. Retrieved from https://www.hhsc.state.tx.us/crcg/ InformationForLocalCRCGs/docs/YES_Overview.pdf Texas Environment Texas 172 Gaines. S. (February 18, 2016). Testimony to the Select Committee on Mental Health: 41:20. Retrieved from http:// tlchouse.granicus.com/MediaPlayer.php?view_id=37&clip_id=11770 173 Texas Department of State Health Services. (2016). Youth Empowerment Services (YES) Waiver: A Medicaid Waiver Program For Children with Severe Emotional Disorders. Retrieved from http://texanscareforchildren. org/Images/Interior/mh%20forum/yes%20waiver.pdf 174 Hogg Foundation for Mental Health. (June 22, 2015). Texas 84th Legislative Session Summary for Mental Health-Related Legislation. Retrieved from http://hogg.utexas.edu/wp-content/uploads/2015/11/Legislative- Summary_Final_2015.docx 175 Texas Department of State Health Services. (June 28, 2016). Personal communication: YES Waiver program at the Texas Department of State Health Services. 176 Ibid. 177 Texas Health and Human Services Commission. (2016). STAR Kids. Retrieved from https://hhs.texas.gov/ services/health/medicaid-and-chip/programs/star-kids 178 Texas Health and Human Services Commission. (2016). STAR Kids. Retrieved from https://hhs.texas.gov/ services/health/medicaid-and-chip/programs/star-kids 179 Texas Health and Human Services Commission. (2016). STAR Kids. Retrieved from https://hhs.texas.gov/ services/health/medicaid-and-chip/programs/star-kids 180 Coalition of Texans with Disabilities. (2016). STAR Kids: A new Medicaid Managed Care Program. Retrieved from http://www.txdisabilities.org/star-kids 181 Texas Health and Human Services Commission. (2016). STAR Kids. Retrieved from https://hhs.texas.gov/ services/health/medicaid-and-chip/programs/star-kids 182 Texas Department of Family and Protective Services. (n.d.). STAR Health – a guide to medical services at CPS. Retrieved from http://www.dfps.state.tx.us/Child_Protection/Medical_Services/guide-star.asp 183 Superior Health Plan. (2014). Welcome to STAR Health. Retrieved from http://www.superiorhealthplan.com/ for-members/programs/star-health/ 184 Texas Department of Family and Protective Services. (n.d.) Health Passport - A Guide to Medical Services at CPS. Retrieved from https://www.dfps.state.tx.us/Child_Protection/Medical_Services/guide-passport.asp 185 Texas Health and Human Services Commission. (n.d.) About Medicaid, Chapter 7: Medicaid Managed Care. Retrieved from https://www.hhsc.state.tx.us/medicaid/about/PB/Chapter7.pdf 186 Texas Department of Family and Protective Services. (n.d.) STAR Health — A Guide to Medical Services at CPS. Retrieved from https://www.dfps.state.tx.us/Child_Protection/Medical_Services/guide-star.asp#glance 187 Texas Health and Human Services Commission. (2015). Texas Medicaid and CHIP In Perspective, Tenth Edition. Retrieved from http://www.hhsc.state.tx.us/medicaid/about/PB/PinkBook.pdf

54 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas National Context

A national paradigm shift is underway to transform behavioral health delivery systems. Policy decisions made at the federal level have significant impact on programs and services in Texas. Initiatives at the federal level are impacted by key federal agencies such as the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Medicare and Medicaid Services (CMS). Both SAMHSA and CMS are increasingly focused on emphasizing recovery, wellness and self-directed care in behavioral health care. This broad change in treatment strategy offers a new approach to behavioral health that is designed to provide the right care at the right time and in the right setting.

The National Context section of this guide focuses on analyzing select bills and

issues that are being discussed or implemented at the national level and have a direct National Context impact on behavioral health systems and services in Texas.

SAMHSA

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services charged with advancing behavioral health and reducing the impact of substance use and mental illness throughout the nation.

SAMSHA also retains the responsibility for administering a combination of competitive innovation mental health and substance use grants and block grants to states, as well as collecting data, conducting and publishing research, and running a variety of behavioral health programs and campaigns. For more information about SAMHSA’s publications, grants and resources, visit www.samhsa.gov/home.com.

The Helping Families in Mental Health Crisis Act – H.R. 2646

Rep. Tim Murphy (R-Pa) and bill co-sponsor Rep. Eddie Bernice Johnson (D-Tx) introduced the Helping Families in Mental Health Crisis Act (H.R. 2646) to the House of Representatives in June 2016. (Note: The Helping Families in Mental Health Crisis Act is an updated version of H.R. 3717, a bill with the same name as

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 55 H.R. 2646 and introduced by Rep. Murphy in December 2013).2 The legislation gained widespread bipartisan support in the House, culminating in 207 co-sponsors and a near unanimous passage of the bill (422-2) in July 2016. The future of the Helping Families in Mental Health Crisis Act is still uncertain and dependent on passage by the Senate, but the bill’s strong bipartisan support in the House has given hope to Rep. Murphy (R-Pa) and the bill’s other supporters.3

The full text of the bill is over 150 pages and can be found at the following link: https://www.congress.gov/bill/114th-congress/house-bill/2646/text

H.R. 2646, as passed by the House, includes (but is not limited to) the following components: · Establishes a new position within SAMHSA (Assistant Secretary for Mental Health and Substance Use) to take over the duties of SAMHSA’s Administrator · Requires grant recipients to use evidence-based practices · Mandates congressional oversight of all federal behavioral health grants · Creates an interdepartmental branch in SAMHSA that focuses on mental health · Increases alternatives for diverting individuals from institutionalized settings (e.g. diversion from jail, emergency rooms, psychiatric hospitals) · Increases psychiatric inpatient bed capacity · Expands crisis intervention training (CIT) for law enforcement personnel · Reduces HIPAA restrictions on the sharing of protected health information during crises · Opens Medicaid and Medicare incentive funds for peer supports and the meaningful use of electronic health records in behavioral health settings · Expands telemedicine services for rural and underserved populations · Promotes integrating mental health treatment with primary health care · Clarifies mental health parity laws and strengthens enforcement of parity · Increases funding for critical neuroscience research into the underlying causes of mental health and the efficacy of early intervention programs4,5,6

While H.R. 2646 has received widespread support from some behavioral health organizations and professional groups, many civil rights and patient advocacy groups — for example, the American Civil Liberties Union (ACLU) and the American Association for People with Disabilities (AAPD) — have expressed concerns over certain parts of the bill.7 Some of those concerns include:

· New requirements that may increase the number of involuntary outpatient commitments through the expanded use of “Assertive Outpatient Treatment” (AOT) programs · Reduced privacy protections for protected health information (PHI) · The dramatic restructuring of SAMHSA and the creation of the new Assistant Secretary for Mental Health and Substance Use Disorders position.8,9

The Cassidy-Murphy Mental Health Reform Act of 2015 — S. 1945

On August 4, 2015, U.S. Senators Bill Cassidy (R-La) and Chris Murphy (D-Conn) introduced the Mental Health Reform Act of 2015. Since its introduction, the bill

56 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas has gained widespread support from national organizations, including the National Council for Behavioral Health, the National Alliance on Mental Illness (NAMI), the American Psychiatric Association, and the American Psychological Association.10 As of October 1st, 2016, the Mental Health Reform Act of 2015 had been referred to the Committee on Health, Education, Labor and Pensions but had not had a hearing.11

The Mental Health Reform Act of 2015 introduced by Senators Cassidy and Murphy is similar to Sen. Tim Murphy’s Helping Families in Mental Health Crisis Act that passed in the House of Representatives. However, the Cassidy-Murphy bill includes several important differences:

· Creates a new behavioral health grant program for early childhood intervention programs · Creates the National Mental Health Policy Laboratory – an entity designed to fund innovation grants, bring new and effective models of care to scale, and fund demonstration grants. · Reforms Medicaid and Medicare rules so that individuals can receive primary care and behavioral health services at the same location on the same day. · Partially repeals the IMD Exclusion within Medicaid by allowing enrollees age 22-64 to receive inpatient psychiatric care so long as it “would not lead to a net increase in federal funding”12 · Does not extend the Excellence in Mental Health Act demonstration program or expand the Health IT Meaningful Use program to behavioral health providers, nor provide additional grants specifically for mental health awareness training.13 National Context The Mental Health Reform Act of 2016 — S. 2680

In March 2016, Senator Lamar Alexander (R-Tn) introduced a new federal mental health reform bill into the Senate — the Mental Health Reform Act of 2016.14 It is still too early to know the ultimate outcome of the proposed legislation, but in its current form, The Mental Health Reform Act of 2016 (S. 2680) is supported by NAMI and several other national organizations. The bill would make a number of improvements to behavioral health services at the national level, including but not limited to:

· Addressing rising suicide rates by authorizing the National Suicide Prevention Lifeline program and extending the Garret Lee Smith Memorial Act to provide suicide prevention, · Increasing the mental health workforce by expanding grants for child psychiatry telehealth, creating a Minority Fellowship Program, and reauthorizing mental health training grants. · Strengthening enforcement of mental health parity by increasing requirements for health plan audits and expanding federal guidance on complying with parity laws. · Improving early intervention services by establishing more grants for early childhood mental health and requiring 5 percent of mental health block grants to fund early interventions. · Expanding integration of mental health services into primary healthcare by supporting integrated care trainings for providers and creating new grants for integrated services.15,16

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 57 Updates on the Implementation of the Patient Protection and Affordable Care Act (ACA)

The Affordable Care Act (ACA) was passed in 2010 and dramatically reshaped the landscape of healthcare, health insurance, and behavioral health care in America. Among other provisions, the ACA requires that individuals maintain a minimum level of health insurance coverage or pay a penalty for noncompliance, known as the “individual mandate.”17 The ACA also requires that health plans sold in individual and small group markets (both inside and outside of the Health Insurance Marketplace) offer a comprehensive package of items and services known as essential health benefits. In order to satisfy the essential health benefits requirements, a health plan must include items and services that address the 10 essential health benefit categories. One of those 10 essential benefits is “mental health and substance use disorder services”, which includes a range of behavioral health treatment such as counseling and psychotherapy. 18

In addition to the individual mandate and essential health benefit requirements, the ACA also includes a number of provisions that significantly improve access to public and private behavioral health care services, including a requirement that health insurers provide coverage regardless of an individual’s preexisting conditions, age, gender, disabilities, genetic information or health status. As of January 1, 2016, all of the ACA provisions applying to individual and group health insurance plans had been implemented (except for a specific excise tax on certain employee-sponsored health plans with high expenses).19 National Context National Medicaid Expansion Under the ACA

As part of the ACA’s goal to expand health insurance coverage for all Americans, the ACA initially required states to expand Medicaid coverage to adults and children up to 138 percent of the federal poverty level (FPL). In Texas, this expansion primarily would have covered low-income adults generally not eligible for Medicaid unless they were receiving social security income (SSI) as a result of a disability. However, many states pushed back against the mandated Medicaid expansion and the Supreme Court’s ruling in the case ended up preventing the federal government from withholding Medicaid payments to states for not expanding Medicaid coverage. As a result of the Supreme Court’s ruling, states were able to choose whether to expand their Medicaid program. If a state chose to expand coverage, the federal government paid 100 percent of the cost for the first three years starting in 2014 and no less than 90 percent of the cost in future years.20,21

Because Congress wrote the ACA assuming that all U.S. citizens below 138 percent of FPL would be covered under the Medicaid expansion, the ACA does not provide tax credits for people below the poverty line (i.e., 100 percent of poverty).22 Because these individuals have incomes below the threshold to qualify for subsidies on the

58 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Health Insurance Marketplace but cannot afford private insurance and are not eligible for Medicaid (either because their income is too high or because they don’t meet Medicaid’s categorical eligibility requirements), they fall into a “coverage gap” and are likely to remain uninsured.23 Figure 9 gives a visual depiction of the gap in coverage created in states that chose to not expand Medicaid under the ACA.

Figure 9. Coverage Gap for Adults in States Without the ACA’s Medicaid Expansion National Context

Source: Garfield, R. & Damico, A. (January 21, 2016).The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update. Kaiser Family Foundation. Retrieved from http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults- in-states-that-do-not-expand-medicaid-an-update/

Following the release of the Supreme Court decision, Governor Rick Perry announced that Texas would not participate in the Medicaid expansion. This decision has effectively forfeited an estimated $6 billion in federal healthcare funds each year and created a gap in coverage for roughly 864,000 Texans.24,25

As of July 2016, 25 states (plus the District of Columbia) have expanded their traditional Medicaid program for adults while six other states have adopted an alternative coverage plan using federal waivers. The remaining 19 states (including Texas) have not expanded coverage and are currently using temporary solutions such as 1115 Medicaid waivers to provide services for individuals who fall in the coverage gap depicted in Figure 9. 26 Roughly 2.9 million individuals fall in this coverage gap nationwide, and more than a quarter of them (26 percent) live in Texas.27

There have been increased concerns about the long-term viability of the ACA as some insurers have started to cut the number of plans they offer through state health insurance exchanges. In 2016, Aetna reported a $300 million loss in 2016 on its ACA plans nationwide. Aetna decided to join United Healthcare and Scott & White by leaving the health insurance exchanges in Texas and other states.28 Humana has also signaled it might withdraw from the ACA health insurance marketplaces soon, but other insurers with more experience serving low-income individuals through HMOs prior to the ACA (e.g. Centene and Molina) have done a better job of accurately

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 59 estimating client risks, service utilization, and health care costs in order to keep their ACA plans profitable.29,30 Many insurers are choosing to rebound from underestimated costs and lower- than-expected revenues by increasing the prices of the health The uninsured rate in Texas has fallen plans they offer on the exchange, from roughly 25 percent before with Blue Cross Blue Shield the ACA was implemented to 16.8 proposing rate hikes as high as percent in 2015, but Texas remains 57-59 percent for some individual 31 the state with the highest percentage plans in Texas. of uninsured individuals — almost double the national average of 9.1 The number of Texans purchasing 33 percent. private health insurance plans through the Texas exchange rose from 1,205,174 individuals in 2015 to 1,306,208 in 2016.32 The uninsured rate in Texas has fallen from roughly 25 percent before the ACA was implemented to 16.8 percent in 2015, but Texas remains the state with the highest percentage of uninsured individuals — almost double the national average of 9.1 percent.33 Rule Changes to CMS Managed Care

On April 25, 2016, the Centers for Medicare & Medicaid Services (CMS) finalized 1,425 pages of revision and updates that strengthen Medicaid managed care rules.34 The new rules will be slowly phased in beginning on July 1, 2017 and help clarify the federal government’s increased expectations for state-run Medicaid managed care 35 National Context National programs. The new managed care rules from CMS aim to improve the quality of managed care services by improving accountability and incentivizing innovation and program integrity.36 These new rules affect the approximately 72 million people enrolled in Medicaid managed care programs across the country — almost two thirds of all Medicaid enrollees.37 The rule changes address a wide range of issues in the Medicaid managed care system. Some of the more important rule changes related to behavioral health services under managed care include:

· Establishing network adequacy standards that managed care programs must meet, particularly for specialty providers, so that enrollees have access to a full range of providers (including referral to out-of-network providers if other arrangements cannot be made) · Updating the IMD exclusion rules so that states can receive capitated federal matching funds for individuals age 18-64 who need short-term inpatient treatment “in lieu of” state plan services · Requiring managed care plans to comprehensively assess enrollees who need long-term services and supports (LTSS) and engage them in community-based, person-centered planning · Enabling managed care enrollees to continue receiving services during appeals of denials · Providing prospective and current enrollees with complete and easy-tounderstand information detailing the providers and services available in different managed care plans · Requiring states to have a written quality strategy that includes performance

60 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas measures, mechanisms for identifying enrollees with complex needs and a plan to reduce health disparities · Increasing requirements for data reporting, transparency and accountability (e.g. requiring screenings of all new managed care network providers and makes federal matching funds conditional on the timely and complete reporting of enrollee encounter data) · Establishing an 85 percent medical loss ratio (MLR) for reimbursement in order to create a sound rate-setting base that ensures reasonable and adequate payment for services. 38,39

While it is still too early to know the full effect of implementing these new rule changes to Medicaid managed care, proponents of the changes are confident the new rules will help to modernize managed care programs and align standards more closely with the practices of private health insurance sector.

Mental Health Parity and Addiction Equity Act (MHPAEA)

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is considered one of the most impactful pieces of mental

health legislation in recent decades. Enacted in 2008, MHPAEA was created to National Context further expand the mental health parity requirements included in the 1996 Mental Health Parity Act. MHPAEA also added coverage requirements for substance use services. In addition to the restriction on annual or lifetime limits enacted under the 1996 law, MHPAEA requires insurers or health plans that offer mental health or substance use services to offer the benefits equally with other medical and surgical benefits covered under the plan, otherwise known as “parity”. The law does not require plans to offer mental health or substance use disorder benefits.

MHPAEA did not require that behavioral health services be included in every group plan. However, the ACA required all marketplace plans to provide ten categories of Essential Health Benefits (EHB), which included mental health and substance use conditions beginning January 2014.40 Through the intersection of MHPAEA and the ACA, most health plans offer mental health and substance use disorder benefits, creating a new group of individuals in the U.S. who could gain access to treatment if needed.

Federal MHPAEA laws apply to: · Large employer-funded plans (with more than 51 insured employees) · Small employer-funded plans (with 50 or fewer employees, unless “grandfathered”) · Individual market plans · Medicaid managed-care programs · Children’s Health Insurance Program (CHIP) · Medicaid Alternative benefit plansand benchmark equivalent plans.41

While MHPAEA does not directly apply to small group health plans, its requirements are applied indirectly in connection with the ACA’s EHB requirements42. Medicare,

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 61 Medicaid, and CHIP are not group health plans or issuers of health insurance but are public health plans through which individuals obtain health coverage. Provisions of the Social Security Act that govern these plans require compliance with certain requirements of MHPAEA.43

MHPAEA is meant to ensure that individuals with a mental health or substance use condition are able to receive benefits equal to the medical and surgical benefits covered by their individual health plan. The Departments of Labor, Health and Human Services, and Treasury released the Final MHPAEA rules on November 13, 2013. The rules provided details about the implementation of the law, such as:

· Health plans must cover the treatment of mental health or substance use conditions at the same level as they cover other health care treatment. Again, MHPAEA does not require plans to cover mental health benefits. · States may choose to mandate specific mental health benefits, and MHPAEA requires that such benefits must be in parity with medical and surgical benefits in the same policy. Some states may have mental health and substance use parity requirements that are stricter than federal requirements. · The regulations distinguish between quantitative treatment limitations and non-quantitative treatment limitations. Quantitative treatment limitations are numerical, such as the number of visits a plan allows each year or the number of days covered for in-patient treatment. Non-quantitative treatment limitations (NQTLs) include but are not limited to step therapy and pre-authorization. Step therapy refers to the practice of using the most cost-effective medication and progressing to other more costly medications only if necessary.44 Pre- authorization means that the health insurer or plan decides that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.45

National Context National · A group health plan or coverage cannot impose an NQTL with respect to mental health or substance use conditions unless the same processes are comparable to, and applied no less stringently than, those process used in applying the limitation with respect to medical and surgical benefits. The final regulation eliminated an exception that allowed for different NQTLs “to the extent that recognized clinically appropriate standards of care may permit a difference”. · The regulations provide that all plan standards that limit the scope or duration of benefits for services are subject to the non-quantitative treatment limitation parity requirements. This includes restrictions such as geographic limits, facility- type limits, and network adequacy.46

To learn more about MHPAEA’s implementation in Texas, please refer to the Texas Environment section of this Guide.

Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI)

Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) have close ties to health insurance for people with disabilities. SSI is administered by the Social Security Administration (SSA) and falls under Title 16 of the Social

62 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Security Act. SSI is for people with limited income who have a qualifying disability or are over 65. SSI is funded by general funds from the U.S. Treasury, not Social Security taxes. In most states, including Texas, individuals who receive SSI benefits are also immediately eligible for Medicaid under the same eligibility requirements. In 2014, the nation had 9,259,225 SSI beneficiaries and Texas had 665,989 beneficiaries.47,48 The monthly maximum amount for SSI in 2016 are $733 for an eligible individual and $1,100 for an eligible individual with an eligible spouse.49

SSDI is also administered by SSA and falls under Title 2 of the Social Security Act. SSDI is for people who have a disability, have worked in a job covered by Social Security, and have earned enough credits in the Social Security program. In December 2014, there were 10,261,268 individuals receiving SSDI as workers with a disability, widow(er)s of a worker with a disability, or adults with disabilities. 87 percent of the total receiving SSDI were workers with a disability, 10 percent were adults with a disability, and 2 percent with widow(er)s with a disability.50 Of individuals receiving SSDI benefits for a mental disorder at a national level in December 2014, 14.7 percent were men and 19.7 percent were women.51 In 2014, there were 617,848 SSDI recipients in Texas accounting for 3.7 percent of the total state population.52

Figure 10. All SSDI Beneficiaries in December 2014 National Context

Source: Social Security – Office of Retirement and Disability Policy. (2016).Annual Statistical Report on the Social Security Disability Insurance Program, 2014. Retrieved from https://www.ssa.gov/policy/docs/statcomps/di_asr/2014/sect01.html

Most people receiving SSDI benefits have not been able to work due to their disability for at least one year. SSDI beneficiaries have to undergo a two-year waiting period before they can receive Medicare benefits. During those first two years of SSDI enrollment, SSDI beneficiaries may be able to obtain health insurance through their former employer or Medicaid, and some will be uninsured during that waiting period.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 63 Some people are approved to receive SSDI and SSI concurrently. This occurs when an individual receives a low SSDI payment, possibly due to not working in recent years or making little while working. When the SSDI payment falls below the federal benefit rate, SSI can be used to make up the difference.

Figure 11. below details the major difference between the two programs.

Figure 11. SSI and SSDI Differences

Program Supplemental Security Income (SSI) Social Security Disability Insurance (SSDI) Funding Financed through general revenue from Financed through Social Security taxes paid by work- taxes. Benefits are not based on prior work ers, employers and self-employed persons. history. Eligibility Have limited income and resources to meet Worker must earn sufficient credits based on taxable cost of living. Must be a U.S. citizen or have work to be insured for Social Security purposes. eligible noncitizen status. Benefit Recipients Benefits are payable to: Benefits are payable to: · individuals over 65 · workers with a disability · adults and children with a disability or · their children blindness · their widow(er)s · adults who have had a disability since childhood

Payment Payment amount varies up to the maxi- Payment amount is based on the Social Security mum federal benefit rate, which may be earnings record of the insured worker. supplemented by the state.

Source: The United States Social Security Administration. (2016). Federal Benefit Rates, Total Annual Payments, and Total Recipients. Retrieved from https://www.ssa.gov/policy/docs/statcomps/supplement/2015/supplement15.pdf The United States Social Security Administration. (2015). Disability Benefits.Retrieved from https://www.ssa.gov/pubs/EN-05-10029.pdf National Context National

64 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Endnotes 1 Allen, K. (June 4, 2015). Bill Introduced in Congress Brings Meaningful Use Parity for Behavioral Health and Addiction Treatment Providers. Retrieved from http://www.ntst.com/News-And-Events/pr/MurphyBillIntro 2 C-SPAN. (December 12, 2013). Rep. Rim Murphy, Helping Families in Mental Health Crisis Act. Retrieved from https:// www.c-span.org/video/?c4477276/rep-tim-murphy-helping-families-mental-health-crisis-act 3 Office of Congressman Tim Murphy.July ( 25, 2016). Latest News In Case You Missed It: Ray of Light on Mental Illness. Press release. Retrieved from https://murphy.house.gov/latest-news/icymi-ray-of-light-on-mental-illness/ 4 Office of Congressman Tim Murphy. (2016). The Helping Families in Mental Health Crisis Act: One Pager. Retrieved from https://murphy.house.gov/uploads/MHOnePager2.18.15.pdf 5 Merson, E. (June 5, 2015). Murphy reintroduces mental health reform — NIH contamination raises questions — CO-OPs struggle to keep down rate hikes — Hawaii exchanges eyes move to federal website. Politico. Retrieved from http://www. politico.com/tipsheets/politico-pulse/2015/06/murphy-reintroduces-mental-health-reform-nih-contamination- raises-questions-co-ops-struggle-to-keep-down-rate-hikes-hawaii-exchanges-eyes-move-to-federal-website-212543 6 National Alliance on Mental Illness. (June 14, 2016). Letter of Support for H.R. 2646. Retrieved from https://murphy. house.gov/uploads/hr%202646%20nami%20ltr%206-14-16.pdf 7 Office of Congressman Tim Murphy. (2016). The Helping Families in Mental Health Crisis Act: One Pager. Retrieved from https://murphy.house.gov/uploads/MHOnePager2.18.15.pdf 8 The Leadership Conference on Civil and Human Rights. (March 8, 2016). Oppose the “Helping Families in Mental Health Crisis Act of 2015” (H.R. 2646). Retrieved from https://www.aclu.org/sites/default/files/field_ document/16_3_8_leadership_conference_letter_of_opposition_h.r._2646_final.pdf 9 The Judge David L. Bazelon Center for Mental Health Law. (June 20, 2016). Final Statement on Amended Murphy Bill. Retrieved from http://www.bazelon.org/LinkClick.aspx?fileticket=q32V4pBCQtU%3d&tabid=77 10 Office of Senator Chris Murphy. ugust(A 4, 2015). Press Release: Cassidy, Murphy Introduce Comprehensive Overhaul of Mental Health System. Retrieved from https://www.murphy.senate.gov/newsroom/press-releases/cassidy-murphy- introduce-comprehensive-overhaul-of-mental-health-system 11 https://www.congress.gov/bill/114th-congress/senate-bill/1945 12 Office of Senator Chris Murphy. ugust(A 4, 2015). Press Release: Cassidy, Murphy Introduce Comprehensive Overhaul of Mental Health System. Retrieved from https://www.murphy.senate.gov/newsroom/press-releases/cassidy-murphy- introduce-comprehensive-overhaul-of-mental-health-system 13 Farley, R. (August 4, 2015). Senators Murphy, Cassidy Introduce Comprehensive Mental Health Reform Bill. National Council for Behavioral Health. Retrieved from https://www.thenationalcouncil.org/capitol-connector/2015/08/ senators-murphy-cassidy-introduce-comprehensive-mental-health-reform-bill/ National Context 14 https://www.congress.gov/bill/114th-congress/senate-bill/2680/all-actions?overview=closed#tabs 15 National Association of Mental Illness. (2016). S 2680, the Mental Health Reform Act of 2016: Summary. Retrieved from http://www.nami.org/getattachment/Learn-More/Mental-Health-Public-Policy/Mental-Health-Reform/ What-Is-Happening-with-Comprehensive-Mental-Health/MentalHealthReform-general.pdf 16 https://www.gpo.gov/fdsys/pkg/BILLS-114s2680rs/pdf/BILLS-114s2680rs.pdf 17 Congressional Research Service. (May 4, 2010). Private Health Insurance Provisions in Patient Protection and Affordable Care Act (PPACA). CRS #R40942. Retrieved from http://www.ncsl.org/documents/health/privhlthins2. pdf 18 Community Catalyst. (October 2012). Essential Health Benefits: Mental health and substance use disorders advocacy. Retrieved from http://www.communitycatalyst.org/doc-store/publications/EHB_SUD_Memo_reboot_10_1_12.pdf 19 Henry J. Kaiser Family Foundation. (2016). Health Reform Implementation Timeline. Retrieved from http://kff.org/ interactive/implementation-timeline/ 20 Kaiser Family Foundation. (July 2016). Status of State Action on the Medicaid Expansion Decision. Retrieved from: http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care- act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 21 Dunkelberg, A. (February 21, 2013). Medicaid Expansion Resource Guide: All the Latest on the Costs and Benefits for Texas. Center for Public Policy Priorities. Retrieved from http://forabettertexas.org/images/HC_2013_02_PP_ MedicaidExpansion.pdf 22 Garfield, R. & Damico, A. (January 21, 2016). The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update. Kaiser Family Foundation. Retrieved from http://kff.org/health-reform/issue-brief/the- coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/ 23 Garfield, R. & Damico, A. (January 21, 2016). The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update. Kaiser Family Foundation. Retrieved from http://kff.org/health-reform/issue-brief/the- coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/ 24 Dunkelberg, A. (March 14, 2016). Detailed Updates on the Texas Medicaid 1115 Waiver Renewal and the Health Care Coverage Gap. Center for Public Policy Priorities. Retrieved from http://forabettertexas.org/images/HW_2016_ PP_1115WaiverAndtheCoverageGap.pdf 25 Center for Public Policy Priorities. (June 2016). What is the Texas Coverage Gap? Retrieved from http:// forabettertexas.org/images/HW_2016_WhatIsTheCoverageGap.pdf 26 Kaiser Family Foundation. (July 2016). Status of State Action on the Medicaid Expansion Decision. Retrieved from: http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care- act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D 27 Garfield, R. & Damico, A. (January 21, 2016). The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update. Kaiser Family Foundation. Retrieved from http://kff.org/health-reform/issue-brief/the- coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 65 28 Mathews, A. W. (August 2, 2016). Aetna Joins Rivals in Projecting Loss on Affordable Care Act Plan for 2016. The Wall Street Journal. Retrieved from http://www.wsj.com/articles/aetna-tops-views-stops-aca-expansion- plans-1470134736 29 Poigue, S. (August 19, 2016). Fewer Insurers in the Marketplace: What it Means for Texas. Center for Public Policy Priorities. Retrieved from http://bettertexasblog.org/2016/08/fewer-insurers-marketplace-means-texas/ 30 Mathews, A. W. (August 2, 2016). Aetna Joins Rivals in Projecting Loss on Affordable Care Act Plan for 2016. The Wall Street Journal. Retrieved from http://www.wsj.com/articles/aetna-tops-views-stops-aca-expansion- plans-1470134736 31 O’Hare, P. (July 17, 2016). Obamacare ripples through Texas as health insurers propose steep rate hikes. Houston Chronicle and San Antonio Express-News. Retrieved from http://www.houstonchronicle.com/business/article/ Obamacare-ripples-through-Texas-as-health-8383391.php 32 Norris, L. (August 23, 2016). Texas health insurance exchange/marketplace: UnitedHealthcare, Aetna, Scott & White exiting; Cigna may exit. Retrieved from https://www.healthinsurance.org/texas-state-health-insurance-exchange/ 33 Deam, J. (May 17, 2016). Texas uninsured rate falls to 16.8%; national rate now in single digits. Houston Chronicle. Retrieved from http://www.houstonchronicle.com/business/medical/article/Texas-uninsured-rate-falls-to-16-8- national-7542199.php 34 https://www.federalregister.gov/articles/2016/05/06/2016-09581/medicaid-and-childrens-health-insuranceprogram-chip-programs-medicaid-managed-care-chip-delivered 35 U.S. Department of Health and Human Services. (April 25, 2016). HHS issues major rule modernizing Medicaid managed care. Retrieved from http://www.hhs.gov/about/news/2016/04/25/hhs-issues-major-rule-modernizing- medicaid-managed-care.html 36 Paradise, J. & Musumeci, M. (June 9, 2016). CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions. The Henry J. Kaiser Family Foundation. Retrieved from http://kff.org/medicaid/issue-brief/cmss-final- rule-on-medicaid-managed-care-a-summary-of-major-provisions/ 37 U.S. Department of Health and Human Services. (April 25, 2016). HHS issues major rule modernizing Medicaid managed care. Retrieved from http://www.hhs.gov/about/news/2016/04/25/hhs-issues-major-rule-modernizing- medicaid-managed-care.html 38 Paradise, J. & Musumeci, M. (June 9, 2016). CMS’s Final Rule on Medicaid Managed Care: A Summary of Major Provisions. The Henry J. Kaiser Family Foundation. Retrieved from http://kff.org/medicaid/issue-brief/cmss-final- rule-on-medicaid-managed-care-a-summary-of-major-provisions/ 39 Rosenbaum, S. (May 5, 2016). Twenty-First Century Medicaid: The Final Managed Care Rule. Health Affairs Blog. Retrieved from http://healthaffairs.org/blog/2016/05/05/twenty-first-century-medicaid-the-final-managed-care- rule/ 40 HealthCare. (n.d.). What Marketplace health insurance plans cover. Retrieved from https://www.healthcare.gov/ coverage/what-marketplace-plans-cover/ 41 Substance Abuse and Mental Health Services Administration. (2016). Implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA). Retrieved from http://www.samhsa.gov/health-financing/implementation-mental-

National Context National health-parity-addiction-equity-act 42 Centers for Medicare and Medicaid Services. (2013). The Center for Consumer Information and Insurance Oversight – The Mental Health Parity and Addiction Equity Act. Retrieved from https://www.cms.gov/CCIIO/Programs-and- Initiatives/Other-Insurance-Protections/mhpaea_factsheet.html 43 Centers for Medicare and Medicaid Services. (2013). The Center for Consumer Information and Insurance Oversight – The Mental Health Parity and Addiction Equity Act. Retrieved from https://www.cms.gov/CCIIO/Programs-and- Initiatives/Other-Insurance-Protections/mhpaea_factsheet.html 44 eHealth Medicare. (n.d.) What is prior authorization, step therapy, and quantity limit? Retrieved from https://www. ehealthmedicare.com/faq-what-are-prior-authorizations-quantity-limits-and-step-therapy/?redirectFromHTTP 45 HealthCare. (n.d.). Preauthorization Definition. Retrieved from https://www.healthcare.gov/glossary/ preauthorization/ 46 Centers for Medicare and Medicaid Services. (2013). The Center for Consumer Information and Insurance Oversight – The Mental Health Parity and Addiction Equity Act. Retrieved from https://www.cms.gov/CCIIO/Programs-and- Initiatives/Other-Insurance-Protections/mhpaea_factsheet.html 47 Social Security Administration. (2015). SSI Annual Statistical Report, 2014. Retrieved from https://www.ssa.gov/ policy/docs/statcomps/ssi_asr/2014/sect01.html 48 Henry J. Kaiser Family Foundation. (2016). Total SSI Beneficiaries - Texas. Retrieved from http://kff.org/medicaid/ state-indicator/total-ssi-beneficiaries/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22 sort%22:%22asc%22%7D 49 Social Security Administration. (2016). SSI Federal Payment Amounts for 2016. Retrieved from https://www.ssa.gov/ OACT/cola/SSI.html 50 Social Security – Office of Retirement and Disabilityolicy. P (2016). Annual Statistical Report on the Social Security Disability Insurance Program, 2014. Retrieved from https://www.ssa.gov/policy/docs/statcomps/di_asr/2014/sect01. html 51 Social Security – Office of Retirement and Disabilityolicy. P (2016). Annual Statistical Report on the Social Security Disability Insurance Program, 2014. Chart 7. Retrieved from https://www.ssa.gov/policy/docs/statcomps/di_asr/2014/ sect01.html 52 Henry J. Kaiser Family Foundation. (2016). Total Disabled Social Security Disability Insurance (SSDI) Beneficiaries, Ages 18-64 - Texas. Retrieved from http://kff.org/medicare/state-indicator/total-disabled-social-security-disability- insurance-ssdi-beneficiaries-ages-18-64/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Locati on%22,%22sort%22:%22asc%22%7D

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S their public health and child protective services functions, until further legislative until further legislative functions, services and child protective health their public in 2018. review individuals who are blind, Independent Living Services for older individuals who Services for older individuals Living Independent are blind, who individuals the were all transferred to program Texas Enterprises of and Business are blind, 1, 2016. on September Commission Workforce Texas DADS Regulatory functions at DSHS, on will be discontinued DADS operate DSHS and DFPS will continue to Phase two structure. and functions currently housed across the four other HHS agencies over to HHSC. to HHS agencies over other across the four housed and functions currently reforming the enterprise’ on transformation, focused Phase one of the Behavioral DSHS and D health programs at general v DARS will transfer to hospitals, state (SSLCs) and the centers supported living state 1, 2017. HHSC September by services at DARS, were transferred to HHSC; DARS was discontinued as a separate to HHSC;transferred were was DARS DARS, services at agency1, 2016. on September organizational structure, concluded on September 1, 2016. on September concluded structure, organizational SB 200 (84

Commission’s recommendation to reorganize the HHS enterprise (SB 200, 84 (SB 200, the HHS enterprise to reorganize recommendation Commission’s In July 2016, the commission published a revised version of Health and the commission published a revised version 2016, In July the Plan, outlining its plan for carrying out Transition Human Services System in SB 200 (84 transformation directives During the 84 During the HH anticipated changes is shown in Figure 13. anticipated changes is shown · · · · · · · Nelson/Price). The HHSCNelson/Price). HHS agenciesthe five requires legislation to Sunset and DSHS and maintaining and DADS DARS into three, discontinuing consolidate agenciesDFPS as separate review in 2018. until further legislative HIGHLIGHTS · 76 HHSC structural areexpectedtobecomplete changes by September 1,2017, theagency · The reorganizationoftheHHSsystems isoccurringintwophases: http://www.hhsc.state.tx.us/hhs-transformation/ Source: Texas Health and Human Services Commission. (2016). Health and Human Services system transition plan. Retrieved from Figure 13. Proposed Health andHumanServices Transformation Timeline to clientservicesduringthe transformationprocess. The two-phasereorganization processisdesignedtominimizeinterruptions · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

By September 1, 2018 (Continuing) By September 1, 2017 (Phase Two) By September 1, 2016 (Phase One) Date programs, asnecessary. will begin to pursue reorganization within core functional divisionsorspecific is expected to becomplete by September 1, 2017. Duringthisphase, the agency and facility operations to HHSC. Thetransfer of programsandfunctionstoHHSC Phase Two: attempting intra-program or intra-division organizational reform. in theirentirety before hasbeen to transfer programs to HHSC division. The goal the transfer of the majority of social andmedical services intooneHHSC broad structural totheHHS system. facilitated changes During thisphase,HHSC Phase One:Completed During this phase, the agency plansto transfer remainingregulatory During this phase, the agency 12 on September 1, 2016, this phase focusedonimplementing DSHS and DFPS as separate agencies Legislative Oversight Committee on whether to continue Submit study and recommendations to the Transition HHSC: in-program operations within-division and with- Begin organizational review of HHSC: Agency maintains public health functions Regulatory and licensure functions transfer to HHSC DSHS: Protective services functions remain at agency Childcare placement licensure functions transfer to HHSC DFPS: Agency is discontinued Regulatory, licensure, and SSLC functions transfer to HHSC DADS: Public health and regulatory functions remain at agency All client services transfer to HHSC (social and medical) DSHS: agency Protective services and regulatory functions remain at HHSC to DFPS Prevention and Early Intervention programs transfer from DFPS: Agency is discontinued Remaining programs and functions transfer to HHSC Workforce Commission (TWC) Vocational Rehabilitation Programs transfer to Texas DARS: agency Regulatory, licensure, and SSLC operations remain at All client services transfer to HHSC (social and medical) DADS: Proposed Changes 13 Whilethemajorityof HHSC 77

, 18 16 SB h t , h t tion: a 200 (84 niz SB a : DSHS has established DSHS has established 277 (84 , Nelson/Price), the Texas , Nelson/Price), the Texas R 17 th

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f ield) rice) P ff e ommittee C Sh tion o a elson/ vioral health integration efforts vioral health integration See the section on “Behavioral Health Services” section for more Health See the section on “Behavioral rice) N In its analysis of Senate Bill 200 (84 20 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation P 15 , , h ted the Sunset Commission’s recommendations, removing reference removing recommendations, Commission’s ted the Sunset t Advisory wertner/ S h Produce cost savings cost Produce beha Facilitate funding access to federal Enhance elson/ inu iscont c

S two Behavioral Health Authorities (BHAs) that will provide an alternative model alternative an (BHAs) that will provide Authorities Health two Behavioral eligible for Medicaid). for indigent services for those not care (mental health January, 1 2017. January, In 2014, the Sunset Commission found that NorthSTAR’s behavioral health delivery health delivery behavioral Commission found that NorthSTAR’s the Sunset In 2014, efforts to integrate system-wide with Texas’ inconsistent outdated and was system health services and Medicaid basic physical healthcare with other behavioral managed care. information about NorthSTAR. House Research Organization reported that dismantling NorthSTAR would: NorthSTAR Research Organization reported that dismantling House role in the HHS enterprise, providing the agency with feedback from clients, the agencyrole in the HHS enterprise, providing with feedback from clients, on specific issues. stakeholders and other families, HHS advisory a cross-agency evaluated the 133 existing workgroup In 2015, The HHSC legislation also directs important changes to the advisory Sunset advisory eliminating 36 existing in the HHS enterprise, structure committee Commissioner to while enabling the HHSC statute Executive from state committees in rule. new advisory committees establish HH SB 200 adop · · · clients NorthSTAR Medicaid-eligible program from statute. to the NorthSTAR managed care health care services through the same their behavioral will receive health care. their physical organization that provides 200 (84 D discontinue the NorthSTAR to The HHSC also requires the state legislation Sunset the Since 1999, project on December 31, 2016. health demonstration behavioral use services to health and substance behavioral program has provided NorthSTAR to system area through a capitated payment clients in the Dallas Medicaid-eligible one managed organization. health care behavioral expects that reorganization within divisions and programs will occur over the course course the over occur will programs and divisions within reorganization that expects years. of several to the Texas submit a report agency the additionally, must, 2018, 1, September By DSHS whether as to recommendations providing Committee Oversight Legislative agencies to operate as separate should continue and DFPS merged or be into HHSC. at http:// Transition Plan Human Services and Health see the more information, For www.hhsc.state.tx.us/hhs-transformation/transition-plan.shtml. LifePath Systems and the North Texas Behavioral Health Authority (NTBHA) have (NTBHA) have Authority Health Behavioral and the North Texas Systems LifePath been selected as the two BHAs in the region. N 78 HHSC is relatedtothenationalandstate ofbehavioral healthproviders. shortage Network forMedicaid adequacy behavioral healthproviders remainsaconcernand behavioral healthintegrationandSenateBill58[83 into thebundleofservicescovered by Medicaid care(seediscussionof managed providers amongMCOsisincreasinglyimportantastheseservicesareintegrated Res.pdf.) Maintaininganadequatenetwork ofbehavioral andmentalhealthcare http://hogg.utexas.edu/wp-content/uploads/2016/04/Workforce-Brief-20168-Low- The Texas MentalHealthWorkforce: Continuing ChallengesandSensibleSolutions, · · · · difficulty findingin-network providers, includingbehavioral health providers. to identifynetwork asanissueforMedicaid adequacy patients whoexperience adequate network ofdifferentprovider types, butanumberof stakeholders continue (MCOs). Historically, hascontractuallyrequiredMCOplanstomaintainan HHSC available toclientsenrolledinplansthroughMedicaid careorganizations managed ofproviderthe legislaturehasexpressedconcernaboutadequacy networks carebecomesTexas’As managed primaryservicedelivery modelforMedicaid, 81, H SB N . tx.us/hhs-transformation/docs/transition-plan.pdf please seetheHealthandHumanServicesTransition Planathttp://www.hhsc.state. For afulllisting oftheCommissioner’s finaladvisorycommittee recommendations, behavioral healthwellness andrecovery. coordination,ensureaccesstoandintegrationofservices,cross-agency andpromote provide recommendationstotheHHSExecutive Commissioner onhow topromote Committee helditsinauguralmeetingAdvisory inJanuary 2016. Itsroleisto committee thatwouldaddressbehavioral healthissues, andtheBehavioral Health toestablish Sunset anadvisory legislationexpresslydirectedHHSC The HHSC hhs-transformation/transition-plan.shtml. committees canbefoundinthetransformationplanathttp://www.hhsc.state.tx.us/ committees tokeep, consolidate,ordismantle.Alist oftherecreatedadvisory recommendations totheHHSExecutive Commissioneronwhichadvisory committees. Following apublicinputprocess, theworkgroup submitted Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas gather feedback onSB760’s implementation. conductedapublic inputprocessand stakeholder foruminthefallof2015HHSC to · · Among itsmultipledirectives, SB760 (84

etwork Adequ transparency standards,transparency and anMCOcompliance monitoring process;and Expand consumersupport resources for clients Establish and implement Ensure that MCOs submit plans for standards; Submit reports tothe legislature Implement new remedies forMCOs Establish accessstandards for different provider types inanMCOnetwork; 760(84t B 1, Article h , S c h an expedited credentialing process, heightened a II wertner/ (84t cy in on MCO compliance withnetwork adequacy compliance with newaccessstandards; h that fail to complywithaccessstandards; M 22 , th O , Schwertner/Price) to: requires HHSC edic tto/ 26 P InFebruary 2016, helda the agency rice) enrolled in MCO plans. a rd N id , Nelson/Zerwas]). elson) Ma a nd HH n a ged SC 25

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A follow-up forum was held in June 2016. June held in was forum A follow-up lu 27 h a elson/ ene v ntegr N health authorities (LMHAs) were eligible to receive Medicaid reimbursement Medicaid health authorities (LMHAs) were eligible to receive LMHAs case managementfor mental health rehabilitation and targeted services. arrangement payment with DSHS. these services under a fee-for-service provided and incorporate Senate Bill 58 directed the agency network to widen this provider managed Medicaid care by these services into the package of services covered Integration Advisory Health a Behavioral The bill established organizations (MCOs). phases recommendations and guidance through two distinct to provide Committee of implementation. the integration During Phase I of implementation, HHSC successfully oversaw In managed care networks. and STAR+PLUS STAR of LMHAs into the state’s case management targeted and mental health rehabilitative 2014, September managed care providers. through the state’s services became fully reimbursable healthcare behavioral contracted with MCOs to provide are now LMHAs statewide in those networks. served services to Texans reimbursement for technically eligible to receive are While private providers The 2009 legislation required that HHSCThe 2009 legislation required that discontinue the benefit if the agency finds in Medicaid growth use services results in overall adult substance that providing with HHSC Rider 44, HB 1, Article II (84 spending. In 2015, wit In an effort to optimize health outcomes for Medicaid beneficiaries with mental health outcomes for In an effort to optimize the integration of behavioral approved the legislature in 2013 healthcare needs, managed care. under Medicaid healthcare into the package reimbursable of services of Senate Bill 58 (83 Prior to the passage I Article E B Use Disorder (SUD) benefit for adult a Substance legislature approved the In 2009, Medicaid program (SB in the beneficiaries with the costs goal of reducing Medicaid 1, Article IX, 81 managed care stakeholder meeting to discuss the agency’s draft response to public to draft response agency’s the to discuss meeting managedstakeholder care input. publish a report on network adequacy or the number of disciplinary compliance and report on network publish a agency actions that the MCOs. noncompliant corrective against has taken legislature directed HHSCoverall to evaluate the SUD benefit and its effect on HHSC released a progress report outlining spending and client outcomes. Medicaid and is required to submit either a final in December 2015 its evaluation methodology 2016. by December 1, Governor update to the Office of the report or status Budget Board (LBB) findings that people with substance use disorders incur twice use disorders that people with substance Board (LBB) findings Budget disorders. as people without those the medical costs Relatedly, HHSC Article II (84 Rider 81, HB 1, Relatedly, 80 HHSC Figure 14. Former DARS Programs The figurebelow illustrates whereformer DARS programsarenow placed. social, emotional, well-being. andgeneral health conditionsobtain independence,becomeintegratedintosociety, andachieve live independentandproductive lives.” children withdevelopmental delays enjoy thesame opportunitiesasother Texans to Rehabilitative Services(DARS) was “toensurethatTexans withdisabilities and The missionoftheTexas formerlyknown asDepartment ofAssistive agency and DARSFROM TOANDTWC HHSC PROGRAMS TRANSFERRING · · · · · implementation: 2015, planstofocusonthefollowing objectives duringPhaseIIof andtheagency oversight. Theadvisorycommittee releaseditsPhaseIIrecommendationsinJuly effortand expectsthatachievingfullintegrationwillrequireyearsofongoing HHSC to offertheintegratedservicesnecessary toreceive reimbursement. participation fromprivateproviders isexpectedover timeastheybuildthecapacity bundle ofmentalhealthservicesrequiredrehabilitative serviceproviders. More becauseLMHAshaveThis islargely established capacitytodeliver theintegrated behavioral healthservices, MCOscontinuetocontractprimarilywithLMHAs. mental healthconditions. behavioral, andsocialdevelopment canhelptoprevent thefuturedevelopment of promotion ofmentalhealthforTexans. Thenurturingofachild’s healthy emotional, programs formerlyadministered underDARS areofspecialrelevancetothe The EarlyChildhoodIntervention (ECI)andVocational Rehabilitation(VR) Services andother programstransferredtoTWC canbefoundintheTWC section. as aresultofSunset legislation.More informationonVocational Rehabilitation ortheTexasHuman ServicesCommission(HHSC) Workforce Commission(TWC) all DARS functionsandresponsibilitiesweretransferredtoeithertheHealth and long-term supportfromother publicprogramsandservices. AsofSeptember 1,2016, Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

Blind Children’s Vocational Discovery and Development Program Independent Living Services Program Business Enterprises of Business Enterprises of Texas Criss Cole Rehabilitation Center Independent Living Services for Older Individuals Who are Blind Vocational Rehabilitation for Individuals with Mental or Physical Disabilities Program Name Developing and implementingtwo Defining thebehavioral Conducting outreachandeducationtoensurethatintegrationishappeningatalllevels; Implementing sys Broadening the provider tems changes recommended bytems changes theadvisorycommittee; 32,33 health medical policy benefits; and health medical policy base toinclude private providers; Employment canhelpadultswithmentalorbehavioral home health pilots. 31 DARS was intendedtoreduce theneedfor 34

HC9/1/16 HHSC HC9/1/16 HHSC TWC TWC TWC TWC Placement New Agency 30 9/1/16 9/1/16 9/1/16 9/1/16 Date Transition HHSC 81

Page. 22. Retrieved Retrieved 22. Page. 36 Transition Transition Date Those 35 Legislative Session. Legislative th New Agency Agency New Placement HHSC 9/1/16 HHSC 9/1/16 HHSC 9/1/16 HHSC 9/1/16 HHSC 9/1/16 HHSC 9/1/16

37,38 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation http://www.hhsc.state.tx.us/hhs-transformation/docs/transition-plan.pdf Program Name Program Blindness Education, Screening and Treatment Program (BEST) Program Treatment and Screening Education, Blindness Children’s Autism Children’s Comprehensive Rehabilitation Services Rehabilitation Comprehensive Deafof Hard and Services Hearing Early Childhood Intervention Childhood Early Disability Determination Services Determination Disability from from PROGRAMS TRANSFERRING FROM DADS TO HHSC TO FROM DADS TRANSFERRING PROGRAMS Department plan, the Texas of the HHS transformation Prior to the implementation long-term responsible for providing was Services (DADS) of Aging and Disability with physical people the age of 60, over for Texans services and supports (LTSS) (IDD). disabilities developmental people with intellectual and other and disabilities, and community services) help individuals receive residential both (including LTSS in their homes and communities of choice. DADSneeded care and services to remain the state’s and administering of LTSS providers also had responsibility for regulating the HHSCguardianship program. As a result of as a separate transformation, DADS agency the HHSC will be abolished and the programs and services incorporated into Transformation Recap below. more information, see DADS For organizational structure. Advisory under the review of the Sunset Commission, along with the was DADS before the 84 agencies, and Human Services Health Texas other Health and Human Services System Transition Plan. Plan. Transition System Services Human and Health (2016). Commission. Services Human and Health Texas Source: The failure of SB 204 means that every SSLC will remain open until further The failure of SB 204 means that every DADS-related other many However, direction is received. legislative in the final HHSC were adopted Commission recommendations from the Sunset changes bill (SB 200), including to nursing home requirements and services Sunset for individuals with IDD. recommendations, along with statutory recommendations on other programs within recommendations on other along with statutory recommendations, The bill, SB 204 (Hinojosa/Raymond). DADS Sunset were solidified in the DADS, discussion on the House but after lengthy bill passed the Senate with a few changes, SSLC Austin to close the recommendation SB 204’s House members removed floor, of the conference Commission. Members the SSLC Restructuring and establish bill, Sunset reach an agreement on the content of the DADS could not committee session. before the end of the legislative consequently SB 204 died days Sunset staff carefully reviewed DADS’ internal policies, procedures, and service and service procedures, internal policies, DADS’ carefully reviewed staff Sunset Commission ultimately recommended dissolving the agency The and delivery. and Human Services Commission (HHSC), its functions into the Health in moving intellectual, and Texans and individuals with physical, older serve an effort to better (IDD). disabilities developmental other issues surrounding the tackled the highly controversial Commission also The Sunset centers (SSLCs). The Commission support living continued operation of the state of 2017 September SSLC by recommended closing six SSLCs: closing the Austin of 2022. by September additional SSLCs to close and identifying five 82 HHSC sources forthe 2016-2017 HHS enterprisebudget. funding thatwas dedicated to eachofthefive agencies, andFigure 16shows funding 37 percentoftheentire state budget. for FY2018-19. $30,906,433,838 GeneralRevenue and$6,013,975,759 inexceptional itemrequests increase fromthe2014-15 budgetof$49billion. HHSC percent oftheHHSsystem budget (seeFigure15).This represents a17percent $57 billion,constituted 27percentoftheentireTexas state budgetandover 70 84 following paragraphsofferinformationontheFY2016-17 budget approved by the requests fortheoperationsthatarenot currentlybeingconsolidated.The appropriations agencies. DFPSandDSHSwillcontinuetosubmitindividualagency needed tocontinueprogramsandservicestransitionedfrom theonceseparate hasproposedaFY2018-19HHSC consolidatedbudget thatincludes thefunding HHSC Funding of the84 Commission’sThe Sunset Advisory StaffReportof DADS, includingthefinalresults andDSHSSunset changes,HHSC seetheTexas Environment sectionofthe guide. of state-owned facilities:state hospitalsandSSLCs. For moreinformationonthe the newFacility OperationsDivisionunderHHSC, whichwilloperatetwotypes outlines thefutureofDADS’ programsandfunctions. TheSSLCswillbeplacedin review by theTransitionLegislative Oversight Committee. Theproposedplan The Health andHumanServicesTransitionPlanwas releasedinMarch2016 for willbediscontinued. point theagency functions andoperationoftheSSLCswilltransferby September 1,2017, atwhich onSeptember 1,2016.functions transferredtoHHSC Theremainingregulatory will thenbeabolished.Themajorityoftheagency’s clientservicesandprogram by September functions willtransferentirelytoHHSC 1,2017 andtheagency Sunset bill(SB200)transfersfunctionsfromDADSThe HHSC toHHSC. DADS’ growth forprogramssuchasMedicaid, CHIP, andfoster care. health andhumanservicesinTexas isprimarilydriven by anticipatedcaseload these figureswerepriortotherestructuring oftheHHS system. Spendingon hhs/hhs-transformation. hhs/hhs-transformation. Transformation Planis available athttps://hhs.texas.gov/about-The finalHHSC Final%20Results.pdf texas.gov/public/uploads/files/reports/DADS%20Staff%20Report%20with%20 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas According toHB1(84 According enterprise structure. over $77billionincombinedstate andfederalfunding, The FY2016-17 HHSsystem (HHSC, DADS, DARS, DSHS, andDFPS)budget was ininfrastructurechanges andconsequentlegislative appropriationsrequests. th legislatureaswelltheFY2018-19 forthenew budgetproposedby HHSC th legislative sessionisavailable atthefollowing link:https://www.sunset. 41 Theseamountscannot becomparedtoprioryearsdue tothe th , Otto/Nelson) the2016-17 budgetofapproximately HHSC 42 Figure 15 shows the percentage ofHHS Figure15shows thepercentage

39 representing approximately Itshouldbenoted that 40 HHSC isrequesting HHSC HHSC 83

Reg. Sess., art. art. Sess., Reg. Reg. Sess., art. art. Sess., Reg. th th http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017.pdf http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017.pdf A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Coordinated Statewide Behavioral Health Expenditures Proposal Proposal Expenditures Health Behavioral Statewide See the Coordinated 43,44 Source: Hogg Foundation analysis of General Appropriations Act, H.B. 1, Conference Committee Report, 2015 Leg., 84 Leg., 2015 Report, Committee Conference 1, H.B. Act, Appropriations ofanalysis General Foundation Hogg Source: Figure 16. Health and Human Services Enterprise Budget by Method of Health 16. Figure (2016-2017) Finance Note: Excludes system-wide employee benefits, debt service, and interagency contracts, which together comprise 1 percent of percent 1 comprise together which budget. HHS the contracts, interagency and service, debt benefits, employee system-wide Excludes Note: Source: Hogg Foundation analysis of General Appropriations Act, H.B. 1, Conference Committee Report, 2015 Leg., 84 Leg., 2015 Report, Committee Conference 1, H.B. Act, Appropriations ofanalysis General Foundation Hogg Source: The majority of the HHSC budget (92 percent) is dedicated to Medicaid (see Figure Figure (see of the HHSCmajority The to Medicaid is dedicated percent) (92 budget matching and federal (GR) Revenue General state 17), by jointly is funded which comprises a large funding percentage the HHSC (58 percent) of Federal funds. arrangement funding for Medicaid. to the joint federal-state in part due budget, Proposal Expenditures Health Behavioral Coordinated 2016 According to the July state services across for mental health is budgeted $1.8 billion approximately agencies. for section. and Social Services Division FY 2017 in the Medical Agency (2016-2017) Budget by and Human Services Enterprise Health 15. Figure II. (Tex. 2015). Retrieved from from Retrieved 2015). (Tex. II. II. (Tex. 2015). Retrieved from from Retrieved 2015). (Tex. II. 84 HHSC IX sec. 10.04. (Tex. 2015). Retrieved from Financing, BaselineBudget Figure 19. 2018-19Legislative Appropriations Request byMethodof FY2018-19.HHSC The figurebelow depictsthebreakdown oftheanticipatedsourcesfundingfor Source: Data Captured from HHSC Legislative Appropriations Request for FY 2018/19. September 12, 2016. Figure 18.Funding HHSC Trends align withthesame programsandservicesofpreviousbiennium. not compareapples-to-apples, astheamountsrequested for2018 and2019 donot andmanymoved moved outofHHSC intoHHSC. Therefore,thebudgettrendsdo As aresultoftheHHSsystem transformation,someprogramsanddivisionswere Source: Hogg Foundation General analysis of Appropriations Act, H.B. 1, Conference Committee Report, 2015 Leg., 84 the total HHSC budget.percent of Note: Excludes allocations for program support, IT support, the Inspector General, and the Office of which together comprise less than 1 Appropriation (2016-2017) Figure 17. Health andHumanServicesCommission BudgetbyItemof Source: Data captured from HHSC Legislative Appropriations Request for FY 2018-19. September 12, 2016. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas HC$3229762$4248333$7047402$7263015$38,376,971,823 $37,266,380,145 $37,044,744,012 $34,274,853,313 $33,282,957,612 HHSC Strategy xedd21 siae 06Bdee 07Rqetd21 Requested 2019 Requested 2018 Budgeted 2017 Estimated2016 Expended 2015

http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017.pdf th Reg. Sess., art. Medical and

HHSC Social Services Division 85 Additionally, the Office of Mental Health Mental Office of the Additionally, 45 Disabilities & Behavioral Health Services Health & Behavioral Disabilities elopmental & Independence Services; and Services; & Independence elopmental A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Health, Dev Health, and Development Intellectual

· · Medicaid and CHIP and Medicaid which includes: Services, Community AccessEligibility Services and ccording to the HHS System Transition Plan, the Medical and Social Services Transition Plan, the Medical ccording to the HHS System

A services including placing client fragmentation by Division will address historic and community service programs in one activities, Medicaid eligibility services, division with a single line of authority. · · Under the new HHSC the chief deputy executive organizational structure, Facilities and Social Services Division and the State the Medical commissioner oversees responsibility for Social Services Division will have and Division. The Medical · Medical and Social Services Division Services Social and Medical Coordination now reports to the deputy executive commissioner of the Medical and commissioner of the Medical to the deputy executive reports Coordination now Social Services Division. 86 Medical and Social Services Division HHSC of 14 state agencies. In 2015, mentalhealthinitiatives spanninga total theofficedocumented54cross-agency The websitecanbefoundathttp://www.mentalhealthtx.org. may have mentalhealthrelatedneedsorwhowant tosupportsomeonewhodoes.” of providingwith the goal information, resources, anddirection to Texas residents who information onmentalhealthandwellness. tothesite,itwas “developed According has developed awebsitetoprovide consumers, families, andproviders up-to-date executive commissioneroftheMedical and Social ServicesDivision.Theoffice sites/hhs/files//050216-statewide-behavioral-health-strategic-plan.pdf. andstrategiesgoals includedintheplan.Theplancan befoundathttps://hhs.texas.gov/ together underthedirectionofOffice Mental HealthCoordinationtodevelop the and place.” behavioral healthservicesthatallows Texans tohave accesstocareattherighttime withavision“toensurethat TexasHHSC hasaunifiedapproachtothedelivery of of behavioral healthprogramsandservices. coordination oversight forstateaswellmanagingcross-agency mental healthpolicy the Officeof Mental HealthCoordination,whichittasked withproviding broad planning,coordination,andcollaboration.In2013,agency thelegislaturecreated delivery, andfunding,theTexas Legislaturetooksteps toincreaseandimprove cross dialogue. Recognizingtheneedtobemorestrategic inbehavioral healthservice In recentyears, mentalhealthandsubstance usehave becomemajortopicsofnational Mental Health OfficeCoordination of Medicaid Services.(HHSSystem Transition Plan,July2016) submits MedicaidStatePlanamendmentsandwaivers totheCenter Medicare and for and supports;develops policy, oversees provider andhealthplancontracts, and behavioral healthservices,intellectualdisability andrehabilitation services women’s primaryandpreventative services,awareness andeducationservices, oversees orprovides clientservices,includingagingcommunitycare, servicesandproviding regardingthe entrypointfor information access toservices; Medical andSocialServices Division–Determinesclienteligibilityservingas Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas until thebudget was developed andtherequiredapprovals were obtained. and theLegislative Budget Board.FY2017 appropriationscouldnot beexpended directive requiredapproval oftheproposal executive by theHHSC commissioner expenditure proposal” formental healthservicesforFY2017. Thelegislative Health CoordinatingCouncil was directedtodevelop a“coordinatedstatewide In additiontodevelopment ofthebehavioral healthstrategic plan,theBehavioral at HHSC serves aschairofthecouncil. at HHSC assistant commissionerwhooverseesHHSC theOfficeof Mental Health Coordination establishing astrategic statewide planformentalhealthprogramsandservices. The established theBehavioral Health CoordinatingCouncil,whichittasked with and departments(includingthoseoutsideoftheHHSenterprise),legislature Also in2015, aspartofthestate’s effortstocoordinateservicesacrossagencies ongoing be foundathttps://hhs.texas.gov/sites/hhs/files//documents/about-hhs/cabhi.pdf. 47 Undertheneworganizationalstructure, thisofficereportstothedeputy 48 The report on these cross agency behavioral health initiatives can behavioral healthinitiatives can Thereportonthesecrossagency 49 Eighteen agencies and departments worked anddepartmentsworked Eighteenagencies 46 The office was initially housed within The office wasinitiallyhousedwithin 50

Medical and

HHSC Social Services Division 87

A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Source: Health and Human Services Commission, (July 2016). Coordinated Statewide Behavioral Health Expenditure Proposal for FY FY for Proposal Expenditure Health Behavioral Statewide Coordinated 2016). (July Commission, Services Human and Health Source: http://www.hhsc.state.tx.us/news/presentations/2016/fy-2017-csbh-expenditure-proposal.pdf from Retrieved 2017. As a result of the legislative directive, the Behavioral Health Coordinating Council Council Coordinating Health Behavioral the directive, the legislative result of As a Proposal, Expenditure Health Behavioral Statewide Coordinated the developed full The the proposed budget. summarizes 20 below, Figure 2017. Fiscal Year http://www.lbb.state.tx.us/Documents/Publications/ can be found at proposal . Presentation/3190_Statewide_Behavioral_Health_Strategic_Plan.pdf reports Health Coordination Mental of the Office System, “transformed” HHS Under the and Social Services Division. of the Medical commissioner to the deputy executive for Proposal Expenditures Health Behavioral Statewide Coordinated 20. Figure 2017 Year Fiscal 88 Medical and Social Services Division HHSC Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Medicaid & CHIP Services 89 54

52 The Texas Medicaid Medicaid The Texas 51

give the state leniencythe state to give aivers W allow the state to require clients to the state allow aivers Waiver programs, however, allow state to waive basic to waive state allow however, programs, Waiver 53 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation id a edic experiment with new service delivery models. delivery service with new experiment Research and Demonstration 1115 Research and Demonstration of Choice 1915(b)Freedom W enroll in managed care plans and use the cost savings to enhance the Medicaid to enhance the Medicaid savings managedenroll in use the cost plans and care package.benefits

federal Medicaid requirements, such as mandated eligibility or required benefits, in such as mandated eligibility or required benefits, requirements, federal Medicaid efficiency cost or service that improve alternatives service delivery order to develop waivers: in three types of Medicaid States can participate quality. program caseload is projected to exceed 4.6 million by 2017. 4.6 million by program caseload is projected to exceed · · M health care program authorized is a jointly funded federal and state Medicaid health to provide Act.in Title XIX of the Social Security a way created as It was and pregnant women, families, in low-income care benefits primarily to children in established first Program was Medicaid The Texas people with disabilities. million) rely of 27.5 (4.1 million out Texans Roughly one in seven in 1967. Texas month. for acute and long-term services each on Medicaid Medicaid & CHIP Services CHIP & Medicaid The federal government defines the mandatory services that state Medicaid state defines the mandatory services that The federal government option the States have serve. and populations they must provide programs must those the services offered and the populations eligible to receive to expand both Medicaid waivers. and Medicaid services through State Plan Amendments (SPAs) the eligibility criteria who meets is an entitlement program, meaning that anyone Neither lists. be placed on waiting needed services and cannot has a right to receive can limit the number of eligible persons who nor states the federal government enroll in the program. · Home and Community-based Services 1915(c) Waivers allow the state to provide community-based services to individuals who would otherwise be eligible for institutional care. For more information on 1915(c) Waivers, see the Intellectual and Developmental Disability Services subsection of this guide

STATE MEDICAID AGENCY

HHSC has been the designated state Medicaid agency since 1993, administering the program and acting as a point of contact between Texas and the federal government on issues related to Medicaid. The federal government establishes most Medicaid guidelines but grants several important tasks to the states, including:

· Administering the Medicaid State Plan, which functions as the contract between the agency and the federal government · Establishing Medicaid policies, rules, and provider reimbursement rates · Establishing eligibility beyond the minimum federal eligibility groups55

Historically, Medicaid-funded behavioral health services have been provided through multiple HHS agencies. However, the HHS enterprise is currently undergoing reorganization (see Changing Environment). Figure 21 outlines the Medicaid-funded programs that each legacy agency has historically administered that will transition to HHSC.

Figure 21. Medicaid-Funded Programs Across HHS Agencies Included in or Transitioning to HHSC (2016)

State Agency Medicaid-Funded Programs and Services Health and Human Services Oversees Texas Medicaid State Plan services. Examples of duties include: Commission Medicaid eligibility determination Managed care oversight 1115 Waiver oversight Department of Aging and Medicaid 1915(c) Waiver Programs (transferred to HHSC Sept. 2016): Disability Services Community Living Assistance and Support Services (CLASS) Medically Dependent Children Program (MDCP) Deaf-Blind with Multiple Disabilities (DBMD) Home and Community-Based Services (HCS) Texas Home Living (TxHmL) Medicaid State Plan Entitlement Programs (transferred to HHSC Sept. 2016): Primary Home Care (PHC) Day Activity and Health Services (DAHS) Community Attendant Services (CAS) Nursing Facilities Intermediate Care Facilities (for individuals with IDD) Other Services (transferred to HHSC Sept. 2016): Preadmission Screening and Resident Review (PASRR) Money Follows the Person Targeted case management for IDD Hospice Program of All-inclusive Care for the Elderly Facilities and Regulatory Functions (transferring to HHSC Sept. 2017): Long Term Care Licensing, Survey, and Certification State supported living centers State hospitals

90 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Medical and

HHSC Social Services Division Medicaid & CHIP Services 91 Health and Health a Retrieved Retrieved 2-11. edition, tenth perspective in CHIP and Medicaid Texas . http://www.hhsc.state.tx.us/hhs-transformation/docs/transition-plan.pdf This is an increase from 2.8 million in 2013, prior This is an increase from 2.8 million in 2013, (transferred to HHSC Sept. 2016): Sept. HHSC to (transferred 56 Retrieved from from Retrieved Early Childhood Intervention Program (ECI) Program Intervention Childhood Early impaired visually or blind the for management case Targeted Program Development and Discovery Vocational Children’s Commission Workforce Texas the to transferred rehabilitation vocational Adult Note: clients): DFPS serving and HHSC by (administered Care Managed Medicaid Health STAR Medicaid-Funded Programs and Services and Programs Medicaid-Funded 2016): Sept. HHSC to (transferred Programs Waiver 1915(c) Medicaid (YES) Services Empowerment Youth Services Other Testing) and Diagnosis Screening, Periodic and (Early Steps Health Texas children and women pregnant for management Case screening hearing including screening, Newborn planning Family (HCBS-AMH) Health Mental Adult for Services Community-Based and Home a with persons for services rehabilitation psychosocial and management case Targeted diagnosis health mental 2016): Sept. HHSC to (transferred Programs , Nelson/Raymond), managed, Nelson/Raymond), the primary care has become rd A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation ; Texas Health and Human Services Commission. (2016). (2016). Commission. Services Human and Health Texas ; http://www.hhsc.state.tx.us/medicaid/about/PB/PinkBook.pdf Department of Family and ofDepartment Family Services Protective State Agency State of Department Health State Services and ofDepartment Assistive Services Rehabilitative Non-Medicaid funded programs at DARS transferred to the Texas Workforce Commission in September 2016. September in Commission Workforce Texas the to transferred DARS at programs funded Non-Medicaid platform for delivering Medicaid services in Texas. Texas. services in Medicaid platform for delivering client selects a health plan (a the Medicaid-eligible In a managed care system, from that managed care organization) and identifies a primary care physician two or more health plans a choice between Clients have network. provider plan’s the line if they are to change plans down the option have in each region. Members state monitoring, members’ In addition to contractual requirements and unsatisfied. health plans that between plans generates of competition some level ability to switch is expected to result in higher quality services. Access managed care program that Reform) is the statewide (State of Texas STAR beneficiaries. majority of Medicaid acute care services to the Medicaid provides acute and both managed that provides care program is the statewide STAR+PLUS and elderly participants. long term services and supports to people with disabilities clients (86 percent) were enrolled in Medicaid million Texas 3.5 Approximately managed care as of March 2016. from from Sources: Texas Health and Human Services Commission. (2015). (2015). Commission. Services Human and Health Texas Sources: CARE MANAGED MEDICAID through two service Medicaid coverage has offered Texas Since the early 1990s, model, and managed care. The traditional fee-for-service models: fee-for-service is now based on the unit of service delivered, payment receive wherein providers managed care system, Medicaid Under the participants. few Medicaid limited to very a monthly pays the care of each client, and the state oversees a single provider 1115 Medicaid for each enrollee. With support from the capitated rate to the provider managed expanded its Medicaid has incrementally Texas Transformation Waiver, Environment more services and populations (see The Texas to include care system under the recent direction Moreover, Waiver). for more information on the 1115 of Senate Bill 7 (83 a Human Services system transition plan. plan. transition system Services Human 92 Medical and Medicaid & CHIP Services Social Services Division HHSC Figure 22. Texas MedicaidandCHIPManagedCare Programs Health, CHIP, andSTAR Kids. These programsincludeSTAR (StateofTexas Reform),STAR+PLUS, Access STAR Figure 22describesthefive Texas care programs.Medicaid andCHIPmanaged receiving waiver services, asrequiredby SenateBill7. pilot forthedelivery oflong-term servicesandsupportsforpeoplewithIDD November 2016. andDADS arealsoworking together tocreateacapitation HHSC care programforchildrenwithdisabilities calledSTAR Kids, expectedtolaunchin addition toexpandingcareinSTAR+PLUS, SenateBill7established anewmanaged program receive both acuteandlong-termcareservicesthroughSTAR+PLUS. In through STAR+PLUS, andTexans withSSInot enrolledina1915(c)IDDwaiver through theMedicaid 1915(c)Waiver programsnow receive acutecareservices services andsupportsforadultschildrenwithIDD. Texans whoreceive services directed thedesignandimplementationofasystem ofacutecareandlong-term to theimplementationofSenateBill7(83 who arethreetimesmorelikely toexperienceamentalhealthcondition. Many instituted ofthechanges by SB7addresscoverage forindividualswithIDD, disabilities (IDD)intoSTAR+PLUS. services andacutecareforindividualswithintellectual ordevelopmental STAR+PLUS toserve allareasofthestate, aswelltransitioningnursingfacility majorsystemSenate Bill7generated inMedicaid delivery changes by expanding mandatory participationintheexisting STAR+PLUS careprogram. managed Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Start date: 1998 STAR+PLUS Start date: 1991 Access Reform) Description Texasof (State STAR Program Operates statewide. tion is main feature. care services. Service coordina- macy services, and long-term Integrates primary care, phar those who have a disability. to individuals age 65 or over or term services and supports (LTSS) Provides acute care and long- Operates statewide. services. targeted case management health rehabilitative and Includes behavioral/mental income. women in families with limited children, infants, and pregnant care, and pharmacy services to Provides primary care, acute - · · · · · Mandatory: · · · Mandatory: Eligible Population Acute car · · Optional:

rd , Nelson/Raymond), whichexpanded 1915(c) waiver program mediate care facility or Medicaid infants, and children Individuals with IDD individuals Medicare/Medicaid dual-eligible Long-term car covered by Medicaid Individuals in nursing disability Income-eligible adults with a Adults with SSI (> (18-20) Former foster (21-25) Former foster TANF r Income-eligible pregnant women, e only: ecipients (> 21) e only: care children care children 21) in an inter facilities b -

30.96% Outpatient or ER: tient: 0.72% Intensive Outpa- Inpatient: 3.93% Total: 31.34% zation Rate (2014) Mental Health Utili- 13.73% Outpatient or ER: tient: 0.10% Intensive Outpa- Inpatient: 0.42% Total: 15.4% 57 Thebill a Medical and

HHSC Social Services Division Medicaid & CHIP Services 93 a 5.0% c 0.70% c http://www. http://www. 0.20% c 5.30% c Mental Health Utili- Health Mental (2014) Rate zation Not Available Not (new program) Professional: Inpatient: Outpatient: Total: Total: 82.04% 82.04% Total: 7.60% Inpatient: - Outpa Intensive tient: 1.38% ER: or Outpatient 82.05% b http://www.hhsc.state.tx.us/medicaid/ http://www.hhsc.state.tx.us/medicaid/ TAR or STAR STAR or TAR 20) (< SSI (18-21) in voluntary voluntary (18-21) in (18-20) receiving (18-22) formerly young adults in a in adults young income under 200% under income olled in Medically in olled 17) under DFPS under 17) < Medicaid 1915(c) waiver program, program, waiver 1915(c) Medicaid program YES the including conservatorship, including foster including conservatorship, care kinship and Health): who Level Poverty ofFederal the Medicaid. for ineligible are with Children enr Children Program Children’s Dependent 20) (< and Children Children ( Children adults Young placements care foster S (choose Optional adults Young Foster Former the under Medicaid Medicaid or (FFCC) Children Care Youth Care Foster Transitioning for titles. (MTFCY) adults Young in enrolled care, foster under education higher in (<17) children Uninsured with families Texas Medicaid managed care and Children’s Health Insurance Insurance Health and Children’s care managed Medicaid Texas

Eligible Population Eligible · · Mandatory: · · only: Acute services · Mandatory: · · · · -

Provides all medically necessary necessary medically all Provides den- care, acute as services such and health, behavioral vision, tal, children to services pharmacy con- under formerly or currently ofservatorship Department the Services Protective and ofFamily (DFPS). and management case Provides - caregiv families, to training caseworkers, clinicians, ers, ofmembers and the advocates, judiciary. statewide. Operates Provides acute and communi- and acute Provides and children to ty-based services disabilities. with adults young the in enrolled children All Children’s Dependent Medically STAR to transition will Program Kids. statewide. operate Will Provides acute health care ser care health acute Provides living children uninsured to vices do who families low-income in Medicaid. for qualify not statewide. Operates A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation STAR Health STAR 2008 date: Start Program Description STAR Kids STAR Nov. date: Start 2016 CHIP Health (Children’s Program) Insurance 1999 date: Start CHIP mental health utilization data were provided by HHSC and reflect the number of number the reflect and HHSC by provided unduplicated the by divided were claim a data with utilization clients health mental CHIP Medicaid 1915(c) waiver programs for adults and children include Home and Community-based Services (HCS), Community Community (HCS), Services Community-based and Home include children and adults for programs waiver 1915(c) Medicaid Mental health utilization numbers are for 2014 prior to the statewide expansion of STAR+PLUS and the implementation ofimplementation the and andIDD the of expansion statewide the to prior 2014 for are numbers utilization STAR+PLUS health Mental nursing home carve-ins, which became effective September 1, 2014. Total utilization refers to the summation of: (1) inpatient services; (2)services; inpatient (1) of: summation the to refers utilization Total 2014. 1, September effective became which carve-ins, home nursing report. EQRO the in services department emergency or outpatient (3) and services; hospitalization partial or outpatient intensive c a b CHIP population. Utilization data for other programs were provided by the External Quality Review Organization (EQRO) report and are are and report (EQRO) Organization Review Quality External the by provided were programs other for data Utilization population. CHIP comparable. directly not therefore are sources two The methodology. separate a using calculated Sources: (2015). ofthe University at Florida. Policy Health Child for Institute from Retrieved 2014. Year Contract ofsummary quality, organization healthcare in review quality trends and activity external Program, http://www.hhsc.state.tx.us/reports/2015/EQRO-Summary-Healthcare-2014.pdf from Retrieved CPS. at services medical to guide a – Health STAR (n.d.). Services. Protective and ofDepartment Family Texas dfps.state.tx.us/Child_Protection/Medical_Services/guide-star.asp from Retrieved ofOverview STAR+PLUS. (n.d.). Commission. Services Human and Health Texas managed-care/starplus/overview-of-starplus.pdf from Retrieved . expansion STAR+PLUS (n.d.) Commission. Services Human and Health Texas managed-care/mmc/starplus-expansion/ from Retrieved 2012-2016. strategy quality Care Managed Medicaid (n.d.). Commission. Services Human and Health Texas hhsc.state.tx.us/medicaid/about/QIS-1115.pdf Retrieved ofquality Medicaid reporting. care Texas (2016). Policy. Child Health for Institute Collaborative, Learning Healthcare Texas Living Assistance & Support Services (CLASS), Texas Home Living (TxHmL), and Deaf Blind with Multiple Disabilities (DBMD). Youth Youth Deafand (DBMD). Disabilities Multiple with Blind (TxHmL), Living Home Texas (CLASS), Services Support & Assistance Living youth. and children serves (YES) Services Empowerment 94 Medical and Medicaid & CHIP Services Social Services Division HHSC billion) ofthestate budget for2016-2017. health expendituresnationally. InTexas, Medicaid represents29percent($61 (SAMHSA) projectsthatby 2020Medicaid willcomprise30percentofallmental the average state percapitaincomecomparedtotheU.S. average. (FMAP),isdeterminedpercentage onanannualbasisandisdependentprimarily The federalshareoftheMedicaid program,known asthefederalmedicalassistance expenditures. health servicesnationwide, comprisingaquarterofallpublicbehavioral health government. Nationally, Medicaid isthelargest sourceofpublicfundingfor mental The Texas Medicaid programisjointlyfundedby thestate andthefederal MEDICAID FUNDING Waivers-by-State.html#texas https://www.cms.gov/outreach-and-education/american-indian-alaska-native/aian/ltss-roadmap/resources/state-federal-relationships/1915c- Health and Human Services,US Department of Centers for Medicare and Medicaid Services. (2016). 1915(c) Waivers by State. Retrieved from implementation.pdf Texas Health and Human Services Commission. Retrieved from Traylor, C. & Ghahremani, K. (August, 2014). Presentation to the Senate Health and Human Services Committee: SB 7 implementation. Retrieved from data request to agency Texas Health and Human Services Commission. (2016). Texas CHIP Behavioral and Mental Health Utilization CY 2014 [xls file]. from pay 44percentand43ofallcosts, respectively. rates for2016 and2017 are56.18 percentand57.13 percent;thatis, thestate must Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 63.17 percent.Figure23below shows Texas’ decliningFMAPfrom2004to2017. illustrate Texas’ trendofdecliningfederalMedicaid funding,in2004Texas’ FMAPwas American Reinvestment inplace.To andRecoverybut thosefundsarenolonger Act, This declinewas mitigatedby threeyearsofenhancedfederalfundsduetothe the state’s averagepercapitaincomehasincreasedrelative tothenationalaverage. Texas’ rateoffederalparticipationhasbeensteadily decliningover thelast decade,as intheFMAPcanresultmillionsof dollars offundingfluctuations.Small changes https://thlcportal.com/index.php/public# 58 TheSubstance Abuse andMental Health ServicesAdministration https://www.hhsc.state.tx.us/news/presentations/2014/SB-7- 59 61

60 Texas’ matching Medical and

HHSC Social Services Division Medicaid & CHIP Services 95 Requested 2019 Requested Requested 2018 62 http://kff.org/medicaid/state-indicator/federal- A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation $794,556,896 $821,596,273 $833,899,485 $642,151,261 $642,126,323 Expended 2015Expended Estimated 20162017 Budgeted AID ELIGIBILITY AND SERVICES AID ELIGIBILITY Total $25,058,109,060 $26,346,341,341 $31,467,379,104 $30,639,906,057 $31,738,166,888 Medicaid $24,263,552,164 $25,524,745,068 $30,633,479,619 $29,997,754,796 $31,096,040,565 Medicaid Contracts Admin. & Strategy In determining program eligibility, Texas considers a variety of factors such as of considers a variety Texas program eligibility, In determining and state citizenship, pregnancy status, income and family size, age, disability, must an individual to be eligible for Medicaid, In Texas, residency requirements. Categorical eligibility requires that income and categoricalmeet requirements. beneficiaries be part of specific population group. Source: Data Captured from HHSC Legislative Appropriations Request for FY 2018/19. September 12, 2016. 12, September 2018/19. FY for Request Appropriations Legislative HHSC from Captured Data Source: MEDIC programs to recipients of cash assistance only available originally was Medicaid and Supplemental (TANF) for Needy Families Assistance such as Temporary the federal during the late 1980s and early 1990s, Security Income (SSI). However, population, the needs of a broader expanded the program to meet government delinking and people with disabilities, including pregnant women, older adults, of cash assistance. eligibility from receipt Medicaid . matching-rate-and-multiplier/ Trends Medicaid Funding 24. Figure Source: The Henry J. Kaiser Family Foundation, State Health Facts. (2016). Federal Medical Assistance Percentage (FMAP) for Medicaid for (FMAP) Percentage Assistance Medical Federal (2016). Facts. Health State Foundation, Family Kaiser J. Henry The Source: from Retrieved download]. data [CSV 2004-2017) FY (Timeframe: Multiplier and Figure 23. Texas Federal Medical Assistance Percentage (2004-2017) Percentage Assistance Medical Federal Texas 23. Figure 96 Medical and Medicaid & CHIP Services Social Services Division HHSC Figure 25. IncomeLimitsforSelectMedicaidandCHIPEligibilityCategories whileFigure26shows theaccompanyingcategory Federal Poverty Levels for2016. currently ineligibleforMedicaid. two-parent household $251. ‡Eligibility is based on dollar amounts. In 2014, the allowed monthly income for a single-parent household was $230 and for a †Category includes only pregnant women and children with medical bills exceeding the monthly Medicaid income limit *Long-term Care Medicaid includes nursing facility and long-term care waivers administered by DADS. 15 percentofFPL. household incomeisbelow $251amonth(fortwo-parenthousehold);thatisapproximately Currently inTexas, low-income parentsareeligibletoreceive Medicaid onlyiftheir childless adultsandsomeworkinglow-income parents. continue toexclude many individualswithmentalillnessfromcoverage, including decision not toexpandMedicaid eligibilitymeansthatTexas eligibilityruleswill disability status. Texas haselectednot toparticipateintheexpansiondate.The percent oftheFederal Poverty parentalstatus, Level (FPL),regardlessofage, or option toexpandeligibilityforMedicaid toalladultswithincomesatorbelow 133 In 2014,governmentAct, thefederal granted undertheAffordableCare states the · · · · · · · include: categories There aremultipleMedicaid inTexas. eligibilitycategories Someofthe primary severe psychological distress, and11percenthave asubstance usedisorder. eligible forMedicaid expansionhasaseriousmentalillness(SMI),11percentexperience environment. and 255,000 withsevere psychological distress couldbeserved inanexpandedMedicaid to thesedata,approximately 130,000 uninsuredTexas adultswithseriousmentalillness Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

Children and pregnant women who ov Adults Individuals receiving Supplemental Security Parents and care Families receivingTemporary Assis Pregnant women and infants 18andunder Children age er age 65and people with disabilitieser age 67 Figure 25 shows the income eligibility requirements for each Medicaid Figure25shows theincomeeligibilityrequirementsforeachMedicaid 64 Childlessadultswhoarebelow66anddonot have age adisability are taker relatives 65 SAMHSA estimated that 6 percent of the population SAMHSAestimated that6percentofthepopulation tance for NeedyFamilies (TANF) qualify asmedicallyneedy Income (SSI) 63 66 According According Medical and

HHSC Social Services Division Medicaid & CHIP Services 97 $97,200 $48,600 $32,319 $24,300 $3,645 Family of Four Family $47,520 $23,760 $15,800 $11,880 $1,782 Individual . https://aspe.hhs.gov/poverty-guidelines Mental health assessment and diagnosis and assessment health Mental professional licensed workers, social clinical licensed psychologists, psychiatrists, by Therapy therapists family and marriage licensed and counselors, hospital care acute general a in care psychiatric Inpatient older and 65 those and 21 under persons for hospitals psychiatric Inpatient medications Prescription persistent and severe with people for services management case targeted and Rehabilitative disturbance emotional severe with children or mental illness conditions health behavioral treat or diagnose to required services Ancillary physician of care primary a by provided conditions treatment and health behavioral Care participants waiver YES for services community Comprehensive facilities state-licensed by counseling dependency chemical adolescent Outpatient services for need client’s a determine to Assessment counseling treatment disorder use substance outpatient group and Individual therapy assisted Medication detoxification residential and Outpatient treatment Residential A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Retrieved from from Retrieved http://www.hhsc.state.tx.us/medicaid/about/PB/PinkBook.pdf . http://www.hhsc.state.tx.us/medicaid/about/PB/PinkBook.pdf 400% 200% 133% Substance Use Substance Mental Health Service CategoryService Services Medicaid 100% 2016 Federal Poverty Level Poverty 2016 Federal 15% , 6-20 and 6-23. and 6-20 edition, tenth perspective in CHIP and Medicaid Texas (2015). Commission. Services Human and Health Texas Source: from Retrieved Source: US Department of Health and Human Services. (2016). U.S. federal guidelines used to determine financial eligibility for certain for eligibility financial determine to used guidelines federal U.S. (2016). ofDepartment US Source: Services. Human and Health . programs federal access to the mental health and children, have adults both recipients, Medicaid as psychiatric State Plan, such use services included in the Medicaid and substance also counseling, medication, and medication management. Medicaid services, providers, approved and targeted case managementfunds rehabilitative services by (LMHAs) operating under DSHS. Authorities Health primarily the Local Mental programs that offer waiver Medicaid-funded several in addition, administers DADS, These supports to specialized populations. health or long-term services and behavioral sections of further described in the DSHS and DADS services and eligibility criteria are Medicaid. by covered health services of behavioral this guide. Figure 27 contains a list Services Health Medicaid Behavioral Approved 27. Figure Figure 26. Annual Household Income for Federal Poverty Level Guidelines (2016) Level Poverty Federal Income for Annual Household 26. Figure , 5-1 to 5-9. to 5-1 edition , tenth perspective in CHIP and Medicaid Texas (2015). Commission. Services Human and Health Texas Source: from Retrieved 98 Medical and Medicaid & CHIP Services Social Services Division HHSC Status (2016) Figure 28. Texas MedicaidCaseload andExpenditures by Age andDisability https://hhs.texas.gov/texas-medicaid-and-chip-pink-book. Medicaid andCHIPinPerspective, commonlyknown asthe“PinkBook”,available at For moreinformationregardingMedicaid, consultHHSC’s latest editionofTexas enrollees andprogramexpendituresby anddisability age status. of total estimated expenditures. account for26percentoftheMedicaid populationbutrepresentover 60percent by state andfederalgovernments. AswithMedicaid, CHIPisjointlyfunded 1997 underTitleXXIoftheSocialSecurityAct. The federalgovernment createdtheChildren’s Health InsuranceProgram(CHIP)in Ch 2016. Retrieved from http://www.hhsc.state.tx.us/news/presentations/2016/040616-hhsc-ltss.pdf . Source: HHSC presentation to House Appropriations Subcommittee on Article II: Medicaid Long Term Services and Supports. April 6, of21. was undertheage benefits. In2013, 55percentofthe Medicaid population was femaleand77percent Women andchildrenaccountforthemajorityofindividuals receivingMedicaid DEMOGRAPHICS OFMEDICAID RECIPIENTS or purchasing ontheindividualmarket. for Medicaid, butnot enoughtoafford privateinsurance,either throughemployment option forchildrenwhose familieshadtoomuchincomeormany assets toqualify The federalgovernment developed CHIPtoprovide ahealthinsurance coverage CHIP ELIGIBILITY under asingleadministrative umbrella,Texas administers theseprogramsseparately. care services. of allMedicaid recipientsbutrepresentonly31percentofspendingondirect health Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas CHIP Plan. develop, andthatthe CentersforMedicare andMedicaid Services(CMS)approve, astate ildren’s He 72 WhileCMSallows states tocombinetheirMedicaid andCHIPprograms 69 Incontrast, individualswhoareelderlyorhave adisability only 68 a Childrenwithoutdisabilities comprisenearly67percent lt h 70

71 I Figure28displays thepopulationofMedicaid State participation in CHIP requires that the state StateparticipationinCHIPrequiresthatthestate nsur 73 CHIP is available to children ages 0–18 CHIPisavailable tochildrenages who a nce P rogr a m Medical and

HHSC Social Services Division Medicaid & CHIP Services 99 82

Requested 2019 Requested In 2014, In 2014, 76 79 Requested 2018 Monthly CHIP enrollment Monthly 77 HHSC that 70 percent of the CHIP estimates 81 This drop in enrollment is consistent with the expected This drop in enrollment is consistent 78 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation $10,998,892 $12,760,126 $12,714,677 $15,744,225 $15,744,225 Expended 2015Expended 2016 Estimated 2017 Budgeted $867,568,090 $868,632,909 $938,854,839 $988,775,530 $1,024,093,067 Texas has also opted to administer a CHIP perinatal program which covers program which covers CHIP perinatal a to administer has also opted Texas 75 For these children, CHIP provides access to health care, including inpatient care, including access to health CHIP provides these children, For 74 CHIP & Contracts Admin. Strategy Total $878,566,982 $881,393,035 $951,569,516 $1,004,519,755 $1,039,837,292 CHIP Services levels increased steadily in the decade leading up to 2014, reaching more than in the decade leading up to 2014, steadily increased levels the program however, (see Figure 30). In 2014, members per month in 2013 600,000 children under 400,000 just experienced a decline in enrollment. In October 2015, were enrolled in CHIP. therefore, Texas and 21 other states transferred all CHIP enrollees with household transferred all CHIP enrollees with household states and 21 other therefore, Texas into Medicaid. and 133 percent of the FPL 100 percent incomes between effects of a 2014 ACA requirement directing states to expand Medicaid eligibility states to expand requirement directing ACA effects of a 2014 to agefrom 100 percent to 133 percent of the FPL for children up 19. CHIP FUNDING the coming biennium. funding and projections for trends of past provides The figure below Trends CHIP Funding 29. Figure Source: Data captured from HHSC Legislative Appropriations Request for FY 2018-19. September 12, 2016. 12, September 2018-19. FY for Request Appropriations Legislative HHSC from captured Data Source: ENROLLMENT the ages 61 percent between of 6 with age 5, over The majority of CHIP clients are the ages of 15 and 18. and 22 percent between and 14, are ineligible for Medicaid and who are living in households with an income of up an income with households living in who are and for Medicaid are ineligible of a family for $48,600 of approximately income (annual of the FPL percent to 201 four). budget is spent on inpatient and outpatient hospital services and physician services, services, and physician spent on inpatient and outpatient hospital services is budget and the remaining 15 percent on administration. drugs, 15 percent on prescription and outpatient mental health and substance use services. In contrast to Medicaid, to Medicaid, In contrast use services. and substance mental health and outpatient that are based fees and co-payments through enrollment sharing cost CHIP requires fee for a 12-month a $50 enrollment up to pay may Families income. on a family’s period. perinatal services, including labor, delivery, and post-partum care for women and their care for and post-partum delivery, including labor, perinatal services, percent of the FPL. household incomes of up to 201 unborn child with CHIP has experienced sporadic spending growth in the last decade. However, the However, decade. in the last CHIP has experienced sporadic spending growth an 11 percent $1.8 billion to CHIP, appropriated approximately budget 2016-2017 budget. reduction from the 2014 100 Medical and Medicaid & CHIP Services Social Services Division HHSC 50 column indicatesthatTexas’ 2014 performanceonthemeasureexceeded theHEDIS behavioral healthqualityofcaremeasures. Acheckmarkinthe“benchmark” Figure 31presentsTexas’ performancestatistics forselectMedicaid andCHIP care, includingbehavioral healthservices. are usedacrossthecountrytomeasureperformancein importantareasofhealth establishes.alternatively tobenchmarksthatHHSC ThenationalHEDISstandards national Healthcare Effectiveness DataandInformationSet (HEDIS) standards, or programs. Theannualquality ofcareevaluationcomparesTexas’ performancetothe to performtheexternal qualityreviewfortheTexas Medicaid Care Managed Texas contractswiththeUniversity ofFloridaInstitute forChildHealth Policy Quality ofCarePerformance Renewals, Attempted Renewals, and Disenrollment by Month each year.Note: Data are from October of Source: Texas Health and Human Services Commission. (2015). Figure 30. MonthlyCHIP Enrollment (2010-2015) CHIP/ChipDataTables.asp where Texas lags behindmost other states onagiven performanceindicator. above average comparedtotherest ofthecountry. Nocheckmarkindicatesanarea Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas th percentilenationally–inother words, showing whereTexas isperformingator (XLS) [data file]. Retrieved from http://www.hhsc.state.tx.us/research/ Statewide CHIP Enrollment, Medical and

HHSC Social Services Division Medicaid & CHIP Services 101 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Benchmark HEDIS ≥ - Percen 50th tile 32% 39%58% 60%0.30 42% 0.25 64% N/Aa N/A 45% 59% 57% 34% 43% 43% 1.68 1.43 N/Aa N/A 87% 86% 83% 63% 59% 61% 59% 93% 93% 52% 88% 89% 60% 44%47% 31%31% 42% 30%54% 30% 51%5.52 34% 5.41 57% N/Aa N/A 32% 32%55% 54%0.21 37% 0.23 61% N/Aa N/A 51% 62% 67% 39% 47% 50% TX Performance Rate Performance TX 2012 2013 2014 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Follow-up care after hospitalization for men- for hospitalization after care Follow-up days 7 within illness tal Follow-up care after hospitalization for men- for hospitalization after care Follow-up days 30 within illness tal (per Readmissions Preventable Potentially months) 1,000 member After continuously taking medication to treat treat to medication taking continuously After follow-up additional two least at had ADHD Phase) (Continuation months 9 within visits After dispensed new medication to treat treat to medication new dispensed After days 30 within visit follow-up a had ADHD Phase) (Initiation Potentially Preventable Readmissions (per Readmissions Preventable Potentially months) 1,000 member Follow-up care after hospitalization for men- for hospitalization after care Follow-up days 30 within illness tal Follow-up care after hospitalization for men- for hospitalization after care Follow-up days 7 within illness tal Follow-up care for children prescribed ADHD prescribed children for care Follow-up phase continuation the at medication medication at the initiation phase initiation the at medication Antidepressant medication management at management medication Antidepressant phase acute the Antidepressant medication management at management medication Antidepressant phase continuation the men- for hospitalization after care Follow-up days 7 within illness tal men- for hospitalization after care Follow-up days 30 within illness tal (per Readmissions Preventable Potentially months) 1,000 member Follow-up care after hospitalization for men- for hospitalization after care Follow-up days 7 within illness tal Follow-up care after hospitalization for men- for hospitalization after care Follow-up days 30 within illness tal (per Readmissions Preventable Potentially months) 1,000 member Follow-up care for children prescribed ADHD prescribed children for care Follow-up phase continuation the at medication Follow-up care for children prescribed ADHD prescribed children for care Follow-up phase initiation the at medication CHIP STAR Health STAR ADHD prescribed children for care Follow-up STAR+PLUS STAR Program Measure 2014 data on potentially preventable readmissions for Medicaid managed care are not included in the new the in included not are care managed Medicaid for readmissions preventable potentially on data 2014 a Figure 31. Selected Behavioral Health Quality of Care Measures for Medicaid for Medicaid Measures of Quality Health Behavioral Selected Care 31. Figure (2012-2014) CHIP Programs and External Quality Review Organization report. Organization Review Quality External 102 Medical and Medicaid & CHIP Services Social Services Division HHSC https://thlcportal.com/index.php/public# Texas Healthcare Learning Collaborative, Institute for Child Health Policy. (2016). Texas care reporting. Medicaid quality of Retrieved from http://www.hhsc.state.tx.us/reports/2014/EQRO-Healthcare-Summary-Report-2013.pdf Program, external activity and trends quality review in healthcare organization quality, summary of Contract Year 2013. Retrieved from Institute for Child Health Policy Florida. at the University of (2014). https://hhs.texas.gov/sites/hhs/files//eqro-summary-healthcare-2014.pdf Program, external activity and trends quality review in healthcare organization quality, summary of Contract Year 2014. Retrieved from Institute for Child Health Policy Florida. at the University of (2015). Sources: Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Texas Medicaid managed care and Children’s Health Insurance Texas Medicaid managed care and Children’s Health Insurance

Medical and

HHSC Social Services Division Community Services 103 abilities and Behavioral Health Services abilities and Behavioral Health elopmental, and Independence Serviceselopmental, and Independence A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Intellectual and Developmental Dis Intellectual and Developmental Dev Health,

· spread The programs and services included in this division were previously All four of the units under these two and DSHS. DARS, DADS, throughout HHSC, other health services in addition to departments offer some type of behavioral For and mental health conditions. services and supports for people with disabilities program areas that offer the purposes of this guide, we will focus on the service and or supports. health treatment, services, of behavioral some level Source: Texas Health and Human Services Commission. (August 2016). A Report to the Legislature: Health and Human Services System System Services Human and Health Legislature: the to Report A 2016). (August Commission. Services Human and Health Texas Source: Plan. Transition Services and Social Services Division is SectionThe Community of the Medical The programs in a wide range 70 programs delivering of services. comprised of over two major departments: following this section are organized into the · Community Services Community 104 Medical and Community Services Social Services Division HHSC Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Intellectual and Developmental Disabilities & Behavioral Health Services 105 Disability Services Disability ealth Services; and A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Behavioral H Behavioral & Developmental Intellectual

Information on these units is provided in this section. Information on these units is provided · The Intellectual and Developmental Disabilities & Behavioral Health Services Health & Behavioral Disabilities and Developmental The Intellectual individuals for services responsibility for community Department combines health and those living with mental disabilities with intellectual/developmental This Department is one associate commissioner authority. conditions under responsible for: · Intellectual and Developmental and Intellectual Health Behavioral & Disabilities Services Behavioral Health Services (formerly provided through the Department of State Health Services) Policy Concerns

· Ensuring access to quality community-based behavioral health services through integrated service delivery and managed care models that emphasize prevention and continuity of care. · Addressing the critical shortage of mental health professionals, particularly in rural areas. · Expanding peer specialist, recovery coach, and family partner support services. · Successfully implementing the statewide expansion of YES waiver services to better support children with complex needs and keep them in their communities whenever possible. · Repairing and replacing the physical infrastructure of the aging state hospital system. · Improving client outcome performance measures to focus more on behavioral outcomes and patient-centered recovery, and less on easy-to-measure outputs (e.g., enrollment numbers). · Reducing the time people spend incarcerated while waiting for competency restoration services. · Ensuring that state hospital prescription drug formularies align with jail formularies so that individuals are able to retain progress and maintain continuity of care between both settings. Fast Facts

· The population growth in Texas between 2010 and 2015 (9.2 percent) was double the national average and the highest of all 50 states, increasing demand for DSHS services.83,84 · As of July 2015, 81 percent of counties in Texas (206 out of 254) were designated as full or partial Mental Health Professional Shortage Areas.85 · As of June 2016, Texas has 846 people trained as certified peer specialists and 526 individuals with active peer specialist certifications, enabling them to use their lived experiences with behavioral health issues to help recipients of DSHS-funded services. · NorthSTAR — a managed care pilot program providing DSHS-funded behavioral health services for seven counties around Dallas — will be discontinued on January 1, 2017. · There is an increasing number of individuals on waiting lists for forensic inpatient beds — 414 people as of February 2016, more than four times as many as there were in 2013.86 · In FY 2014, there were 240,088 adults with serious and persistent mental illness living below 200 percent of the Federal Poverty Level (FPL) in Texas. Of these, only 72 percent received DSHS-funded services through community mental health centers or NorthSTAR.87 · Similarly, only 38 percent of the 126,052 children with a serious emotional disturbance living below 200 percent of FPL received DSHS-funded mental health services in FY 2014.88

106 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 107 continuum of care. continuum of es to institutionalization; and es to institutionalization; very and resilience; and very A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation ckground Focused on alternativ on Focused the full of services on Comprised Person-centered; reco in Rooted

The HHS system prioritizes access to treatment for serious mental health conditions The HHS system · · Public Texas of the Within Timeline Selected Major Developments 32. Figure System Mental Health · Public behavioral health services are mainly comprised of community mental mental comprised of community are mainly health services Public behavioral provided These services are hospital services. use, and inpatient health, substance and (LMHA) regions authority local mental health through the 39 to residents The 254 counties. Texas’ in all of (RHPs) healthcare partnerships 20 regional for responsibility oversight (MSSD) will have and Social Services Division Medical Division (SFD) will while the State Facilities health services community behavioral services. of inpatient oversight have at DSHS and HHSC decade, staff has worked the past over Despite limited funding in behavioral innovations efforts to implement made consistent with legislators and of key a timeline Figure 32 shows through major initiatives. health service delivery system more modern a general shift toward DSHS’ and reforms that reflect events mental health services that are: that emphasizes · Ba 108 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC community publichealthservices(e.g.,maternalandchildprograms). immunizations), publichealth(e.g.,foodsafetyresponse)and andemergency its missionofpublichealthby refocusingitonissues suchasinfectiousdisease(e.g., (see Figure81:DSHSOrganizationalStructureAfterSeptember 1,2017). departments: PublicHealth Operations, Infectious Disease,andCommunityHealth will focusmorenarrowly onpublichealthissuesandbesplitintothreedistinct The 84 Cha see theTexas Environment section. health services. For moredetailed informationontheentiretransformationplan, health andbehavioral healthservicesduringthesystem-wide transformationof DSHS andtheHHSsystem asawholeaimtomaintainseamlessoperationof public September 1,2017. hospitals scheduledtomove tothenewStateFacilities by DivisionwithinHHSC Medical andSocialServicesDivision,withstate transferred tothenewHHSC As ofSeptember 1,2016, allofDSHS’ communitybehavioral healthprogramswere the 84 In anefforttoimprove theefficientcoordinationandqualityof statehealthservices, S input theirzipcodeandfind available behavioral healthservicesintheirarea. improve accesstoinformationby actingasacentraldatabasewhereindividualscan system, DSHSdeveloped thewebsitewww.mentalhealthtx.org, whichaimsto appropriate fortheirlevel ofneed.PriortoitstransitiontheconsolidatedHHS mental healthconditionscanreceive thelevel ofcareandsupportthatareclinically services. Texas continuestoseekways toimprove accesssothatindividualswith delivery systems aretheprimarydeterminants oftheaccessibilityandquality under theprioritypopulationscriteria.Resources, eligibilityforservices, andservice for individualswhoareeligibleMedicaid, determinedorwhofall tobeindigent, within thenewHHSsystem. Licensing andRegulation(TDLR),orthenewlycreatedRegulatoryServicesDivision programs willbetransferredtotheTexas Medical Board,theTexas Departmentof facilities, andoccupations. By September 1,2017, allofDSHS’ regulatory andlicensing more thanadozen programsthatlicenseandregulatehealth-relatedbusinesses, directed inthe83 ofthestate’smanagement behavioral healthcaresystem. Additionally, changes Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas for Medicaid clientsandindividuals withvery low incomewhoarenot eligible care modeltointegratesubstanceuse amanaged useandmentalhealthservices The Texas Legislature createdtheNorthSTAR programin1999an attempt to DISCONTINUATION OF THE NORTHSTAR PROGRAM monitoring. require ongoing health services. how state andstate-funded agencies programsdeliver behavioral, physical, andpublic passed SB200(84 unset th nging th Legislaturefollowed recommendationsfromtheSunset Commissionand Legislative Session brought significant changes tothedelivery Legislative and Sessionbroughtsignificantchanges a 89 nd InregardstoDSHSspecifically, SB200redirectedDSHStoward rd th 91 E Legislative Sessionarecontinuingtobeimplementedand , Nelson/Price).Thislegislationreorganizedandrestructured Inadditiontoclientservices, DSHShasalsohistorically managed nvironment T r a ns 92 Following theSeptember 1,2017 deadline,DSHS f orm a tion Hig h lig h ts 93 90 Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 109 , th

95 Legislature (SB 200, 84 (SB 200, Legislature th and ery of forensic services, including the services, ery of forensic , Garcia/Naishtat) requiring DSHS to appoint, Garcia/Naishtat) requiring DSHS th

96 of forensic patients from inpatient settings to from inpatient settings patients of forensic 98 As a result of recommendations from the Sunset Advisory Sunset from the of recommendations As a result 94 erseeing forensic services, including competency exams, exams, including competency services, erseeing forensic , Otto/Nelson) assumes the discontinuation of NorthSTAR of NorthSTAR the discontinuation assumes , Otto/Nelson) th The most up-to-date information on the progress of the Joint on the progress of the Joint up-to-date information The most 99 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation As of spring 2016, both NTBHA and LifePath Systems had met required met had Systems LifePath NTBHA and both As of spring 2016, 97 Addressingissues concerning the deliv Facilitating the transition Facilitating programs; or community-based services outpatient community; forensic monitoring in the Managing research and training; forensic Coordinating Coordinating and ov Coordinating competency restoration services, and mental health services provided in the in health services provided and mental services, restoration competency facilities; at DSHS or community system. illness in the criminal justice with mental of people involvement increased

Commission and subsequent legislation passed by the 84 by legislation passed and subsequent Commission · · · The bill requires the forensic director to work with a group of experts and The bill requires the forensic director to work with a group forensic service for improved recommendations to develop stakeholders on Access Committee and Forensic the Joint coordination. This workgroup, including different organizations, includes more than a dozen Services, (TDCJ), of Criminal Justice Department Texas DSHS, from HHSC, representatives Office on Offenders Correctional Texas Department (TJJD), Justice Juvenile Texas local mental health authorities Impairments (TCOOMMI), or Mental with Medical Disability Hospital Association, Texas Texas, (LMHAs), Sheriff’s Association of in the social, health, and legal aspects of agencies involved and other Rights Texas, forensic services. a statewide forensic director in order to improve the coordination and oversight of the coordination and oversight forensic director in order to improve a statewide director for mentalstate forensic The first Texas. forensic mental health services in include: responsibilities director’s The 2016. appointed in February health was · · Rider 85 in HB 1 (84 Rider 85 FORENSIC DIRECTOR POSITION FORENSIC DIRECTOR passed SB 1507 (84 legislators In 2015, and reallocates funds to the successor agencies funds to the and reallocates for responsibility take that will 2017. clients by NorthSTAR’s for Medicaid. In FY 2015, NorthSTAR provided services for 71,913 individuals individuals for 71,913 services provided NorthSTAR In FY 2015, for Medicaid. Kaufman, Hunt, Ellis, Collin, — Dallas, Texas in North region in a seven-county and Rockwall. Navarro, benchmarks for the transition and were on schedule to take over NorthSTAR’s NorthSTAR’s over to take transition and were on schedule benchmarks for the professionals from During this transition period, 2017. January responsibilities by their IT to develop Systems DSHS and HHSC and LifePath helped NTBHA have of their networks and strengthen local funding streams, diversify infrastructure, health providers. behavioral Committee on Access and Forensic Services workgroup can be found at: https:// can be found Services workgroup on AccessCommittee and Forensic . dshs.texas.gov/mhsa/SB1507/SB-1507.aspx There are plans in place to transfer NorthSTAR’s responsibilities for providing for providing responsibilities place to transfer NorthSTAR’s There are plans in Texas North providers; local use services to other substance mental health and provider health will become the behavioral (NTBHA) Authority Health Behavioral counties Hunt, and Rockwall Kaufman, Navarro, Ellis, Dallas, for individuals in in Collin LMHA responsibilities NorthSTAR’s over will take Systems while LifePath County. Nelson/Price), funding for NorthSTAR will be discontinued on January 1, 2017. on January be discontinued will NorthSTAR funding for Nelson/Price), 110 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC During the84 restoration programin 2015. to theseconcerns, DSHSissuedreviseddraftrulesforthejail-basedcompetency · · director role: SB 1507alsoincludedtwoother provisions relatedtothenewforensic tangentially 2016 and2017. $1.74 million annuallytofundthejail-basedcompetency restoration pilot forFY Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas more consistency andoverlap withJBCRmodelsinother states. providing servicesandprogrammingduringregularbusinesshoursrequired discussion oftheinitialdraftrulesthatTexas JBCR pilot neededtofocuson only presentintherapeuticenvironments. Itwas alsodetermined duringpublic competency restoration programs requirestaffing ratiosand otherresources not traditionallybeentherapeuticenvironments, andthatthemost effective release ofthepilot program’s draftrules, advocates raisedconcerns that jailshave and didnot beginonschedule (duringthe2014-2015 biennium).Uponinitial services. TheJBCRpilot programhasfacedsignificantbarrierstoimplementation The pilot programwas projected toprovide 20bedsforjail-basedrestoration program includes: restoration programinCaliforniasimilartotheoneproposed inTexas. That to LibertyHealthcare Corporation(LHC).LHCrunsajail-basedcompetency proposals toimplementandoperatetheJBCRpilot, andthecontractwas awarded SB 1475 (83 ONGOING JAIL-BASED COMPETENCY RESTORATION PILOT PROGRAM (LMHA). through acontractwithprivatecontractororlocalmental healthauthority a workgroup in2013 toset rulesforthepilot programthatwouldbedeveloped residential carefacilityforcompetency restoration services. SB1475 alsoestablished individuals whootherwise wouldbecommitted toamentalhealthfacilityor services throughajail-basedcompetency restoration (JBCR) pilot programfor

(83 SB 1507 also requires DSHS torecon ordered to receive mental health services. hospitalization for forensic patients who areeligible for diversion andcourt Texas. The training must include information on alternatives to inpatientstate andattorneysdevelop a mentalhealth-related training curriculum for judges in DSHS, the forensic Joint andForensic Committee on Access Services took onthisfunction. funded psychiatric beds and abedutilization review protocol. Thenewlycreated distinct bed-allotment regions and adopt anallocation methodology forstate- · · · · ·

rd , Coleman/Hinojosa) to workwith stakeholders to dividethe state into Psychological assessments Weekly casereviews Weekly follow Twice daily1:1sessionswithastaff member Daily groupmeetings 100 DSHSreceived onlyoneproposal inresponsetoitsinitial request for rd , Duncan/Zerwas) authorizedDSHStoprovide competencyrestoration th 103 Legislature,Rider70inthe DSHSsectionofArticleIIappropriated DSHSstated ofthe JBCRpilot thatthegoals are: director, andthe Court of Criminal Appealsarerequired to -up sessionswithapsychiatrist . 101

vene anadvisory panel createdby HB3793 102 Inresponse Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 111

104 Among other Among other

105 112 In 2016, HHSC In 2016, 111 JBCR proposals that met that met JBCR proposals 106 Also passed in 2015, Rider 73 in the Also passed in 2015, ViaHope has also provided 889 has also provided ViaHope , Hinojosa/Rodriguez) improved improved , Hinojosa/Rodriguez) 113 th 110 Peer support specialists are a cost- support specialists Peer 108,109 clinical and financial effectiveness of the JBCR pilot. of the JBCR effectiveness clinical and financial tress of incarceration for individuals enrolled in the JBCR pilot; enrolled in the JBCR pilot; for individuals of incarceration tress 107 Legislative session, SB 578 (84 Legislative A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation th a cost-effective alternative to providing restoration services in state in services restoration to providing alternative a cost-effective access to competency restoration services for individuals who do not who do not for individuals services restoration competency access to are determined to be incompetent to stand trial (IST) due to behavioral to behavioral (IST) due trial to stand be incompetent to are determined qualify for outpatient competency restoration (OCR) services; (OCR) restoration competency outpatient qualify for the s minimize To and data on the collect To To provide provide To develop To To reduce the number of individuals on the State Mental Health Program waiting waiting Program Health Mental State on the of individuals the number reduce To who list hospitals; health issues; health

efficient and effective intervention that can reduce the need for other more intensive other more intensive that can reduce the need for intervention efficient and effective the outcomes for both and improved costs in lower resulting services, and expensive as a whole. individual and the healthcare system the initial certification developed Foundation and the Hogg Via Hope, DSHS, ViaHope 2016, As of June in Texas. requirements for mental health peer specialists certifications) and (526 active 846 certified peer specialists has trained over certifications). 183 family partners (127 active the new program requirements were due on March 4, 2016 but because DSHS did due on March 4, 2016 the new program requirements were the future of the JBCR they received, of the proposals the contract to any award not is uncertain. pilot specialized trainings (e.g., “Trauma Informed Peer Support” and “Co-occurring Support” and “Co-occurring specialized trainings (e.g., “Trauma Informed Peer family partners. and Disorders”) for certified peer specialists Associate Commissioner for Mental Health Services Sonja Gaines called peer Services Sonja Gaines Health Associate Commissioner for Mental done.” things we have effective services “one of the single most CONTINUED EXPANSION OF PEER SUPPORT SERVICES OF PEER SUPPORT EXPANSION CONTINUED from behavioral that has increased opportunities for recovery initiative Another and certified peer support specialists health conditions is the use of certified lived both individuals who have support programs allow Peer coaches. recovery experiencing mental of others to aid in the recovery experience and relevant training self-direction, responsibility, wellness, focusing on recovery, health conditions by deemed an evidence-based been support services have and independent living. Peer (CMS) and reimbursed Services and Medicaid the Centers for Medicare practice by Services Health Mental and Abuse and the Substance since 2007, Medicaid by in their peer support interventions several lists Administration now (SAMHSA) database of evidence-based programs. · · · · · access to peer services by requiring peer support specialists to be included in the requiring peer support specialists access to peer services by to individuals mandated to be given that are now resource packets county-specific when they are discharged from TDCJ facilities. DSHS section of HB 1 appropriated $1 million for the 2016-17 biennium for DSHS DSHS section of HB 1 appropriated $1 million for the 2016-17 program for individuals with mental to design and implement a peer support pilot changes, the updated 2015 rules increased staffing standards by requiring that “the by requiring standards staffing rules increased the updated 2015 changes, providers and the JCBR program are more substantial shift has services that day and welfare of safety to ensure the for collaborating with jail staff will be responsible hours.” night, and weekend evening, participants in the During the 84 DSHS distributed a new Request for Proposals in January 2016. in January Proposals for a new Request DSHS distributed 112 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC plan ofcare. available tocreateanintensive, comprehensive, andindividualizedchildfamily ofMedicaidfull range services, non-traditionalservices andfamilysupportsare and out-of-homeplacementforchildrenwithseriousemotional disturbance. A psychiatric hospitalexpenses, voluntary parental relinquishmentstoobtain care, based waiver3to19yearsoldintendedreduceMedicaid programforchildrenages Youth isaMedicaid 1915(c)homeandcommunity- Empowerment Services(YES) IMPLEMENTATION OF THE STATEWIDE EXPANSION OF THE YES WAIVER benefits ofpeersupportservices, seethe Texas Environment section. innovative treatments, suchasintensive in-homesupportorspecializedtherapies. respond welltotraditionaloutpatientservicesandmighthave better success through behavioral healthneeds. Theseservicesareparticularlyeffective foryouthwhodonot community-based coordinatedcareforyouthwithparticularlycomplexorsevere The YESwaiver programoffersanalternative toinpatienttreatment by providing family incometodetermine eligibility. legislative session (Rider60). The YESwaiv · · · · · · · · · · individuals inFY2017. that thisreentrypeersupportprogramwillserve 96individualsinFY2016 and648 illness whoarere-enteringthecommunityafterincarceration. DSHSestimated health peerandrecovery specialist services. requirements, anditwouldhave expandedMedicaid reimbursementtoincludemental support andrecovery specialist services, certificationrequirements, andsupervision todefineinrulementalhealthpeer to pass;HB1541wouldhave requiredHHSC Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas available. ServicesofferedthroughtheYES waiver programinclude: with communityserviceproviders toensureallrequiredYESwaiver servicesare waiver servicesineachoftheirrespective serviceregions. LMHAsthencontract YES contractswithlocalmental healthauthorities(LMHAs)tomanage HHSC Medicaid, YESwaiver servicesarejointlyfundedby states andthefederalgovernment. be extended ifthereisstill clinicalneedfortheservicesprovided. Aswithtraditional Services undertheYESwaiver areinitiallyauthorizedforan18-monthperiodbutcan services underMedicaid andMedicare. InTexas, HB1541(84 effortatthefederallevel toexpandcoverageThere isalsoanongoing ofpeersupport pilot, seetheTDCJsection.

Transitional services Supportive family-based Respite Professional and paraprofessional services Non-medical transportation Minor home modifications Family supports Community living supports Adaptiv Comprehensive case manag e aids andsupports 116 er programwas approved forstatewide expansionduringthe84 Aswithother 1915(c)waivers, YESwaivers donot take intoaccount 114 For amoredetailed description ofthereentrypeersupport alternatives 119 ement By September 2015, every LMHA inTexas had started 115 For amorethoroughdiscussionofthe th , Burkett/Perry) failed 118 th

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Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 113 Figure 120,121 In February 2016, 2016, In February 122 126 Legislature also appropriated th http://www.dshs.texas.gov/WorkArea/linkit. HHSC in the process of is also 124 123 from Retrieved Between January 2014 and the beginning of 2016, and the beginning of 2016, 2014 January Between 125 Number of Children and Youth Enrolled in YES Waiver Services Waiver YES in Enrolled Youth ofNumber and Children 46 63 167 294 722 1,237 Legislative Session) at residential treatment centers Legislative rd A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 2011 2012 2013 2014 2015 2016 Year DSHS began requiring that children at “imminent risk” of being relinquished to at “imminent risk” of being DSHS began requiring that children Services. be prioritized for YES Waiver the state (RTCs). These 30 beds are specially allocated for the prevention of parental These 30 beds are specially allocated for the prevention (RTCs). (SED) solely to disturbance relinquishment of children with serious emotional mental health services. obtain aspx?LinkIdentifier=id&ItemID=8590006580 expansion, the 84 statewide In addition to the waiver Presentation to the Select Committee on Mental Health: Children’s Children’s Health: Mental on Committee Select the to Presentation 2016). 22, (March Jessee. Gary & Lewis Lacefield Lauren Source: ofDepartment Services. Health State Texas Services. Health Mental more youth with serious even should allow The expansion of the YES waiver health community behavioral (SED) to access intensive disturbance emotional are inpatient care and/or of children who receive services and decrease the number Services (DFPS) solely and Protective Family relinquished to the Department of mental health services. because of an inability to access needed providing YES waiver services to individuals across the state, and funding for the funding and state, the across to individuals services waiver YES providing changedprogram 2016. in April dollars general from to Medicaid revenue . at www.dshs.state.tx.us/mhsa/yes/ updates and information are available YES Waiver AND PERFORMANCE MEASURES OUTCOME OF CLIENT IMPROVEMENT and update the outcomes in an ongoing process to improve DSHS has been involved 61 children were served by these specially-allocated RTC beds — 25 of those children RTC these specially-allocated by 61 children were served 54 of them (89 and successfully discharged back into their home from the RTC program criteria. Thirteen after meeting custody percent) remained in their parent’s altogether as a result of receiving outpatient stay an RTC children were able to avoid or at their local LMHA. services through the YES Waiver $4.8 million to create an additional 20 beds (30 total, as funding for 10 beds was as funding for 10 beds was $4.8 million to create an additional 20 beds (30 total, appropriated during the 83 33 shows that enrollment in YES waivers has increased steadily over the past six years: the past over steadily has increased in YES waivers that enrollment 33 shows 2011-2016 Enrollment: Waiver Services (YES) Empowerment Youth 33. Figure approving a YES Waiver amendment (Amendment #9) that would make children children that would make (Amendment #9) amendment a YES Waiver approving Up-to-date services. YES Waiver conservatorship eligible to receive who are in state of this amendment can be found at www.dshs.texas.gov/ information on the status . mhsa/yes/Proposed-Waiver-Amendments.aspx 114 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC Following madeby thechanges the83 using theCANS andANSAassessments. SeetheDFPS sectionformoreinformation. client outcomedata.TheDepartmentofFamily Protective Serviceshasalsobegun isfortheCANSgoal andANSAtoimprove andconsistencyofDSHS theaccuracy Assessment (CANS) NeedsandStrengthsAssessment(ANSA).The andtheAdult Needs mentalhealthprograms—theChildandAdolescent across DSHS-funded and reported,includingtheadoption ofnewuniformassessmenttoolsforuse tohownumber ofchanges clientoutcomesandresponsetoservicesaremeasured to encourage providingto encourage highqualityservices. mental healthauthorities(LMHAs)eachquarterasaperformance-based incentive revenue (GR)fundsfromlocal requires DSHStowithhold10percentofgeneral September 2013 (underRider78)andperformanceisassessedevery sixmonths. that was pre-emptively withheld.Initialoutcometargets wereset by DSHSin client outcometargets inordertoreceive thefinal10percentoftheirfullfunding begins eachquarterata10percentfundingdeficit andis requiredtoreachcertain for failingtomeet theoutcometargets, Rider58isstructured sothatevery LMHA performance andmake adetermination whether toreleasethewithheldfunds. Figure 34shows asampleLMHA ofsomethemeasures thatDSHSusestogauge In ordertobetter understand thetypesofmeasures currentlyusedby DSHS, services. Rider58(83 and measuresusedtoevaluateclientprogresstheeffectiveness ofDSHS Rider 58, “Mental Health Outcomes and Accountability” (HB1,84 Rider 58, “Mental Health OutcomesandAccountability” RIDER 58 Commission’s concernsaboutperformancemeasuresandclient outcome data. behavioral healthproviders. DSHS topubliclyreporteasilycomparableperformance measuresforcommunity required by state orfederal legislation). services, 211ofthemaremeasurescreatedby DSHSitself(asopposedtobeing health performancemeasuresDSHScollectsforsubstance use andmentalhealth delivery. TheSunset Commission’s finalreportnoted thatofthe302behavioral meaningfully toevaluateprograms, compareeffectiveness, andimprove service of clientoutcomemeasures(over 300)withoutfocusingonhow tousethedata amount Commission raisedconcernsthatDSHSappearedtobecollectingalarge Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas the 84 DSHS tracksclientoutcomesandmeasuresprogramperformance. Inresponse, and Medicaid enrollees. Alsopassedin2013, SB126(83 individuals measurement andcollectionofoutcomedataformedically indigent provide services.” not “drive best practicesorprovide enoughflexibilityforclinicianswhoactually that DSHS’ datacollectionandreportingprocesseswerecumbersomemay th Legislature passed two major riders that addressed the Sunset Advisory LegislaturepassedtwomajorridersthataddressedtheSunset Advisory 129 TheCommissionrecommendedacomplete overhaul ofhow rd Legislature),requiredDSHStoimprove theuniform 127 Following the83 rd Legislature, the Sunset Advisory Legislature,theSunset Advisory 128 TheCommissionalsoexpressedconcern 130 Instead ofpenalizingspecificLMHAs rd legislative session,DSHS madea rd , Nelson/Davis) required th , Otto/Nelson), 132 131 Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 115 , Otto/Nelson) “Behavioral “Behavioral , Otto/Nelson) th Description ofDescription Performance DSHS by Used Measure The percentage of adults in a Level of Care (LOC) service package package service of percentage (LOC) of The Level a in adults Care sup- competitive, (independent, employment paid have who self-employed). or ported, The percentage of adults in an LOC service package who receive receive who package service of percentage The LOC an in adults per telemedicine) or telehealth, (face-to-face, service one least at month. The percentage of children in an LOC service package who show who package service of percentage The LOC an in children - assess psychosocial DSHS’ on area one least at in improvement (CANS): Assessment Strengths Adolescent and Child the tool, ment Domain Life Needs, Emotional and Behavioral Child Strengths, School Trauma, to Adjustment Behaviors, Risk Child Functioning, Use. Substance Performance, The percentage of children in a full LOC service package who avoid who package service of percentage The LOC full a in children after bed inpatient DSHS-funded a in hospitalization psychiatric services. LOC begin they The percentage of percentage The avoid and services crisis utilize who individuals inpatient psychiatric contracted or operated DSHS a to admission ofstart the after days 30 for bed hospital health mental initial their episode. crisis The percentage of calls to the LMHA’s crisis hotline that are are that hotline crisis of percentage The LMHA’s the to calls receiving individual that in result and crises health mental true “True (Note: ofday one within services face-to-face call. her or his a to opposed as need, immediate an to refers crises” health mental services.) for request routine Area of Area Functioning Measured Being Employment Client Engagement and Engagement Client of Provision Monthly Services Improvement in Improvement Overall and Symptoms Functioning - Commu the in Tenure nity Effective Crisis Response Crisis Effective Timely Access to Crisis to Access Timely Services Response A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation In addition to reviewing the outcome targets and methodology used and methodology In addition to reviewing the outcome targets 133 Legislature also passed Rider 82 (HB 1, 84 th http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e-9eba-67b14f00ad22.PDF Population Measured Population Adults Adults Children Children Individuals in Crisis in Individuals (Children Adults) or Individuals in Crisis in Individuals (Children Adults) or . Retrieved Retrieved . Health Mental on Committee Select the to Presentation 18). February (2016, ofDepartment Source: Services. Health State from: RIDER 82 The 84 Figure 34. Examples of Performance Measures Used by DSHS as Performance- DSHS Used by Measures of Examples Performance 34. Figure Rider 58) (per GR Funding Quarterly Withhold to Incentives Based Health Services Provider Contracts Review,” that requires DSHS (in collaboration Contracts Review,” Services Provider Health with HHSC) to performance to “conduct a review to identify improvements health mechanisms for behavioral contract processing, and payment measurements, services.” under Rider 58 to withhold 10 percent of GR funds from LMHAs, Rider 82 requires Rider 82 requires LMHAs, under Rider 58 to withhold 10 percent of GR funds from that includes December 1, 2016 Legislature by DSHS to submit a report to the Texas the following: 116 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC improvement. traditional recovery-oriented measuresbasedonserviceutilizationandclinical measures thatexamineboth individualexperiencesofrecovery aswellthe more The figurebelow depicts historical trendsandbiennialrequests fromFY2015-2019. expenditures by state budget strategy wereasdepictedinFigure35. funds (25percent),andlocal(16percent).In 2015, mentalhealthprogram Mental healthservicesarefundedby state revenue (59percent),federal general Health Coordination. health fundingby agency, pleaserefertotheHHSSystem sectionOfficeofBehavioral system butpreviously appropriatedtoDSHS).For asummaryofallbehavioral health sectionoftheMedical andSocialServicesDivision(includedintheHHS provided inthissectionrefersonlytothefundingappropriated tothebehavioral Mental healthservicesareprovided by many state agencies. Theinformation B reach theirfullpotential. use self-directedapproachestoimprove theirhealthand wellness andstrive to of personalrecovery. Recovery throughwhichindividuals isaprocessofchange symptoms orareductioninacuteneedratherthanmeasuring progressinterms outcomes have focusednarrowly onclinicalrecovery suchasadecreasein of recovery, suchasfunctioningandcommunityintegration.Historically, traditional clinicaldiagnosesandincludeboth symptom reductionandconcepts Many newer, moreholistic clientoutcomemeasuresfocusonfeaturesbeyond · · · · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas needed tounderstand measures). psychometric propertiesandconsumeraccessibility (i.e.,lengthandreadinglevel fairly newconcept, therearesomeissuesthatremaintobesolved intermsoftheir

e contract with DSHS. compare the performance of different behavioral healthserviceproviders that A proposal forapublicly a and payments and sanctions purchaseshealthcareservices; that align with how HHSC Consideration of best (MCOs); recovery and whole health, similar to those used by care organizations managed Consideration of client outcome by s Identification ofclient outcomes andperformance measuresthatarenot required DSHS provider contracts; ha tate or federalstatute and could beconsolidated or eliminatedaltogether from vior He 135,136 Becauseconsumer-centered outcomemeasuresarestill a a lt practices inperformance measurement, includingincentive 134 h Thereareanumberofemergingrecovery outcome vailable web-based dashboard sothatindividualscan Funding measures and contracting strategies thatfocuson

Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 117

Exceptional Exceptional Items Request 2019 137 Exceptional Exceptional Items Request 2018 0 0 0 0 Requested Requested 2019 Requested 2018 Budgeted 2017 $51,675,618 $51,675,618 $51,675,678 * 0 0 0 0 138 Estimated 2016 0 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Expended 2015 Expended $291,239,098 $320,975,215 $338,641,135 $326,298,776 $326,298,776 $14,199,471 $14,699,471 $84,603,781 $94,721,423 $79,700,014 $74,050,805 $74,050,802 $2,163,095 $2,163,095 0 $439,414,324 $439,693,161 $441,537,717 $421,935,708 $422,071,390 $112,193,002 $108,194,641 $80,962,106 $99,971,621 $109,971,620 $104,971,620 $104,971,621 $41,116,909 $41,079,969 $114,127,098 $127,248,806 $125,866,980 $126,306,873 $126,306,873 $128,080,169 $143,105,756 $153,660,796 $205,627,295 $189,826,370 $187,024,788 $187,024,787 $11,734,183 $11,734,183 $1,292,087,372 $1,431,343,277 $1,337,219,454 $1,292,264,188 $1,292,399,927 $181,406,660 $177,871,359 Strategy Adult Mental Adult Services Health Children’s Children’s Health Mental Services Behavioral Behavioral Waivers Health Mental Health Mental Hospitals State Mental Health Health Mental Community Hospitals Community Community Health Mental Services Crisis NorthStar Substance Prev/ Abuse Intervention/ Treatment Total It should be noted that Medicaid 1115 Waivers have served a significant role in served have 1115 Waivers that Medicaid It should be noted different mental health programs federal funds to help fund many down drawing 1115 Waivers, information regarding Medicaid detailed For within the HHS System. Section. Environment please refer to the Texas Source: Data captured from the HHSC Legislative Appropriations Request for FY 2018/19, September 12, 2016. 12, September 2018/19, FY for Request Appropriations Legislative HHSC the from captured Data Source: 2017. ofas eliminated be will NorthStar January, 2017. for amounts funding separate include not did LARs DSHS and *HHSC per capita mental health Report, the Foundation According Kaiser to a 2013 compared to the national average of $119.62. $40.65 was spending in Texas Figure 35. Mental Health Funding Trends Funding Health Mental 35. Figure Realizing that transformative actions were imperative to expand access to mental actions were imperative Realizing that transformative appropriated for FY 2014 funding was nearly $332 million in new health services, to a in the previous biennium. This increase put an end allotted than was and 2015 contained DSHS budget health. The FY 2014-15 decade of flat funding for behavioral with $1.7 billion system, an unprecedented $2.6 billion for the public mental health general revenue. from the state 118 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC state. careorganization(MCO)undercontractwiththe access servicesthroughamanaged for behavioral healthservices. InaMedicaid caresystem, managed individuals Texas isincreasinglymoving toward caremodelofhealthcareincluding amanaged MEDICAID MANAGED CARE PROVIDERS · · · · types ofserviceproviders: Publicly fundedmentalhealthservicesinTexas areprovided by thefollowing four S state inthecountry. in 2010 toanestimated 27,469,114 in2015 —a9.2 percentincrease,thehighest ofany state’s rapidlyexpandingpopulation,growing fromatotal populationof25,145,561 Much oftheincreaseddemandforbehavioral healthservicesinTexas isduetothe ofpersons receiving services.percentage Texas population,which has resulted in fewerservices being available andasmaller unable to fullykeep pace with the increased cost ofservicesandthe ever-expanding in mental health appropriations, the preceding decade ofstagnant fundinghasbeen While the amount of funding per person has improved asaresult of recentincreases Retrieved from Source: Ligon, K. (October 21, 2013). Sizing up the 2014-2013 Texas Budget: Mental Health. Figure 36. Texas Public Behavioral Health Annual Spending:2003-2015 rather thanpaying afeefor each individualserviceprovided. and pays acapitatedrate(monthlybasepermember) foreachclientenrolled Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas demand forDSHSservices. 19 percentoftotal populationgrowth intheU.S. duringthattimeand increasing far outpacedother states large like CaliforniaandFlorida, accountingforroughly (9.2 percent)was roughlydoublethenationalaverage growth rate(4.1 percent)and

ervice FQHCs and o NorthSTAR (endinginJanuary 20 Local Mental H Medicaid Carepro Managed 142 The state contracts with MCOs (sometimes referred to as “health plans”) Thestate contractswithMCOs(sometimes referredto as “health http://forabettertexas.org/images/2013_10__PP_Budget_MentalHealth.pdf P roviders ther communityhealth centers ealth Authorities (LMHAs) 140 Thepopulationgrowth rateinTexas between 2010 and2015 141

viders 17) 139 Center for Public Policy Priorities.

Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 119 144 ed care services in Texas. ed care services in (CHIP) 143 support services, edicaid Dental and day programs for acute care. for acute programs and day , Nelson/Zerwas) directed the integration of mental health directed the integration of mental , Nelson/Zerwas) ccess Reform (STAR) Reform (STAR) ccess rd A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation , Nelson/Zerwas) only allows providers to bill for targeted case providers only allows , Nelson/Zerwas) rd Crisis intervention services, Crisis intervention training and Medication Skills training, and services Development State of Texas A of Texas State +PLUS STAR HEALTH STAR Insurance Program Health Children’s M Children’s CHIP and Kids STAR

management and rehabilitative services if they offer a full array of comprehensive of comprehensive management services if they offer a full array and rehabilitative continuity of care and seamless The goal of these requirements is to provide services. needs but as a result of these rigorous integration of services across a client’s of rehabilitative as the primary providers LMHAs continue to serve requirements, case managementand targeted for the majority of people in managed care. MCOs for (STPs) as Significant Traditional Providers also contract with LMHAs to serve clients. Medicaid-eligible AUTHORITIES HEALTH MENTAL LOCAL through designated LMHAs, Public mental health services are primarily provided The HHS System as community mental health centers. also commonly known crisis and or arrange of both for the delivery contracts with 39 LMHAs to provide use services for: ongoing community mental health and substance and physical health services into Medicaid managed care. As of September 2014, 2014, managed care. As of September health services into Medicaid and physical development managed for the network care program is responsible the Medicaid case management for mental health targeted and payment and mental health case managers targeted these added services, Through services. rehabilitative service face-to-face crisis planning and mental health with providing are tasked of these Many needs. individuals with complex coordination for Medicaid-eligible and are being 2014 serving clients in September integrated care programs started Integration Health recommendations from the Behavioral continually guided by of these costs report data on the outcomes and Advisory DSHS will not Committee. programs until summer 2017. SB 58 (83 · · · Rehabilitative services coordinated through targeted case management services coordinated through targeted Rehabilitative include: · In 2013, SB 58 (83 SB 58 In 2013, See HHSC for additional information on manag section · · · · MCOs are responsible for creating a network of public and private providers to providers private and of public a network for creating are responsible MCOs needed to access are able Medicaid receiving children and that adults ensure with and directly contract authorization for service MCOs are responsible services. service providers. and reimburse include: Managed in Texas care programs · · 120 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC are easiertolocateandaccess. DSHS toward moreintegratedandpatient-centeredbehavioral healthservicesthat providers toprovide OSARservices, shiftin butthenewrequirementsreflectalarger as Outreach,Screening,AssessmentandReferral(OSAR)provider authorities. responsible forproviding substance useservicesandaretheonlyentitiesthatcanact Naishtat) thatinadditiontoproviding mentalhealthservices, LMHAsmust be state’s OSARregions. As ofSeptember 1,2015, 12LMHAsaretheOSARprovider authoritiesforallofthe · As anauthority, LMHAsareresponsiblefor: userfiles/file/TexasCouncil%20Map%20201301web.pdf Source: Texas Community Council Centers. of (2015). Community Centers of Texas Map. Retrieved from Figure 37. LMHAsand39ServiceRegions Mapof region. official LMHAswhiletwoserve ascontractedproviders fortheNorthSTAR service training andtechnicalassistance. Ofthe39LMHAsinTexas, 37 aredesignatedas provided toindividualsthroughLMHAsandalsoregularlyprovides LMHAstaff with The Medical andSocialServicesDivisionoversees andregulatesthequalityofservices · · · for LMHAsthatbetter reflectsthenewrequirementsunderSB1507(84 on January 1,2017. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

indigent populations; indigent mental health and substance use services are provided inthelocalservicearea for Allocating funds from the HHSM area, showngeographic below inFigure 37. Any individualseligible for M Individuals with apriority population Children, adolescents, 146 NorthSTAR willbedefundedandallitsdutiestransferredtoother providers 147 LocalBehavioral Health Authority (LBHA)isanewerterm 150 LMHAsarestill authorizedtosubcontractwithsubstance use and adultsmeeting criteria; medically indigent 151 edicaid who reside inthatLMHA’s designated

edical and Social Services Divisiontoensure diagnosis; and 145 http://www.txcouncil.com/ th , Garcia/ 148,149

Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 121 152,153 The mental 156 Legislature, HB th , Schwertner/ th tate health and regulatorytate health Additionally, SB 133 (84 SB Additionally, 155 t effectiveness, and quality of care issues to ensure issues to of care quality and effectiveness, t twork of service providers; of service twork Some LMHAs have found it challenging to establish found it challenging Some LMHAs have 154 t appropriate and available treatment alternatives for alternatives treatment and available t appropriate A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation , Cook/Campbell) improved suicide prevention efforts by requiring suicide efforts suicide prevention , Cook/Campbell) improved th individuals requiring mental health services; and services; health requiring mental individuals standards, whether those services are provided directly by LMHA employees or through LMHA employees directly by services are provided those whether standards, funds. state involving providers private community other subcontractors and Creating and maintaining a ne and maintaining Creating mos the Recommending with s comply provided that the services Demonstrating Balancing community input, cos input, community Balancing funds; of public use the best and choice

successful contracts for services, especially rehabilitation and other routine outpatient and other especially rehabilitation for services, successful contracts mental health reimbursement rates and extensive due to provider in part services, In such border regions. workforce shortages and in the Texas-Mexico in rural counties as primary service providers. LMHAs typically serve cases, at an LMHA with or can arrive health services Individuals seeking behavioral mental healthstep into services is for a qualified without an appointment. Their first that they to verify them with a brief mental health screening professional to provide the client then If so, is equipped to provide. are seeking services that the LMHA standardized and diagnostic a full psychosocial to complete works with licensed staff Adolescent the Child and assessment — youth are given Needs and Strengths (CANS) the Adultand adults are given Needs and Strength Assessment (ANSA). An adult to on the ANSA is combined with a supplemental assessment specific score client’s Symptomology of Depressive (for example, the Quick Inventory diagnosis the client’s of care (LOC) of major depression), and a level (QIDS) for individuals with a diagnosis are used in children, no supplemental assessments is calculated. For determination diagnoses and the child’s and the LOC is based solely on conjunction with the CANS LMHA services by enter into Individuals also may from the CANS. the score obtained Teams [MCOT], mental health Mobile Crisis Outreach utilizing crisis services (via first crisis services package. in which case they are provided or a crisis hotline), deputies, regularly update the CANS providers services, Once an individual is enrolled in LMHA also tracks changes correct. The state in these that the LOC is still and ANSA to verify of individuals are responding individuals and groups how time to estimate scores over use services are referred to Outreach, to treatment. Clients seeking substance Screening, Assessment and Referral (OSAR) providers. enforcement to help integrate treatment LMHAs also work with schools and law During the 84 as early as possible. intervention plans and provide prevention trainings for school staff. prevention · Each LMHA is required to plan, develop, and coordinate local policy, resources, and resources, and coordinate local policy, to plan, develop, Each LMHA is required external required to develop LMHAs are health care. Additionally, services for mental subcontractors resort when other of last as a provider and serve networks provider are unavailable. or providers · · · health first aid training teaches non-medical professionals how to respond to signs non-medical professionals how aid training teaches health first See the TEA section for more detailed mental health needs and crises. of potential initiatives. aid training information on mental health first Coleman) strengthened efforts toward early intervention by allowing DSHS to by allowing early intervention toward efforts Coleman) strengthened aid training to school resource officers who are specially mental health first provide employees. and school district trained, school-based police officers, 2186 (84 122 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC · · · · benefits, including: severely limited. means topay forservices, locationswhereaccesstocareis or areingeographic net forindividualswhoareuninsured,underinsured,do not have thefinancial nonprofit organizationsorhospitalsandtypically serve asthepublichealth safety Finally, many communityhealthcenters inTexas areaffiliatedwithcharitable, all ofthebenefitsascertified FQHCs. —centersthatoffersimilarservicesasFHQCsbutdonotFQHC-lookalikes receive In additiontothe73FQHCs currently operatinginTexas, therearealso three substance usetreatment. comprehensive healthcare,includingservicessuchasmentalhealthcounselingor health centers. ofFQHCs Thegoal istoprovide underserved communitieswith Qualified Health Centers(FQHCs) or other non-federally fundedcommunity individuals inTexas may alsoreceive behavioral healthservicesfromFederally In additiontostate-funded LMHAsandMedicaid careproviders, managed COMMUNITY PROVIDERS FEDERALLY QUALIFIED HEALTH CENTERS(FQHCS) AND OTHER Changing Environment sectionintheHHSSystem section. discontinued asofJanuary 1,2017. For moreinformationonNorthSTAR, seethe The NorthSTAR carecarve-out programwas managed createdin1999andwillbe NORTHSTAR the healthsafety net inmany partsofTexas. careproviders,managed but FQHCs areincreasingly becominganintegralpartof less mandatedreporting on clientoutcomescomparedtoLMHAs and Medicaid health servicesintheirclinics. centers have started topartnerwithLMHAsandother providers toofferbehavioral is toprovide effective andaffordableprimaryhealthcare,many communityhealth Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas services withprimaryhealthcare. become acentralcomponentofthepushtoward integratingbehavioral health funding tobuildandexpandhealthcentersnationwide, andFQHCs have since Act (ACA)in 1991,thepassage oftheAffordableCare allocated$11billioninnew · · funding underSection330ofthePublicHealth ServiceAct: FQHCs must alsomeet thefollowing requirementsinordertoreceive federal of providing comprehensive services andhaving aqualityassuranceprogram, ·

The ability to participate in the 340b (reduced)drug pricing; and to medical malpracticeco Access Cost-based (enhanced) at the FQHC. Have ag Offer asliding feescale (i.e.,individuals Serve an underserv and overning board of directorswith the majority of membersreceivingcare 162,163 164 Whilethecentralmissionofmost communityhealthcenters ed area orpopulation; 157 payment for Medicare and Medicaid patients; WhiletheFQHC benefit was first addedto Medicare 165,166 158,159 National Health Service Corps (NHSC). Becauseoftheway FQHCs arefundedthereis verage through the Federalverage Tort Claims Act; 161 Beingcertifiedasan FQHC bringsanumberof Beyondthebasiccertificationrequirements do not get turned away forinability to pay); 160 Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 123 In September In September 169 170

ervices 172 S

h lt a The framework under which DSHS delivers delivers The framework under which DSHS 171 168 l He a 167 ent ys to manage service utilization; M ANS); A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation (ANSA and C Establishing who is eligible for services through a uniform assessment who is eligible for services through a Establishing wa Establishing rendered; and clinical outcomes and impacts of services Measuring service cost. Determining

2) 3) 4) 1) ommunity ommunity 2012, the Texas mental health system’s guiding framework changed guiding framework to further reflect health system’s mental the Texas 2012, and community-driven family-centered, commitment to person-centered, the state’s The TRR model relies on evidence-based practices approaches. recovery-based outcomes and possible the best and resilience to obtain and principles of recovery resources. of available maximize the therapeutic impact Clinical needs are identified through a psychosocial assessment and a uniform Clinical needs are identified through a psychosocial The Adultclinical instrument. Needs and Strengths Assessment (ANSA) and are used to the Child and Adolescent (CANS) Needs and Strengths Assessment of care (LOC) and corresponding eligibility for the appropriate level determine of services is Within this model, the intensity services and specialty treatments. symptoms place on the continuum of active respective based on an individual’s into the model is The expectation built and corresponding mental health needs. and resilience is built, the majority of individuals are identified that as strengths to a place where they can transition and eventually LOCs, will transition to lower Figure 38 describes the adult target in the community. recovery into sustained Figure 39 of Care (LOC). at each TRR Level population and services provided and adolescents. for children describes the same The TRR system is responsible for: The TRR system C FRAMEWORK RECOVERY AND TEXAS RESILIENCE Recovery Resilience, and services of “Hope, health behavioral vision for The state’s resiliency to incorporate movement aligns with a broader national for Everyone” into and beliefs measures, performance practices, services, and recovery-based the public mental health system. One example of an FQHC is Central Health in Austin, which operates local local operates which in Austin, Health is Central of an FQHC example One CommUnity clinics. Care CommUnity its through centers health community (LMHA) — Austin authority local mental health partnered with the Care has each other’s on draw can organizations that both Care — so County Integral Travis health care. Behavioral more comprehensive provide and expertise to resources counseling, assessments, mental health provide ATCIC from health professionals while health centers Care community in CommUnity services psychiatric and other wellness primary care and from CommUnity Care provide medical professionals clinics. programs in ATCIC public mental health services is known as Texas Resiliency and Recovery (TRR), an Resiliency and Recovery as Texas public mental health services is known launched in 2004 that was of the shift in mental health service delivery outgrowth Resiliency and Disease Management (RDM). under the name Texas 124 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC Figure 38. Texas Resiliency and Recovery Care (TRR)Levels of (LOC) for Adults Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Crisis Services LOC-0: (LOC) CareLevel of Counseling including Basic Services LOC-2: (Skills Training) Basic Services LOC-1S: Management) (Medication Basic Services LOC-1M: and Service Goal Target Population services or psychotherapy. tion through cognitive behavioral therapy (CBT) improving functioning and preventing deteriora- similar to LOC-1S services, with the addition of psychotherapy. LOC-2The goal of services is very intensive interventions and can benefit from supports. These adults do not normally require below 50, harm, very little risk of and some natural major depressive disorder,of a GAF score at or These services are for adults who have a diagnosis access to formal mental health supports. the condition by providing quick and easy tion of and practicing coping skills, and prevent deteriora - symptoms, improve functioning through learning to facilitate recovery by reducing and stabilizing a case manager. care is this level of The goal of from ongoing psychotherapy and support from not require intensive intervention, and can benefit or others,self have reasonable social supports, do population criteria, harm to present little risk of Services for adults who meet DSHS priority community. and pharmacological resources are available in the tion until access to alternate psychiatric supports become available. The goal is to prevent deteriora- to appropriate communityresources wheneverthey and will need help making the successful transition the public mental health system transition out of supports. These individuals are generally ready to natural recovery with coping skills and a network of tion management, but they mostly maintain their some need for occasional services, such as medica- months. Individuals in an LOC-1M package have sustained success in treatment for at least 12 recovery and and who have maintained a level of meet the DSHS definition for priority populations This service package is reserved for adults who the encounter.of ANSA must be completed within two business days the ANSA. However, a crisis assessment and crisis prior diagnosis or authorization for services using at an LMHA or via a crisis hotline and do not require relapse. Crisis services may be accessed in person admission into a state psychiatric hospital) or more intensive and restrictive interventions (e.g., immediate mental health crisis and avoidance of an crisis services is the resolution of The goal of and Billable Services Interventions Description of · · include: new skills and coping mechanisms. Services work toward recovery and stability by learning individuals reduce negative symptoms and Non-intensive interventions that serve to help · · include: new skills and coping mechanisms. Services work toward recovery and stability by learning individuals reduce negative symptoms and Non-intensive interventions that serve to help · · services in the community. Services include: mental illness and ultimately transition to uals maintain stability in their recovery from interventions that serve to help individ- Brief · · services: crisis and prevent the need for more intensive interventions to address the immediate Brief · · · · · · ·

extended observation units [EOU]) such settings to, for example, respite or inpatient setting, or diversion from coordination and transportation to an ual and group) Routine case All crisis services Crisis intervention services Pharmacological management Psychiatric diagnostic vidual and group) (individual and group) Cognitive behavior All LOC-1S Peer support Flexible funds/community Cognitive pr Supported housing Supported employment Medication training Skills training All LOC-1M services services ocessing therapy (CPT) management services and development (individ- al therapy (CBT) (indi- and support services interview supports (including Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 125 https:// al therapy (CBT) therapy al ehabilitative services (indi- services ehabilitative eatment services ams for acute needs acute for ams services All LOC-3 LOC-3 All behavior Cognitive All LOC-1S LOC-1S All r Psychosocial group) and vidual progr Day tr Residential

Description of Description Interventions Services Billable and ofmix interventions A routine and intensive basic learn individuals to help serve that negative reducing while skills life and coping and recovery toward working and symptoms must manager case rehabilitative A stability. services and housing supported provide also substance and psychiatric co-occurring for include: Services disorder. · · · frequent oflevel more This requires care package LOC-3 the than interventions more with ofmany but services, same the complex and interventions intensive frequent safety maintain help to planning treatment services ACT symptoms. negative reduce and ofsort some achieve individuals help to work with supports. functioning, community-level provide must manager case rehabilitative A and housing supported with clients LOC-4 and psychiatric co-occurring services for include: Services disorder. substance · · individualized highly is package LOC-5 The post-crisis intensive very involve can and acute less involve may or planning safety with individuals for planning treatment providers private by handled best diagnoses a include can Services community. the in ofmixture for services billable all and any must services but LOC-4, through LOC-1M crisis a in out laid goals specific to tied still be plan. treatment · A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation These services are for adults who meet DSHS meet who adults for are services These system the enter and criteria population priority of levels severe to moderate with that needs frequent more and rehabilitation intensive require in adult the support to is goal The interventions. - integrat approach, team-based a through recovery and providers across goals and plans treatment ing individ- engage to meant are services The services. improve symptoms, their stabilize to help and uals indepen- foster to strengths leverage functioning, natural increase skills, develop self-advocacy dence, more in made improvements sustain and supports, treatments. past during and/or LOCs intensive as known also services, LOC-4 receiving Individuals severe have (ACT), Treatment Community Assertive - schizophre as (such illness mental persistent and - expe have and disorder) depressive major or nia admissions hospital psychiatric multiple rienced providers. community other or hospitals state at ofhistory A enforcement law with involvement this into placement for required not but likely is and focused a provide to is ofgoal ACT The LOC. of point fixed comprehensive a for responsibility of array ofskills the merge that services clinical, staff rehabilitation and one into together medical, of place takes services Provision whole. integrated team the that so system delivery mobile within a or home their from recovery in person the serve can them. for easiest is community the in else wherever oflevel - This tran are who individuals for is care ofout sitioning require still and package crisis a DSHS- for qualify not do but services, and supports utilized also are services LOC-5 services. funded set- inpatient an from discharges someone when transitioning. and stabilizing help needs and ting in individuals assist to is services ofgoal The LOC-5 crises further preventing and stability maintaining treatment patient-centered in them engaging by by provided services for arranging and planning last can Services professionals. community-based days. 90 to up for Target Population Target Goal Service and LOC-3: LOC-3: TRR Intensive with Services Approach Team Assertive LOC-4: Community (ACT) Treatment - Transi LOC-5: Services tional Level of Care of Level Care (LOC) www.dshs.state.tx.us/mhsa/trr/um/ . Retrieved from: from: Retrieved 2014. Guidelines-FY Management Utilization Adult (2015). ofDepartment Services. Health State Texas Source: 126 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC Childrenand Adolescents Figure 39. Texas Resiliency and Recovery Care (TRR)Levels of (LOC) for Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Management Medication LOC-1: Services Targeted LOC-2: Crisis Services LOC-0: (LOC) CareLevel of providers when available. strengths to help transition to community-based their caregiver’s natural supports and identified is to maintain stability and utilize the child and is medication management. LOC-1The goal of whose only current identified treatment need This service package is for children and adolescents telemedicine, available. if community locations. Services can be provided via caregiver, including offices, school, home, or other in the most convenient location for the child and the group as a whole. Services should be provided on strengths within the child, the caregiver, and symptoms or address behavioral needs by building these services is to improve mood-related of functioning or maintaining basic safety. The goal package have very few needs, any, if in life domain ioral treatment. Children and adolescents in this needs that require either emotional Children and adolescents must have identified CANS assessment. into an LOC-0 via an override process built into the package using the CANS assessment can be placed not meet the usual criteria to be placed into a crisis the encounter.of June 2015,As of children who do CANS must be completed within two business days the CANS. However, a crisis assessment and crisis prior diagnosis or authorization for services using at an LMHA or via a crisis hotline and do not require relapse. Crisis services may be accessed in person admission into a state psychiatric hospital) or more intensive and restrictive interventions (e.g., immediate mental health crisis and avoidance of an crisis services is the resolution of The goal of and Service Goal Target Population or behav- parent skills training. also provided to the child as a component of the primary intervention and skills training is The only exception occurs when counseling is · · targeted service specific to LOC-2 is either: tions more frequently than LOC-1 clients. The LOC-1 services but generally receive interven- Individuals in LOC-2 the can receive all of · services may include: is medication-related appointments. Other but their only routine and regular service or review lessons learned in past treatment, ment services to respond to a specific event occasional need for routine case manage- Children in the LOC-1 package may have an · · services. This can include: crisis andprevent theneedformore intensive interventions to address the immediate Brief · · · · · · and Billable Services Interventions Description of

Skills training Counseling (individual, or Crisis intervention services Pharmacological management Psychiatric diagnostic extended observation units [EOU]) such settings to, for example, respite or inpatient setting, or diversion from coordination and transportation to an Family case Family partner Parent support Routine case Medication training LOC-0 services management management (individual, group). (crisis) supports group and support interview group, or family) (including Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 127 also known also both community-based both services services emphasis on family partner family on emphasis services and integrated care integrated services and All LOC-3 LOC-3 All Stronger management, case Intensive “wraparound” as All LOC-2 LOC-2 All services, Respite and program-based and

Description of Description Interventions Services Billable and · The increased use ofuse increased The services partner family building through resilience caregiver fosters and strengths and supports upon natural the through community resources to linking process. planning wraparound While many of the services are the same, ofmany While same, the are services the receive LOC-3 in adolescents and children LOC-2 than frequently more interventions oflevel a higher have they clients because receive: can LOC-3 in Individuals need. · · · Because ofBecause interven- for need increased the providers LOC-3 package, service this in tions hours office flexible consider to need may support best to weekend) and night (i.e., ofneeds complex the their and child the caregiver. While some ofsome While same the are services the adolescents in and children LOC-3, as more interventions receive packages LOC-4 level higher a have they because frequently maintain to need likely will Providers ofneed. complex the support to hours office flexible needs oftheir and services in child the are packages LOC-4 in Individuals caregivers. receive: to eligible · emotional and A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Target Population Target Goal Service and This service package is for children and adolescents adolescents and children for is package service This behavioral both identified have who treatment needs that require more intensive more require that needs treatment in Children packages. lower than intervention of degree moderate a exhibit may package this life basic in impairments and/or behaviors risk service multiple require that skills and functioning ofgoal The providers. multiple from interventions symptoms stabilize or reduce to is services LOC-3 functioning, overall improve behaviors, risk and child the in resiliency and strengths build and lower to transition can they that so caregiver and in provided be should Services levels ofcare. and child the for location convenient most the other or home, school, offices, including caregiver, via provided be can Services locations. community if available. telemedicine, Children and adolescents in LOC-4 have the high- the have LOC-4 in adolescents and Children emo- and behavioral both with oflevel est need, involvement significant and needs treatment tional is child The systems. child-serving multiple with ofrisk at typically ofoutside placement home their of result a as emotional and behavioral severe often symptoms mood and behaviors These needs. ofhistory a having child the in result ofrisk at (or developing): involvement; justice Juvenile school; from Expulsion home; from Displacement Hospitalization; treatment; Residential to selfinjury Serious and/or others; or Death. focused, a use to is services ofgoal The LOC-4 control and stabilize to approach team integrated overall improve behaviors, risk and symptoms resiliency and strengths build and functioning, provider The caregiver(s). their and child the in Initiative’s Wraparound National the uses team provide to services wraparound for model (NMI) network) support their (and services individual the to access 24/7 and services comprehensive with to team wraparound the on provider one least at should Services placement. out-of-home avoid help for location convenient most the in provided be school, offices, including caregiver, and child the can Services locations. community other or home, if available. telemedicine, via provided be LOC-3: Complex Services Level of Care of Level Care (LOC) LOC-4: Intensive LOC-4: Services Family (Wraparound) 128 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC qualify forTexas Medicaid. have anincomelessthanthefederalpoverty level (FPL)shown inFigure 40may disabilities. and supportsforfamilies, children,pregnantwomen, olderadults, andpeoplewith of adisability). Medicaid covers acutehealthcareneedsaswelllong-termservices individuals whoalsomeet othereligibilityrequirements(e.g.,presence categorical Medicaid isajointlyfundedfederalandstate program thatserves low-income MEDICAID from: Source: Texas State Health Services. Department of (2015). Child & Adolescent Utilization Management Guidelines-FY 2014. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas tional Services LOC-5: Transi- Services Young Child LOC-YC: (LOC) CareLevel of https://www.dshs.state.tx.us/mhsa/trr/um/ 173 OnlyU.S. citizensorlegalpermanentresidentswholive inTexas and for up to 90 days. community-based professionals. Services can last planning and arranging for services provided by engaging them in patient-centered treatment and preventing further crises from evolving by is to assist individuals in maintaining stability community providers. LOC-5The goal of services needs help stabilizing and transitioning to other child discharges from an inpatient setting and services. LOC-5 services are also utilized when a services, but they do not qualify for DSHS-funded a crisis package and still require supports and of care is for individuals who are transitioning out Similar to LOC-5 services for adults, this level of available. if home. Services can be provided via telemedicine, child and caregiver, including the office setting or provided in the most convenient location for the in the child and caregiver. Services should be functioning, and build strengths and resiliency an illness),(or full development of improve overall meant to reduce symptoms, prevent deterioration children experiencing the world. Services are relationship, which is the primary context for young is to focus on improving and leveraging the dyad service interventions. LOC-YCThe goal of services and functional impairments that require multiple deficits in basic life domains moderate degree of treatment needs. The young child may exhibit a with identified behavioral and/or This service package is for all children ages 3-5 and Service Goal Target Population 174 emotional treatment plan. be tied to specific goals laid out in a crisis LOC-1 through LOC-4, but services must still any and all billable services for mixture of in the community. Services can include a diagnoses best handled by private providers treatment planning for individuals with safety planning or may involve less acute and can involve very intensive post-crisis The LOC-5 package is highly individualized the young child and caregiver. of flexible office hours to support the needs approach. Providers may need to consider than is required under the full wraparound services on a less frequent basis array of expected to utilize a less comprehensive are eligible for all LOC-4 services, they are While young children in the LOC-YC package · eligible to receive the following services: Young children in the LOC-YC package are and Billable Services Interventions Description of

All LOC-4 services Retrieved Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 129 Family of 4 Family 15%100% $1,782133% $11,880200% $15,800 $3,645 400% $24,300 $23,760 $32,319 $47,520 $48,600 $97,200 FPL Individual ; https://www.healthcare.gov/glossary/federal-poverty-level-FPL/ State Medicaid and CHIP Income Eligibility Standards Effective July 1, 1, July Effective Standards Eligibility Income CHIP and Medicaid State Most Texans enrolled in Medicaid now receive receive now enrolled in Medicaid Texans Most Retrieved from: from: Retrieved 175 The federal match for ACA Medicaid expansion is much Medicaid The federal match for ACA 176 If Texas were to expand Medicaid eligibility to adults up to 138 were to expand Medicaid If Texas

Federal Poverty Level. Level. Poverty Federal 177 179 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/Medicaid-and-CHIP- For more information on the Texas Medicaid program, see HHS System program, see HHS System Medicaid more information on the Texas For 178 Possesses no property Possesses Has no person legally responsible for their support of support, maintenance, and for the costs Is unable to reimburse the state treatment.

2) 3) 1) Individuals who are deemed to be medically indigent and meet the priority Individuals who are deemed to be medically indigent and meet services through to receive are eligible population criteria (described below) higher than typical Medicaid programs, starting at 100 percent and phasing down to and phasing down at 100 percent starting programs, higher than typical Medicaid 90 percent in 2020. health services through Medicaid managed in the Service care (discussed further health services through Medicaid section in this chapter). Providers Medicaid to expand states allows provision Affordable Care An optional Act (ACA) expand Medicaid has no current plans to but Texas to wider populations, coverage access to insurance have 100 percent of the FPL who do not to adults below coverage through the Marketplace. section. INDIGENT MEDICALLY CONSIDERED INDIVIDUALS to be indigent Code, a person is considered and Safety Health According to the Texas circumstances: under the following As of July 2015, an estimated 1 million adults and 3.3 million children in Texas were in Texas million children 1 million adults and 3.3 an estimated 2015, As of July of all children living in That translates to roughly 45 percent enrolled in Medicaid. being enrolled in Medicaid. Texas Source: Healthcare.gov. (2016). (2016). Healthcare.gov. Source: Figure 40. Eligibility Levels For Subsidized Coverage in Texas in 2014 (Left) 2014 (Left) in Texas in Coverage Subsidized For Levels Eligibility 40. Figure (Right) Coverage to Obtain Required Levels Annual Income and percent of the FPL, the majority of medically indigentpercent of the FPL, the majority of requiring mental individuals access to health LMHAs would have by services served use health and substance insurance. Eligibility-Levels-Table.pdf Eligibility-Levels-Table.pdf Center for Medicare & Medicaid Services (October 24, 2014). 2014). 24, (October Services Medicaid & Medicare for Center from: Retrieved 2014. 130 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC diagnoses listed inFigure41. with sufficientresourcescan now provide servicesforindividualswith any ofthe to communitymentalhealthservicesforawidervariety ofindividuals, LMHAs an efforttoreduceinvolvement inthecriminaljustice system andexpandaccess and/or majordepressive disorder. three”diagnosisofschizophrenia,bipolardepression, serving onlyadultswitha“big Health andSafety Codeto expandtreatmentservicesprovided by LMHAsbeyond mandated theprovision ofservicestoadultswiththosethreemajorillnesses. individuals withother diagnoseswas not prohibitedpriorto2013, previouslaw only · · · different CIHCPs: extraordinary expenses: maximum monthlyfeeornofee,dependingontheindividual’s grossincomeminus a financialassessmentofanindividual’s abilitytopay forservicesandcalculates a services, LMHAstaff conduct (typicallybenefitscoordinatorsorofficemanagers) During the83 PRIORITY POPULATIONS $3,000. the Federal Poverty Guidelines(FPG)andwhosehouseholdresourcesdonot exceed residents whoseincomedoesnot exceed 21-50 percent(dependingonthecounty)of counties, hospitaldistricts, andpublichospitalsthroughoutthestate toeligible CIHCPprovidesindividuals whoaredeemedindigent. healthservicesthrough HealthThe CountyIndigent CareProgram(CIHCP)alsoprovides servicesto · reimbursement forservices. the state mentalhealthsystem withoutthestate receivingcompensation or · · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

hospital services). 18 public hospitals provided CIHCP services 142 hospital dis 143 ofTexas’ family size andincome). All other contribution Individuals whose adjusted incomeisat Individuals whose adjusted incomeisat eligible for fullfunding of allother mental health services;and eligible for fullfunding of substance use services; 183 AsofFebruary 2015, residentswerebeingserved by indigent thefollowing rd Legislative session,HB3793 (83 254 counties administered residents; a CIHCP for indigent tricts were served by CIHCPs; and 184 181 amounts are assessed on a sliding scale basis (based on amounts are assessedon a slidingscalebasis(based 182 180 187,188 Withinthefirst 30days ofrenderingmentalhealth 185 Althoughproviding treatmentservicesto or below 150 percent of theFPL are or below 200 percent of the FPLare (i.e., inpatient and outpatient rd , Coleman/Hinojosa) amendedthe 186 In Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 131 Much of the 189,190 disorder; disorder; mental health disorder. health mental der, including bipolar and depressive types; depressive and bipolar including der, anorexia nervosa, or other eating disorders not otherwise specified; specified; otherwise not disorders eating other or nervosa, anorexia disorder; disorder; functional impairment; functional stress disorder; disorder; stress sive disorder, including single episode or recurrent major depressive depressive major recurrent or episode single including disorder, sive olled in a school system’s special education program because ofbecause program education special serious system’s school a in olled risk ofrisk psychiat- to due ofdisruption environment childcare or living preferred a or serious a Have at Are and/or symptoms; ric enr Are (SED). disturbance emotional Major depres Major Post-traumatic disor Schizoaffective compulsive Obsessive Anxiety disorder; deficit Attention disorder; Delusional nervosa, Bulimia diagnosed other Any disorder; disorder;

· · · developmental pervasive ofdiagnosis single a with adolescents and *Children autism, - crite population priority the meet do not use substance or disability, intellectual disorder, developed programs other through served instead are and services, health mental for ria HHSC). at now DARS; or and DADS at (previously populations special for Eligibility Criteria Eligibility of: diagnosis illness mental persistent and severe and impairment functional Serious · · · · · · ofsymptoms exhibit ofdiagnosis a have who 17 through 3 ages Children illness, mental ofone least at meet and the conditions, health mental or behavioral, emotional, serious criteria: following · · · 192 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation The population growth rate in Texas between 2010 and 2015 (9.2 percent) (9.2 and 2015 2010 between rate in Texas The population growth 191 Children Children Adolescents & Adults Populations increased demand for behavioral health services in Texas is due to the state’s rapidly is due to the state’s health services in Texas increased demand for behavioral to an in 2010 population of 25,145,561 from a total expanding population, growing in the state of any percent increase, the highest — a 9.2 in 2015 27,469,114 estimated country. As illustrated in Figure 42 and Figure 43, there are many more adults and children there are many in Figure 42 and Figure 43, As illustrated in the being served services than are currently who require mental health in Texas who had a adults in Texas there were 240,088 In 2014, public mental health system. illness (SPMI) such as schizophrenia or bipolar disorder mental serious persistent of (FPL); 66,273 Level Poverty 200 percent of the Federal and were living below SYSTEM UTILIZATION (COMMUNITY MENTAL HEALTH SERVICES) HEALTH MENTAL (COMMUNITY UTILIZATION SYSTEM roughly 1.1 million adults and children received FY 2015, through FY 2010 From through LMHAs (including in Texas community mental health services publicly-funded The unduplicated number of persons who received NorthSTAR). five- 40 percent during this same approximately mental health services increased by adults. for services by a greater need in part by year period, driven Figure 41. LMHA Client Population Population Client LMHA 41. Figure was roughly double the national average growth rate (4.1 percent) and far outpaced growth double the national average roughly was accounting for roughly 19 percent California and Florida, like large states other during that time and increasing demand for in the U.S. population growth of total DSHS services. 132 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC 436e-9eba-67b14f00ad22.PDF System [PowerPoint slides]. Retrieved from Source: Texas State Health Services. Department of (2016). Presentation to Select Committee on Mental Health: The Behavioral Health Adolescents inFY 2014 Figure 43. UnmetNeedsforCommunity MentalHealth Services:Children and 436e-9eba-67b14f00ad22.PDF System [PowerPoint slides]. Retrieved from Source: Texas State Health Services. Department of (2016). Presentation to Select Committee on Mental Health: The Behavioral Health health centersorNorthSTAR. communitymental 62.5 percent)–didnot receive servicesthroughDSHS-funded disturbances (SED)livingbelow 200percentoftheFPLin2014; 78,763 ofthem–or mental healthcenters. Similarly, therewere126,052 childrenwithseriousemotional them— or27.6 community percent—didnot receive servicesatDSHS-funded Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Figure 42. UnmetNeedsforCommunity MentalHealth Services: Adults inFY 2014 http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4- http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4- 193

Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 133 Performance Performance Target Contract 2015 FY ≥ 65% ≥ ≥ 98.1% ≥ FY 2013 FY 2014 FY 79,6112015 FY 90,658$352 94,776 $422 $438 FY 2013 FY 2014 FY 17,8782015 FY 20,240$383 23,376 $441 $441 FY 2013 FY 2014 FY 2015 FY n/a 82.8% 79.0% n/a 100% 100% n/a 65.8% 61.4% 25% A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation http://www.dshs.texas.gov/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590002694 http://www.dshs.texas.gov/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590002694 http://www.dshs.texas.gov/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590002694 Quality of Care Measure Quality ofCare Utilization Measure Utilization services health mental community receiving number monthly Average ofcost Average served child per services health mental community Utilization Measure Utilization Average monthly number ofnumber monthly Average services health mental community receiving adults ofcost Average served adult per services health mental community Percentage of mental community in adolescents and children Percentage ofhour one least at receiving services health month per services Percentage of mental community in adolescents and children Percentage tenure community improved experienced who services health Percentage of mental community in adolescents and children Percentage Index Change Reliable the exceeding or meeting services health domains more or one in Note: Data for first two items are from each year’s fourth quarter, data for the last item is from the third and fourth quarters combined. combined. quarters fourth and third the from is item last the for data quarter, fourth year’s each from are items two first for Data Note: slides]. [PowerPoint quarter fourth 2015, FY book, data health Behavioral (2016). ofDepartment Services. Health State Texas Source: from Retrieved Quality of Care Measures Quality adolescent outcome measures selected data on common child and Figure 46 shows for FY 2013-2015. Adolescents Receiving and for Children Selected Measures 46. Figure Services Mental Health Community Note: Data are from each year’s fourth quarter. quarter. fourth year’s each from are Data Note: . slides] [PowerPoint quarter fourth 2015, FY book, data health Behavioral (2016). ofDepartment Services. Health State Texas Source: from Retrieved Youth Service and Costs Utilization Youth for child and adolescent community the utilization and costs Figure 45 shows mental health services in Texas. Services Mental Health Adolescent Community for Child and Utilization/Cost 45. Figure Note: Data are from each year’s fourth quarter. quarter. fourth year’s each from are Data Note: slides] . [PowerPoint quarter fourth 2015, FY book, data health Behavioral (2016). ofDepartment Services. Health State Texas Source: from Retrieved Adult Services:Adult Costs and Utilization health mental community for adult and costs the utilization 44 shows Figure in Texas. services Services Mental Health Adult Community for Utilization/Cost 44. Figure 134 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC on LMHAwaitlists asofMay 2012. 1) provided fundingforadultsandchildrenrequiringmentalhealthserviceswhowere just eightby theendof2015. other hand,droppedfromahighof527youthwaiting forLMHAservicesin2010 to rose backto1,562adultsonwaiting lists attheendof2015. Thechildwaitlists, onthe dropped fromover 7,000 inFY2011 tojust 285adultsby May 2014. Thatnumber into crisisservices. intervention isrequired, theindividualwaiting forroutineservicesmay beplaced determine iftherehasbeenany deterioration oftheir mentalhealth.Ifimmediate 90 days by amentalhealthprofessionaltoassessbasicstatus andto to expeditetheindividualintoservices. Individualsonwaitlists arecontactedevery an individualisapproved forMedicaid whileonthewaitlist, theLMHAhas60days during the 83 same timeperiodduetoaspecialappropriation. waitlists forcommunitymentalhealthservicesdecreased by 24 percentduringthat health servicesincreasedby analarming85percent.Incontrast, childrenon From FY2009to2012, thenumberofadultsonwaitlists forcommunitymental be admitted intoservicesbecausefederallaw prohibitswaitlists forMedicaid. mental healthservicesareaddedtoawaitlist. IndividualswhoareonMedicaid must When LMHAsexhaust theirfunding,non-Medicaid eligibleindividualswhorequire WAITLISTS FORCOMMUNITY-BASED MENTAL HEALTH SERVICES · · The 84 · 2016-2017. receiving community-based serviceswithastated ofpreventing awaitlist goal inFY $46 millionforLMHAsandNorthSTAR toincreasethenumberofindividuals waitlists; Rider71directed$9milliontoward reducingwaitlists andanadditional Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas funding appropriatedby the83 issues atLMHAs. Approximately $48.2 millionofthesupplementalmentalhealth Recent legislative efforts have madesignificantprogress toward addressing waitlist

Meet the the needs of Address Expand community health services; demand for services. and th Legislaturecontinuedtoappropriatefundinghelp eliminateLMHA 197 treatment needs of a growing population that exhibits increasing rd legislative session mentionedabove, thenumber of adultsonwaitlists 195

individuals who are underserved due toresourcelimitations; 199

rd Legislature(Rider92, DSHSsectionofArticleII,SB 196 Anadditional$43millionwas appropriatedto: 198 Asaresultofthebillspassed 194 If Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 135 Presentation to Select Committee on Mental on Select Committee to Presentation http://www.legis.state.tx.us/tlodocs/84R/handouts/ http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4- A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Source: Data obtained from: Texas Department of State Health Services. (2016). (2016). ofDepartment Services. Health State Texas from: obtained Data Source: from Retrieved slides]. [PowerPoint System Health Behavioral The Health: C3822016021810001/5fc9614b-41a4-436e-9eba-67b14f00ad22.PDF 436e-9eba-67b14f00ad22.PDF Through Served Children List and Waiting Adolescents Child and 48. Figure 2015 (Q4) 2010 (Q1) – FY FY Centers: Mental Health Community Presentation to Select Committee on Mental Health: The Behavioral Health Health Behavioral The Health: Mental on Select Committee to Presentation (2016). ofDepartment Services. Health State Texas Source: from Retrieved slides]. [PowerPoint System Figure 47. Adult Waiting List and Adults Served Through Community Mental Mental Community Through Served Adults and List Waiting Adult 47. Figure (Q4) 2015 FY (Q1) – 2010 FY Centers: Health 136 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC 6,767 inFY2015. as aresultofincreasingfundingandresources, fromroughly5,039 inFY2013 to funded programsandproviders: care.Figure49listsin ongoing most ofthecrisisservicesavailable throughstate Crisis servicesareavailable statewide toindividualswhether ornot theyareenrolled The 84 appropriateness, overall design,anddemonstrated localprojectsupport. roomsandthecriminaljustice system,collaboration withemergency clinical servicefundingbased on:demonstrated localneed,costemergency effectiveness, In May 2013, LMHAs(andNorthSTAR) submitted needsassessmentsforpsychiatric During the83 · · · due toamentalhealthcondition,anindividual: The Texas Administrative Codedefinesapsychiatric crisisasasituationinwhich, CRISIS SERVICES crisis services. an additional$13millionperyeartoenhanceandexpandthe reachofpsychiatric Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas enhanced. result, 16newcrisisfacilitieswereaddedandanadditionalthreesites readmissions thatoccurwithin15days ofdischarge. health issuesbeingdisproportionatelyrepresented(28.2 percent)inhospital roomleadstoindividualswithbehavioral of treatingmentalillnessinanemergency account for9.5 percentofallinitialhospitaladmissions, theclinicalineffectiveness rooms,emergency and/or jails. Whileindividuals withbehavioral healthissuesonly services projectsthatserve asalternatives todivert individualsfromhospitals, services acrossthestate by enhancingcommunity-based psychiatric emergency

or her mental orphysical health is at risk ofserious deterioration. Believes that heorshe Is atrisk of seriousdeterioration Presents an immediate dang th Legislaturemaintainedpreviousfundinglevels forcrisisservicesandadded 203 rd 204 legislative session,lawmakers appropriatedfundstoimprove crisis Thenumberofpersonsusingcrisisintervention servicesincreased 205 presents an immediate danger toself orothers,presents an immediate danger orthathis er to self orothers; of mental orphysical health; and/or 200 201 202 Asa Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 137 all 39 LMHAs (and NorthSTAR) NorthSTAR) (and LMHAs 39 all System Health Behavioral The Health: Mental on Committee Select to Presentation - accred are that hotlines crisis with contract or line crisis own their operate either of Association (AAS). Suicidology American the by ited hotlines crisis their with conjunction in program MCOT an operate LMHAs 39 All closely works MCOT areas, service many In field. the in crises to respond and the from individuals divert to enforcement law and department EMS the with interventions. therapeutic more to jail or room emergency of resolution the for treatment tial symptoms. acute ofhours 48 to 23 provide EOUs locked and controlled a in observation psychiatric ofgoal a with more from diversion and stabilization short-term environment, ifservices inpatient intensive and costly appropriate. ofdays 1-14 between provides service This clinical, safe a in services crisis-level ofrisk immediate some present who individuals for setting harm residential or hospitals health state mental in provided be may Services selfto others. or private hospitals. envi- normal individual’s the from ofperiod short a provides respite Crisis relief, 30 to hours eight from anywhere last can Services typical stressors. and ronment ofdays ofrisk low with individuals for care crisis short-term selfto harm others. or planning. treatment focused more for allows Also prepare and symptoms staffon psychiatrist individual’s an stabilize to working ofcontinuity maintaining for them community-based to transitioning while care services. men- with to individuals treatment restoration competency community Provides and jails on burdens unnecessary reduces system, legal the in involved illness tal participant and stabilization psychiatric provides and hospitals, psychiatric state behavior. and skills courtroom in training - assis temporary and care, ongoing services, existing between linkage Provides in homeless, be may Individuals days. 90 to up for post-crisis individuals to tance criminal the in involved need ofcare, health primary or treatment use substance a have and/or hospitalizations, psychiatric multiple experiencing system, justice diagnosis. non-priority Description week, per days seven day, per hours 24 Available http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e- A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Mobile Crisis Outreach Teams Teams Outreach Crisis Mobile (MCOT) (CSU)Units Stabilization Crisis - residen short-term and care psychiatric emergency to access immediate Provide (EOU) Units Observation Extended Services Residential Crisis Services Respite Crisis Stabilization Step-Down Crisis Hospital Settingin Services ofdays 10 to 3 a with setting hospital local a stabilization in psychiatric Provides - Resto Competency Outpatient (OCR) Services ration (LOC-5) Services Transitional Crisis Hotline Services Hotline Crisis Service [PowerPoint slides]. Retrieved from from Retrieved slides]. [PowerPoint Texas Department of State Health Services. (2016). (2016). ofDepartment Services. Health State Texas 9eba-67b14f00ad22.PDF and http://www.dshs.state.tx.us/mhsacsr/ from Retrieved Services. Crisis (2010). ofDepartment Services. Health State Texas Source: Figure 49. Available DSHS Crisis Services Services Crisis DSHS Available 49. Figure 138 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC · · that individualscanbecloselymonitoredinorderto: to mentalillness. Inpatient hospitalizationmay benecessary foraperiodoftimeso hospitals tochildren,adolescents, andadultsexperiencingapsychiatric crisisdue Inpatient mentalhealthservicesareprovided by state, community, andprivate in thissectionandtheDSHSofguide. clearly andconciselyaspossible,informationonstate hospital servicesareincluded for thisguidetoprovide informationonmentalhealthandsubstance useservicesas the state supportedlivingcentersdonot transferuntilSeptember 1,2017. Inorder September 1,2016. However, thestate owned andoperatedpsychiatric hospitalsand Mental on healthandsubstance usecommunityservicestransferredtoHHSC reorganizations thatareonlypartiallycomplete asofthewriting ofthisguide. Price), DSHS, alongwiththeentireHHSSystem massive hasbeenundergoing · · and referred theindividualforinpatient services, ahospitalphysician candetermine hospital consideredtheprovider oflast resort.Whenthe LMHAhasnot screened restrictive treatmentsetting available, withthevery restrictive setting of astate there isaneedforinpatient psychiatric services, theLMHA decidesontheleast psychiatric servicesarerequired.Ifthescreening andassessment determine that screen allindividualsseeking mentalhealthservicesto determine ifinpatient agreementwitha partneringLMHAthatrequirestheto management providing inpatientmentalhealthtreatment.Eachstate hospitalhasautilization this continuumofcare,thestate hospitals’primarypurposeistostabilize peopleby continuity ofcareinmeeting aperson’s needfor mentalhealthservices. Within As discussedearlier, DSHSdesignatesLMHAsasresponsibleforachieving andtheAdmissionsProcess Introduction toInpatientServices As aresultoftheHHStransformationdirectedby SB200(84 IMPORTANT NOTE: INPATIENT MENTAL HEALTH HOSPITAL SERVICES Inpatient Mental Health Hospital Services aspx?LinkIdentifier=id&ItemID=8590002694 health data book, FY 2015, fourth quarter [PowerPoint slides]. Retrieved from Note: Data are from each year’s fourth quarter. Source: Texas State Health Services. Department of (2016). Figure 50. Utilization/Cost forCrisisBehavioral Health Services The utilizationandcosts forcrisismentalhealthservicesareincludedinFigure50below. Crisis Services: Utilization and Costs Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

Average monthly cost per person receiving mental health crisis services Average monthly number of persons receiving mental health crisis services Average monthly number of Assess orrestore aperson’s mental health worsens; and/or, Provide intensiv Adjust, Provide accurate diagnosis stabilize, discontinue,or begin new medications; e treatmentduring acute episodes during whichaperson’s mental and review of past diagnosesandtreatmenthistory; competency tostand trial. http://www.dshs.texas.gov/WorkArea/linkit. th 49$6 $634 $669 $459 ,3 ,0 6,767 5,209 5,039 Y21 Y21 FY 2015 FY 2014 FY 2013 , Nelson/ 206 Behavioral Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 139

216 In 209 215 Within 211,212 Following the Following 214 During the final mental 213 Specific services include diagnostic include diagnostic Specific services 208 210 e been admitted to a hospital by judicial order because they have order because they have judicial by to a hospital e been admitted A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation

207 Individuals hav Individuals

72 hours of the initial detainment, a probable cause hearing must be held to determine be hearing must a probable cause 72 hours of the initial detainment, at a mental health facility or in the community the individual should stay whether health hearing. for their final mental while he or she waits interviews, structured therapeutic programming, collaboration with appropriate programming, collaboration with therapeutic structured interviews, and discharge planning, planning. safety enforcement, suicide courts and law are provided individuals which of inpatient commitments in There are two types Within these services: civil and forensic. inpatient mental health comprehensive an decision is made as to whether an administrative two types of commitments, security placement. a maximum security or non-maximum individual needs COMMITMENTS CIVIL hospitals occur when an individual is involuntarily Civil commitments to state that of mental illness symptoms a peace officer because he or she has by detained or others. themselves and imminent risk of serious harm to present a substantial Chapter 411 of the Texas Administrative Code defines inpatient mental health inpatient Code defines Administrative 411 of the Texas Chapter services, includes medical in a hospital that provided as residential care treatment psychological other and any activities, therapeutic social services, nursing services, the treating physician. by services ordered final mental health hearing, emergency detentions can extend to 30-day orders to 30-day final mental health hearing, emergency can extend detentions (which court-ordered mental health service stays or 90-day custody of protective has three month increments if the treating physician by the court can then extend to the community). to return and safe stabilized the individual is not determined FORENSIC COMMITMENTS go to either hospital in Texas to a state Individuals who are forensically committed this type State Hospital; Campus of North Texas Vernon or the Rusk State Hospital of commitment happens for two reasons: · health hearing, the court takes testimony from medical experts, the patient, and from medical experts, testimony health hearing, the court takes coworkers). friends, life (e.g., family, individuals in the patient’s Once a mental health warrant has been granted and the individual has been has been granted Once a mental health warrant valid for a the initial civil commitment is only transported to a mental health facility, visit with the individual48-hour emergency in which time a doctor must detention, an order of protective an assessment about whether hours) and make (within 24 (OPC) should be issued and the emergency extended. custody detention if the person has an emergency person if the to admission for appropriate condition psychiatric local to the a referral make can physician a hospital Additionally, hospital. the state coordinated alternative only requires acute needs and the person has less LMHA if services. a small number of cases in which minimal improvement is seen in the first 60 days of 60 days is seen in the first a small number of cases in which minimal improvement civil an extended request may treating physician inpatient treatment, an individual’s but individuals subject to extended mental health commitment for up to 12 months, their case heard before a jury rather than a judge. commitments are entitled to have Voluntary civil commitments can also be initiated if the person needing help is person civil commitments can also be initiated if the Voluntary seeking inpatient treatment. actively 140 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC dangerous tothemselves orothers.dangerous determines manifestlytheir treatmentteamandajudge thattheyarenolonger are available forindividualswhotransferoutofmaximumsecurityunitsafter states oninpatientpsychiatric services. Texas spendsmorepercapitathancomparable specific state hospitalservice area.On average, mental healthservicesforresidentsoftheir hospital resourcestocoordinateinpatient 51. EachLMHAreceives anallocationofstate Waco CenterforYouth) displayed inFigure health hospitalsandonepsychiatric residentialtreatmentfacilityforyouth(the The StateHospital ServicesDivisionprovides oversight oftheninestate mental State Hospitals TYPES OFINPATIENT SETTINGS come, first serve basis. all other psychiatric bedsareavailable foreithercivilorforensicpatientsonafirst security bedsaredesignatedasforensicandreserved forthosepopulations; in inpatientsettings, onlytransitionalforensicprogramsandmaximum · period. weapon aresenttoamaximumsecurityunit(MSU)foran initial30-day evaluation All casesinvolving seriousbodilyinjury, imminentthreatofharm,or use ofadeadly · · Patients placedinmaximumsecuritycommitmentsinclude individualswhoare: MAXIMUM VS. NON-MAXIMUMSECURITY PLACEMENTS Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas forensic bedsinstate hospitals. and astatewide ofMSUbedshascontributedtotheincreasingwaitlists shortage for

maximum sentence length of the crimethey committed. and were ordered to a state hospital for aperiodof time not exceeding the Individuals hav understand against the charges them; or restoration services so thatthey can better consult with legalcounseland been determined Incompetent to Stand Trial (IST)andareinneedof competency Charged with aviolent Charged self and/or others; or Civilly committed and bodily injury. 219 MSUsaremoreexpensive tooperatethantraditionalstate hospitalunits 218 e beendetermined to be Not Guilty by ReasonofInsanity (NGRI) determined by professionals to bemanifestly to dangerous felony offense involving anact, threat,orattempt ofserious 220 Transitionalprogramsforforensiccommitments 221 Inregardstothemethod ofbedappropriation 222

services. on inpatient psychiatric than comparable states spends more percapita average,On Texas 217 222 Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 141 Number ofNumber Beds 299 200 74 202 640 55 325 302 288 78 2,463 223 Bed Type Bed Adults and children Adults and Adults only Adults and children children Adults and Adults only Adults and children Adults and Adults only Adults only Adults and children Adults and Adults and children children Adults and Children only Children http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4- A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation State Mental Health Hospitals Health Mental State Austin State Hospital Austin State Big Spring State Hospital State Spring Big El Paso Psychiatric Center Center Psychiatric Paso El Kerrville State Hospital State Kerrville North Texas State Hospital State Texas North Rio Grande State Center Center State Grande Rio Rusk State Hospital State Rusk San Antonio State Hospital State Antonio San Terrell State Hospital State Terrell Waco Center for Youth Youth for Center Waco Total, all bed types bed all Total, 436e-9eba-67b14f00ad22.PDF 2,238 was Texas hospitals in of all state daily census the average In FY 2015, than in 2014. individuals — 25 fewer individuals psychiatric number of beds at each of the state-operated the total Figure 52 shows include community that although this chart does not note hospital facilities in 2015; inpatient treatment, those with DSHS to provide and private hospitals that contract numbers can be found in Figure 56. Hospitals: 2016 Beds In State Psychiatric Inpatient State-Operated 52. Figure Presentation to Select Committee on Mental Health: The Behavioral Health Health Behavioral The Health: Mental on Select Committee to Presentation (2016). ofDepartment Services. Health State Texas Source: from Retrieved slides]. [PowerPoint System Figure 51. State Mental Health Hospitals and Waco Center for Youth: 2016 Youth: for Center Waco and Hospitals Health Mental State 51. Figure 142 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC 41a4-436e-9eba-67b14f00ad22.PDF System [PowerPoint slides]. Slide 25. Retrieved from needed forpatientswithcomplexmedicaland/or behavioral problems. poor buildingdesigns, aginginfrastructure, andincreased resourcesandsupervision total bedcount.Thishappensforanumberofreasons, includinghighstaff turnover, is importanttonote thatahospital’s functionalcapacityistypicallylower thantheir In determining how many psychiatric inpatient bedsthereareinstate hospitals, it STAFFING AND FUNCTIONAL CAPACITY OFSTATE HOSPITALS Source: not have communityalternatives available. needstatedesignated forindividualswhonolonger hospitalinpatientcarebutdo allotted toprovide acuteservicesforchildrenandadolescents116bedswere and adultsinTexas. Ofthe2,463 state-operated psychiatric bedsin2015, 204were 2,995 state psychiatric bedsacrossallbedtypesavailable for children,adolescents, state-operated andstate-funded psychiatric beds. InFY2016, therewereatotal of Figure 53below shows thetotal inpatientbedcapacityinTexas, includingboth the and Substance Abuse division of Texas State Health Services, Department of on June 30, 2016. confirmation that 2015 numbers apply to 2016 obtained via personal communication with Legislative Liaison for the Mental Health from Source: Texas Legislative Budget Board. (April, 2016). State Hospitals: Mental Health Facilities in Texas, Legislative Primer. Retrieved · · · · functional capacitythatallowed themtoprovide servicesfor: Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas of July 2016). estimated available capacityofstate-operated facilities was muchlower (2,297as there were2,463 inpatientbedsinstate-operated psychiatric hospitals, butthe Figure 53. State-Funded Psychiatric BedCapacity: FY 1994-2015

26 individuals onmaximumsecuritycivil commitments. 915 individualsonnon-maximum security civil commitments; and 955 individualsonnon-maximum security forensic commitments; 256 individualsonmaximum security forensic commitments; http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/3ea17faa-4c5b-4a15-9b2d-5af88e9cd4a9.PDF; Texas State Health Services. Department of (2016). 226 AsofMay 2016, thestate-operated hospitalsystem asawholehad http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b- Presentation to Select Committee on Mental Health: The Behavioral Health 224

227 225 In2016 Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 143 Until Exceptional Exceptional Items Request 2019 232 230 Exceptional Exceptional Items Request 2018 229 Requested Requested 2019 Legislature appropriated Legislature appropriated th 231 Requested 2018 infrastructure; and infrastructure; community transition program. transition community Budgeted 2017 $539,664,782 $551,509,337 $526,907,328 $527,043,011 $153,309,911 $149,274,610 $439,693,161 $441,537,717 $421,935,708 $422,071,390 $112,193,002 $108,194,641 $99,971,621 $109,971,620 $104,971,620 $104,971,621 $41,116,909 $41,079,969 Estimated 2016 in GR funds to address inflation-related cost increases; cost address inflation-related to in GR funds Legislature appropriated $872.6 million in all funds to operate the Legislature appropriated $872.6 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation th On top of the already-stressful work environment on state hospitals, hospitals, state on work environment the already-stressful On top of $439,414,324 $80,962,106 Expended 2015 228 $24.4 million $24.4 technology to replace $1.7 million supported a to create $2.5 million Total $520,376,430 Mental Health Community Hospitals Strategy Mental Health Hospi- State tals

salary caps for nurses working in state hospitals make it difficult for nurses to it difficult for hospitals make in state for nurses working caps salary This shortage of skilled nurses sector. in the private as they would earn as much needs and individuals with complex on individuals impact has a disproportionate ratios and higher staff-to-client because they require security units in maximum and units available Many healthy. and to remain safe more frequent interventions the proper have they do not be utilized for treatment because inpatient beds cannot in place. The 84 ratios and required staffing skill sets · · state hospital system for the 2016-17 biennium. In addition to maintaining current for the 2016-17 hospital system state the 7,838 FTE positions per year, and benefits for salary capacity and providing funding also included: · Source: Data captured from HHSC Legislative Appropriations Request for FY 2018/19, September 12, 2016 12, September 2018/19, FY for Request Appropriations Legislative HHSC from captured Data Source: DISEASES (IMD) EXCLUSION FOR MENTAL INSTITUTIONS in Section 1905(a)(B) of the Social Security Act defines an IMD The IMD exclusion that is with more than 16 beds, institution or other as “a hospital, nursing facility, of persons with mental treatment, or care diagnosis, primarily engaged in providing nursing care, and related services.” including medical attention, diseases, Funding from federal sources accounted for 4.4 percent of the total appropriations appropriations the total percent of for 4.4 accounted sources from federal Funding the because of million) but ($38.8 biennium the 2016-17 hospitals in for state used funding will be primarily this Exclusion, (IMD) Diseases for Mental Institutions ageage the under for youth 65. adults over of 22 and FUNDING FOR INPATIENT CARE INPATIENT FUNDING FOR the 84 In total, While turnover in state hospitals has been an issue across all positions, state state all positions, issue across been an has hospitals in state turnover While shortages staffing nursing in skilled with difficulty had particular have hospitals positions. $1.4 million for targeted increases in nursing salaries and appropriated to DSHS an and appropriated to DSHS salaries increases in nursing million for targeted $1.4 through increased and retention recruitment staff improve million to additional $5.6 for nurses. and geographic-based payments incentive salaries 144 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC quality careandprematuredischarge. they alsodidnot receive federalMedicaid matchpayments, creatingtheriskoflower alone psychiatric facilitiescouldnot deny admissiontoindividualsreferredthem,but individual served ofallTexas state hospitalsin2015 ($34,749 perclientyear). had both thehighest average lengthofstay (839days) andthehighest cost per shows, Kerrville State Hospital (whichonlyprovides transitional forensic services) in theaveragecost perstate hospitalclient(an80percentincrease). almost doubled,from$11,912 inFY2006to$21,437 inFY2015, anincreaseof$9,525 Over thepast decade,theyearlyaverage cost perpatientserved instate hospitalshas INPATIENT SERVICES AT STATE HOSPITALS: UTILIZATION AND COSTS Register onMay 6, 2016. carerulesregardingtheIMDexclusionThe finalmanaged wereenteredintothe Federal inIMDs.64 yearsofage recently, excluded theAct fundinginpatientservicesforindividualsbetween 22and · · · improving federalreimbursementsforshort-termadmissionstoIMDsresultsin: report ontheMEPDpilot isnot dueuntilSeptember 2016, initialresultsshow that totheIMDexclusion.data onthepossibleimpactofthisnewchange Whilethefinal PsychiatricEmergency Demonstration (MEPD)pilot, provides somepreliminary in Texas, apilot study intheDistrict ofColumbiaand11states, theMedicaid While itisstill tooearlytodirectlyanalyzetheimpactofthisnewruleonindividuals treatment by providing moreflexiblefinancing options. the IMDexclusion inshort-terminpatientbehavioral health andaddressshortages · · entirely by state fundswithoutfederalmatching. 64, andeffortstoimprove orexpandpublicinpatientserviceswerefundedalmost the primaryfundingsourceforstate hospitalservicesforadultsbetween 22and ages funding forinpatienthospitalservices, state revenue hastraditionallybeen general responsibility forinpatientpsychiatric care.Duetothisfederalrestriction on services andensurethatthefederalgovernment didnot have to assumefinancial was enactedin1965and was intendedtopromote theexpansionofcommunity Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas of stay forallinpatientpsychiatric hospitals is8.2 days. length numberof casesbecausetheaverage expressed thatthisnewrulewillhelpalarge rules incentivizeinpatienttreatmentover community-based interventions, CMShas some advocates have arguedthatthe15-day limitistoorestrictive orthatthenew months (e.g.,10days attheendofJuly and10days atthebeginningofAugust). While in onemonth,butstays canexceed the15-day limitifthedays arespreadoutover two Financial Participation alsoonlyappliesforshort-termIMDstays oflessthan15days use disorderinpatientcare,orbehavioral healthcrisisresidentialservices. private IMDandtheinquestion provides psychiatric inpatientcare,substance is apatientinanIMD,” solongastheindividualelectstoreceive servicesinapublicor 21to64who (FFP) forafullmonthlycapitationpayment onbehalfofanenrolleeaged

Lower o Faster clinicalresponseto Fewer readmissions toemergenc Fewer transfers toother Shorter lengths of s verall costs ofcare. tay; 234

The IMDexclusion hasbeeninplacesinceMedicaid policy Thenewrulespermit“Federal FinancialParticipation psychiatric facilities; patients experiencing a psychiatric crisis;and 238 y rooms and general hospitals; y rooms andgeneral 237 The objective of the rule change was to mitigate was Theobjectivetomitigate oftherulechange 233 236 Before this rule change, stand- Beforethisrulechange, 239 As Figure 54 AsFigure54 235 Federal 240

Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 145 Average Cost per Cost Average Served Client $19,224 $27,292 $13,957 $34,749 $23,834 $10,831 $23,962 $19,479 $15,833 $25,616 $21,437 241 Average Length Length Average ofDis- at Stay charge 49.3 days 138.0 days 138.0 27.5 days 838.5 days 838.5 116.3 days 116.3 25.5 days 137.3 days 137.3 58.5 days 41.8 days 161.8 days 161.8 73.5 days Average Daily Average of(% Census total capacity) 258 patients (86% patients 258 ofcapacity) 180 patients (90% patients 180 ofcapacity) 66 patients (89% of(89% patients 66 capacity) 196 patients (97% patients 196 ofcapacity) 566 patients (88% patients 566 ofcapacity) 52 patients (95% of(95% patients 52 capacity) 313 patients (96% patients 313 ofcapacity) 268 patients (89% patients 268 ofcapacity) 246 patients (85% patients 246 capacity) 72 patients (92% of(92% patients 72 capacity) Population Served Population Mostly civil, some civil, Mostly forensic Mostly civil, some civil, Mostly forensic Maximum security Maximum and (Vernon) forensic forensic and Civil (Wichita) Mostly civil, some civil, Mostly forensic Civil and forensic and Civil Mostly civil, some civil, Mostly forensic Mostly civil, some civil, Mostly forensic 2,236 patients and civil (50.3% forensic) 49.7% A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/3ea17faa-4c5b-4a15-9b2d-5af88e9cd4a9.PDF State Hospital State Austin State Hospital Austin State Big Spring State Hospital State Spring Big forensic and Civil El Paso Psychiatric Center Psychiatric Paso El Kerrville State Hospital State Kerrville only Forensic North Texas State Hospital State Texas North Falls) Wichita & (Vernon Rio Grande State Center State Grande Rio Rusk State Hospital State Rusk San Antonio State Hospital State Antonio San Terrell State Hospital State Terrell Waco Center for Youthfor Center Waco only Civil TOTAL Data obtained from: Texas Legislative Budget Board. (April, 2016). State Hospitals: Mental Health Facilities in Texas, Legislative Primer. Primer. Legislative Texas, in Facilities Health Mental Hospitals: State 2016). (April, Board. Budget Legislative Texas from: Data obtained from Retrieved Figure 54. Utilization and Costs for State-Operated Hospitals in FY 2015 in FY Hospitals for State-Operated and Costs Utilization 54. Figure Figure 54 also shows that despite there being a shortage of inpatient psychiatric beds, beds, shortage being a there that despite shows 54 also Figure psychiatric of inpatient — thisfunded capacities total their are below hospitals of all censuses daily the average in case of emergencies, open bed capacity some retain must because hospitals is partly many difficult for made it have shortages and high turnover staffing but also because been any has also not There they have. number of beds to fully utilize the hospitals — only more contracted in recent years beds state-operated in the number of increase repair and renovation hospital infrastructure beds — and unmet community hospital contracted beds out of operation. state actually taken needs have 146 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC hospital bedsavailable. contracted withDSHS, thestate fundsallocatedforeachfacility, andthenumberof over timewhileFigure 56below shows thecommunityhospitalsthatarecurrently FY 1994-2015 shows thegrowth ofcommunityandprivatecontractedhospitals to individuals. TheredlineinFigure53:State-Funded Psychiatric BedCapacity: instead receive state fundinginordertoprovide mentalhealthinpatientservices Community andprivatehospitalsareneitherowned noroperated by thestate, but STATE-FUNDED COMMUNITY AND PRIVATE HOSPITALS www.dads.state.tx.us/providers/pi/piac/7-21-16-reports.pdf Source: Promoting Independence Advisory Committee. (July 21, 2016). Department Activity Report. Page 59. Retrieved from portion oftheroughly2,236patientswhoareinstate hospitalsonany given day. shows, inandoutofstate individualswhocycle hospitalsaccountforasignificant remaining inthecommunityafterdischargingfromastate hospital.AsFigure55 access tocommunity-based treatmentsandservices, many individualshave trouble Whether duetoanindividual’s especiallysevere mentalhealthneedsortheirlackof community-based serviceshasadirectimpactoninpatienthospitalcapacity. inadequate ornocommunity-based treatments, theavailability andqualityof Since inpatienthospitalsserve asasafety net formany individualswhoreceive September 2013—May2016 Figure 55. Individuals Admitted Numberof toState Hospitals3+ Times in180Days: Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 243 http://

242

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HHSC Social Services Division & Behavioral Health Services Services 147 DSHS Number ofBeds 3 5 3 248 244 245 $96,751,613 532 Annual Funds Annual $647,460 $2,127,040$1,798,500$6,567,025 20 $981,000 10 $1,247,832 30 $686,700 $4,126,274 6 $1,187,010$6,123,860 30 $15,417,450 6 $1,942,380 28 $4,045,158 94 $35,353,199 9 $1,104,125 20 $2,208,250 199 $9,210,000 5 $1,978,350 10 44 10 While efforts are underway to divert individuals experiencing mental to divert While efforts are underway 246 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation While there is no comprehensive information on the statewide utilization information on the statewide While there is no comprehensive 247 Legislature allocated an additional $50 million to DSHS in order to secure 150 Legislature allocated an additional th Contractor Abilene Regional MHMR Center DBA Better Hardwick Center Hardwick Better DBA Center MHMR Regional Abilene (Access) Services Enrichment Community Cherokee Anderson Care Integral County Travis Austin MHMR DBA County Austin-Travis Services Care Health for Center Center MHMR Community Plains Coastal Center MHMR County Denton Center MHMR Region Texas of Heart Health Specialty Starcare DBA Center MHMR Regional Lubbock Authority MHMR of Valley Brazos County Tarrant ofMHMR County Montgomery Center Spindletop DBA Services MHMR Spindletop Gulf The Center Coast IDD and Health Mental for Center Harris The Healthcare Behavioral Tri-County Health Behavioral Texas Tropical Tyler at Center Health Texas ofUniversity MHMR for Centers Texas West TOTAL has since contracted with 13 different LMHAs to provide an additional 94 inpatient bedshas since contracted with 13 different LMHAs to provide million. of $17.1 initial annual cost at an estimated the end of FY 2016, by of inpatient beds in freestanding psychiatric hospitals, a survey by the Texas Hospital the Texas by a survey hospitals, psychiatric of inpatient beds in freestanding beds are full. psychiatric Association found that the majority of non-state-owned health crises away from emergency health crises away rooms and into more therapeutic environments, the inpatient needs of individuals with mental illness. regular hospitals also help meet general beds in non-state-owned there were 2,808 licensed psychiatric As of FY 2015, psychiatric licensed beds in freestanding and 4,408 and specialty hospitals in Texas hospitals. In addition to beds in community hospitals, locally supported beds also help meet In addition to beds in community hospitals, beds across the 1,936 psychiatric approximately providing by inpatient needs psychiatric insurers (e.g., Medicaid half of these locally supported beds are funded by About state. half are used to help indigent while the other individuals who do not and Medicare) insurance. have Source: Personal communication with Legislative Liaison for the Texas Department of Department and Health Mental Services’ Health State Texas the for Liaison Legislative with communication Personal Source: 2016). 30, (June Division. Abuse Substance The 84 Figure 56. Purchased Community & Contracted Private Hospital Beds: Hospital Private Contracted & Community Purchased 56. Figure 2016 of and Number in FY Beds Funds Allocated more contracted beds in community and private hospitals by the end of FY 2017. more contracted beds in community and private hospitals by 148 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC Hospital in2012 afterconcludingthatitwouldnot save moneyorimprove care. awarding thecontract.Thestate droppedasimilarplantoprivatizeRuskState the contractandfailedtoconsultwithTexas Attorney General’s officebefore but thatplanwas abandonedaftertheTexas undervalued StateAuditor foundHHSC Hospital sofarasawarding aswell,even going thecontracttoCCRSinOctober2015, The Texas toattempt LegislaturedirectedHHSC toprivatizetheTerrell State C3822016021810001/5fc9614b-41a4-436e-9eba-67b14f00ad22.PDF The Behavioral Health System [PowerPoint slides]. Retrieved from Source: Texas State Health Services. Department of (February 18, 2016). Hospitals: 2001-2016 Figure 57. DailyCivilvs. Snapshotof Forensic Patient Population inState commitments andfewercivichave continuedin recentyears. Figure 57below shows how theseco-occurringtrendsofmoreforensic inpatient bedsin2001 tomorethanhalfofallstate beds(52percent)in2016. significantly over thepast decade,risingfrom16percentofallpubliclyfunded The forensicpopulation’s useofstate psychiatric hospitalresourceshasgrown ofPublicly-FundedAddressing theShortage InpatientBeds CONTINUING ISSUES hospital inTexas —theMontgomery CountryMental Health TreatmentFacility. and detention services, torunthefirst publiclyfundedandprivatelyrunpsychiatric Correct CareRecovery Services(CCRS),aprivatelyowned provider ofcorrectional Forbed capacityshortage. example,DSHSenteredintoacontractin2011 with privatizing somestate-operated facilitiestohelpalleviatetheinpatientpsychiatric Due inparttotheincreasingneedforforensicbedsrecentyears, DSHSconsidered Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 1995, thatnumberdroppedtoroughly12in2003and10.5 in2015. while therewereanestimated 18inpatientpsychiatric bedsper100,000 Texans in overall decreaseinthenumberofpsychiatric bedsavailable percapitainthestate; The steady increaseinTexas’ populationduringthissame periodcontributedtoan http://www.legis.state.tx.us/tlodocs/84R/handouts/ Presentation to Select Committee on Mental Health: 252,253 251

250 249

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HHSC Social Services Division & Behavioral Health Services Services 149

260 262 Long- Benefits 255 261 Legislature th 263 , Garcia/Naishtat), part of which deals th 257 While a 2012 Texas court ruling that required incompetent Texas While a 2012 258 Unfortunately, the average length of time on forensic waitlists the average length of time on forensic waitlists Unfortunately, In contrast, the average length of stay at discharge only 56 days was of stay length the average In contrast, 259 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 254 in FY 2012; and in FY 2012; Because of the growing proportion of forensic commitments in recent proportion of forensic commitments Because of the growing ys in FY 2015. ys in Legislature also passed SB 1507 (84 256 th 44.9 days in FY 2006; 44.9 days days 58.3 da 74.4

The report from that study was released August 2016. An overview of the Rider 86 An overview 2016. released August was The report from that study at: http://www.dshs.texas.gov/ConsumerandExternalAffairs/ report is available legislative/2016Reports/RPCMemoUniversityPartnershipsMHSA08042016.pdf allocates $1.2 million annually to fund additional civil Rider 74 Also passed in 2015, Center Harris County Psychiatric of Texas the University program at beds in a pilot for individuals needing treatment for less than 90 days. term hospital stays are also on the rise, with the number of individuals residing in are also on the rise, with the number term hospital stays 700 to over in 2001 from less than 400 a year growing hospitals for over state Texas in 2014. · · years, the average length of stay for all state hospital patients (and the corresponding patients (and the corresponding hospital all state for of stay length the average years, has continued to increase: that come with a longer stay) hospital costs · In order to address the needed expansion of inpatient capacity, the 84 of inpatient capacity, In order to address the needed expansion with addressing capacity issues at state hospitals. Beyond improving coordination Beyond improving hospitals. with addressing capacity issues at state position, SB 1507 of forensic services and creating a new DSHS forensic director and the new DSHS forensic stakeholders, requires HHSC to work with LMHAs, for the allocation of state-funded a new regional methodology director to develop inpatient facilities that contract with DSHS. other hospitals and beds in state The 84 The increase in forensic commitments has also resulted in waitlists for these has also resulted in waitlists The increase in forensic commitments 1,668 an estimated FY 2015, in all of 2013; services more than quadrupling since for competency lists and were put on waiting individuals sought forensic services services. restoration The increase in forensic commitments is one of the key drivers of the upsurge of the drivers in the key is one of commitments in forensic increase The commitments forensic because years in recent lists waiting and spending hospital 2015, In FY longerare typically civil commitments. than expensive and more forensic health hospital mental at discharge for state of stay length the average for competency 95 days to just compared 421 days, ruled NGRI was patients a involving restoration for competency 65 days and a felony involving restoration misdemeanor. defendants to wait no longer than 21 days for competency restoration services was no longer for competency restoration defendants to wait than 21 days that it intended to abide by DSHS stated on procedural grounds in 2014, overturned limit. the 21-day from this type of model include: improved medical and psychiatric services, training services, medical and psychiatric from this type of model include: improved and primary health increased integration of behavioral opportunities for residents, recruitment through residency and internship programs. and improved services, for civil commitments and 41 days for voluntary commitments in FY 2015. commitments for voluntary and 41 days for civil commitments has continued to surpass the 21-day mark since 2014; in 2015, individuals needing a 2015, in mark since 2014; has continued to surpass the 21-day significantly longer unit waited thanbed in a maximum-security forensic (102 days) in non-maximum-security facilities (32 days). individuals needing forensic services passed Rider 86, which directed DSHS to evaluate the feasibility and potential which directed DSHS to evaluate the feasibility and potential passed Rider 86, state hospital. to operate a health institution a university-related benefits of allowing the state between facilities through a partnership This model of operating inpatient Kentucky. Georgia, and has already seen success in Ohio, and a university 150 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC combined ($104million): state hospitalmaintenancefundingappropriatedby theprevious five legislatures the threestate hospitalsmentioned above wouldcost morethanallofthedeferred facility renovations, thepreparationandreplacement/renovation costs forjust While all10ofthestate’s hospitalsareinneedofextensive repairsorcomplete Since the84 recommendations regardingtheimplementationofprocess. approved by theLegislature eachbiennium. repair state hospitalinfrastructure andtheamountsrequested by DSHSand Figure 58below shows thevast gapbetween theamountofmoneyneededtofully · · · maximum securitybeds. beds instate-run mentalhealthhospitals—over halfofwhomwerewaiting for As ofApril2016, anestimated 400individualswerestill onwaiting lists forforensic 2016. thenadoptedbed day utilizationreview protocol inthespringof andwhichHHSC submitted forabedday allocationmethodology aninitialproposal anda toHHSC The Joint andForensic Committee onAccess Services(established by SB1507) · list forforensicbedsconsisted of: · waiting lists astherewereinAugust 2013. for theprevious10yearsandroughlyfourtimesasmany individualsonforensic jails waiting foraforensic inpatientbedtobecomeavailable —thatisarecordhigh for forensicinpatientbedshave continued;inJanuary 2016, 424 individualswerein Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas In 2013, the83 IMPROVEMENTS TO AGING STATE HOSPITAL INFRASTRUCTURE State Hospital) andfound all threefacilitiestobein“poorcriticalcondition.” (Rusk StateHospital, NorthTexas StateHospital atVernon, and SanAntonio As partofthe10-year plan,DSHSconductedanin-depth analysisofthreefacilities individuals returning tothecommunity. also includesbest practiceswithininpatientsettings andtransitionalservicesfor on how tobetter serve individualsthroughcommunity-based providers. Theplan operational needs, infrastructure needs, capacityissues, andrecommendations and state supportedlivingcenters(Rider83, SB1,ArticleII).Thisplanoutlines and implementa10-year planonthefutureinfrastructure ofstate hospitals

San Antonio State H North Texas State H Rusk State Hospital 195 individualswaiting for maximum security 219 individualswaiting for non-maximum · · · ·

264,265 Averag 161 individuals(83percent)waiting more than21 Averag 117 individuals(53percent)waiting more than21 Thejointcommittee willcontinuetomeet quarterlytomonitorandmake th e wait: 130days (an 83 percent increase since April 2015) e wait: 34days Legislative sessioncametoaclose,problemswithgrowing waitlists rd LegislaturerequiredDSHS(inconjunctionwithDADS) todevelop ospital at Vernon = $50.1 million = $193million ospital =$202.5 million 269 271

266,267 security beds 272 As ofFebruary 19, 2016, thewaiting beds days days 268 270

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HHSC Social Services Division & Behavioral Health Services Services 151 More recently (2016), the recently (2016), More The JCAFS report also The JCAFS 275 276 Inpatient Mental Health Planning: Presentation to the Senate Senate the to Presentation Planning: Health Mental Inpatient Outside evaluators of the state hospital system hospital system Outside evaluators of the state 278 http://www.dshs.texas.gov/ConsumerandExternalAffairs/ from Retrieved slides]. [PowerPoint 277 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 273 Looking at both privately and publicly funded inpatient beds, a 2014 a 2014 privately and publicly funded inpatient beds, Looking at both 274 Legislature appropriated $18.3 million for critical state hospital repairs for million for critical state Legislature appropriated $18.3 th legislative/2016Reports/SenateHHSinpatientMH.pdf evaluation by CannonDesign estimated that Texas needed 4,300 state-funded needed 4,300 state-funded that Texas estimated CannonDesign evaluation by all inpatient mental health needs. to meet beds in 2014 the FY 2016-2017 biennium — roughly 20 percent of what the department asked asked biennium — roughly 20 percent of what the department the FY 2016-2017 all crucial repairs and needed to complete was for and less than 10 percent of what renovations. In addition to exacerbating the current capacity issues at state hospitals, failure hospitals, state In addition to exacerbating the current capacity issues at impact negatively hospitals may of state infrastructure and repair the to renovate it nearly which would make Commission (TJC), The Joint their accreditation by the needs of individuals with acute to meet hospital system impossible for the state mental health conditions in Texas. Also passed in 2015, Rider 86 allowed DSHS to use up to $12.4 million in surplus up to $12.4 DSHS to use 86 allowed Rider Also passed in 2015, renovations for planning and developing and Services” funds Facilities “Hospital funded beds 570 publicly to add an estimated needs Texas at Rusk State Hospital. inpatient need for the current unmet facilities in order to fully meet in psychiatric services. The 84 Source: Mike Maples & Lauren Lacefield Lewis. (June 16, 2016). 2016). 16, (June Lewis. Lacefield Lauren Maples & Mike Source: Services Human and Health on Committee Figure 58. Deferred Maintenance Funding Requests for State Hospitals: Hospitals: for State Requests Funding Maintenance Deferred 58. Figure 2008-2017 FY recommended that these beds be added through “a significant initial expansion of recommended that these beds be added through “a significant to include additional maximum inpatient capacity, and state-funded state-operated the current and both a gradual increase in beds to meet by followed security beds, future demand.” Joint Committee on Access and Forensic Services (JCAFS) estimated that Texas that Texas estimated Services (JCAFS) on Access Committee and Forensic Joint immediately and eight years – 1,400 the next needs to add 1,800 hospital beds over with population growth. up 50 more each year to keep indicate that five of the state hospitals (Austin, North Texas-Wichita Falls, Rusk, Falls, Texas-Wichita North state hospitals (Austin, of the indicate that five while the replaced and renovated should be completely and Terrell) San Antonio, 152 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC receiving facility. mandating thatrestraints duringtransportationbedocumentedandreportedtothe during restraints thatoccurduringapprehension,detention, ortransportation,and restricts theuseofrestraints by requiringthatindividualsmust beabletositupright proceedings. or herdefenselawyer andhave arationalandfactualunderstanding ofthelegal considered competent tostand trial,thatpersonmust beabletoconsultwithhis be restored tocompetency beforethelegalprocesscan continue.Inordertobe withacrime whoisfoundincompetentA personcharged tostand trial(IST)must toTimelyCompetency RestorationIncreasing Access Services to Restraint andSeclusionsgrants(STARS grant). state’s psychiatric hospitals—thisgrantwas calledtheStateofTexas Alternative SAMHSA toreduceoreliminatetheuseofrestraints andseclusion infourofthe restraint orseclusionperincident.In2007, Texas was awarded afederalgrantfrom seclusion, thenumbersofindividualsinvolved, andthelengthoftimespentin notably reflectedinreductionsboth thenumbersofincidentsrestraint or Texas hasmadeimprovements inthecultureofcareatstate hospitals, most physical, mechanical,orchemicalrestraints. individuals believed tobeatriskofharmingthemselves orothers; thismay include and directcarestaff tophysically isolate(seclude)orholdwithforce(restrain) “Seclusion andrestraint” referstotechniquesusedby administrators, clinical, Texas have received traininginhow toreducetheuseofseclusion andrestraint. being anddecreasetheriskoftraumatizationinjury, staff from RTCs across well- In anefforttopromote techniquesthatencourage behavioral management andRestraintsReducing theUseofSeclusions OTHER ISSUES ASSOCIATED WITH INPATIENT SERVICES the state anestimated $2.9billionover thenext 10years. licensing standards inthefuture.Thesereplacementsandimprovements wouldcost remaining five hospitalsrequiresignificantrepairstocontinuemeeting TJChospital In 2015, the84 Environment canbefoundatwww.dshs.texas.gov/cultureofcare/toolkit.doc. any setting. Creating aCulture ofCare: AToolkit Creating aTrauma-Informed for a STARS grantwas atoolkitdesignedtohelpreduceseclusionandrestraint in Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas and toother individualsplacedintheirprogram. clinical complexity, criminalhistory, andthesafety riskthey posetothecommunity specialty programsisdetermined by amixture offactors, includinganindividual’s competency restoration tracts. Asshown inthediagram, placementintothese Figure 59displays aconceptual frameworkforplacement intothethreedifferent outpatient competency restoration (OCR)programs. restoration (ICR)programs, jail-basedcompetency restoration (JBCS) programs, or mental illnessoranintellectualdisability, may beplacedintoinpatientcompetency techniques helpreducethelikelihood thataresidentyouthwillbere-traumatized. exacerbate theirtrauma.Thus, instituting alternatives toseclusionandrestraint common amongyouthinRTC settings andseclusionrestraint techniquesmay 285,286 th LegislaturepassedSB1129(84 284 Individualsdetermined to beincompetent, typicallydueto 281 Emotional andphysical traumais th , Zaffirini/Raymond), which 287 283 Oneproductresultingfrom 279,280 282 Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 153 292

288 As of May 2016, Disability Disability 2016, As of May 291 The court found that a defendant The court found that a defendant 289 However, in May 2014, the Third Court the Third Court 2014, in May However, 290 security beds, 32 intermediate security beds, and beds, security 32 intermediate security beds, A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Addingmaximum eight (NTSH); State Hospital Texas North beds at to forensic 20 civil beds converting

of Appeals in Austin overturned that ruling on procedural grounds, finding that that ruling on procedural grounds, overturned of Appeals in Austin operates in an list that DSHS’ plaintiffs in the case had failed to demonstrate While the court found that the DSHS detainee. for every manner unconstitutional it indicated that detention unconstitutional, not was practice of maintaining the list beyond a certain period would be unconstitutional. Following the initial ruling in 2012, DSHS made several improvements and improvements DSHS made several the initial ruling in 2012, Following times for beds, to decrease wait in an attempt hospital system expansions to the state including: · Delays in receiving timely restoration and mental health services may violate and mental health services may in receiving timely restoration Delays to detrimental and can be extremely Constitution in the U.S. speedy trial provisions to DSHS attempted 2006, for the individual. In long-term mental health outcomes implementing a resources by shortage of inpatient psychiatric address the growing services policy individuals who are found IST and in need of restoration requiring all Admissions capping be placed on the DSHS State Hospital waitlist, Clearinghouse As a result, 738. hospital beds used for forensic commitments at the number of state hospital forensic beds became more state admission to one of the 738 designated Because forensic because of its being contingent on limited availability. restricted much longer hospitals are on average than civil commitments, commitments at state in jail average of 250 patients were waiting reduced so much that an bed capacity was services. for six months or longer restoration for competency Figure 59. Placement Determination For Competency Restoration Programs Restoration Competency For Determination Placement 59. Figure Rights Texas was still in litigation with DSHS over the constitutionality of the the constitutionality in litigation with DSHS over still was Rights Texas times for forensic Wait the waitlist. individuals on lengths of time experienced by in some cases as long as nine months. still were services in April 2016 In 2012, a Travis County District Court judge ruled on a forensic restoration County District a Travis In 2012, that challengedTexas in 2007 the DSHS Rights by Disability filed capacity lawsuit for people found IST. clearinghouse waitlist deemed IST cannot be held in a jail for more than 21 days prior to admission into be held in a jail for more than 21 days deemed IST cannot program. restoration a competency 154 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC hospitals (2,235). accounted forroughly39percentoftheaverage dailycensusofstate-run psychiatric 2015, individualsreceivinginpatientcompetency restoration (ICR)services(872) competency restoration (OCR) pilot programsinresponsetothegrowing number competency restoration services. be committed toamentalhealthfacilityorresidentialcareforinpatient competency restoration (JBCR) pilot programforindividualswhootherwise would to understand thelegalprocesssothattheycanproceedthroughcourtsystem. resources andservicestheyneedtomaintainalevel ofpsychiatric stability andbeable in acommunity-based, outpatientsetting. The ideaofOCRistogive individualsthe training andother competencyrestorationindividuals services tonon-dangerous Outpatient competency restoration (OCR)isaprocessofproviding legaleducation Outpatient Competency Restoration Changing Environment sectionformoreinformationontheJCBRpilot. based restoration servicesbuthasfacedsignificantbarrierstoimplementation—see and non-violent felony offenses. services,management withmisdemeanors andlegaleducationtopeoplecharged OCR programstypicallyprovide mentalhealthandsubstance usetreatment,case The 83 Jail-Based Competency Restoration competency restoration was theonlyoption forindividualsfoundIST. hopefully restore theircompetency tostand trial.Before2004,inpatient may becommitted toastate hospitalforensicunittoreceive treatmentand Individuals foundIST(i.e.,unabletocompetently understand courtproceedings) Inpatient Competency Restoration than the 21-daywaited significantlylonger objective. maximum-security (102days) ornon-maximum-securityforensicunit(32days) has continuedtosurpassthe21-day mark;in2015, individualsneedingabedin continued toincreaseinrecentyears, theaverage lengthoftimeonforensicwaitlists However, astheTexas population andthecorrespondingdemandforserviceshas · · average perday cost of$603($300-$1,000) forICRprograms. a morerecentnationalstudy of47states andtheDistrict ofColumbiafoundan restoration inaTexas state hospitalinFY2013 was over $415perbedday, and be referredtoOCRprograms in2003. The Texas Code ofCriminalProcedures(TCCP)beganallowing individualsto generallymoreexpensive. making treatmentmoredifficult and local taxpayers andoftenhave theresultofexacerbatingindividuals’mentalillness, mental illnesstoavoidstays prolonged injailsorstate hospitals, which arecostly to Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas patients hasnow surpassedthatofcivilpatients. of stay thancivilorvoluntary commitments, theaverage dailycensusforforensic in recentyearsandbecausethosecommitmentshave averagelength amuch longer offorensiccommitmentsforinpatientcompetencyrestorationpercentage services

Converting security forensic beds Converting 25 civilbeds to forensic beds andconverting 40 beds tomaximum rd LegislaturepassedSB1475 (83 35 civil beds toforensic beds atSan Antonio State Hospital (SASH). 296 Therehasbeenasteady andsignificantincreaseinthe at RuskState Hospital (RSH); and 302 300 OCRprogramscanallow low-risk individualswith Thepilot isprojectedtoprovide 20bedsforjail- 303 rd In2007, Texas initiated four outpatient , Duncan/Zerwas) tocreateajail-based 297 Theaveragecost ofcompetency 294 298,299 295 InFY 301 293

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HHSC Social Services Division & Behavioral Health Services Services 155

305,306 Page 16. Page Figure 60 311 309 In addition, prior 310 OCR program evaluations in multiple 312 Texas Outpatient Competency Restoration Programs: Evaluation Report. Report. Evaluation Programs: Restoration Competency Outpatient Texas Legislative Session) directed DSHS to allocate $4 million each $4 million each DSHS to allocate Session) directed Legislative nd A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation In the Hogg Foundation’s 2014 evaluation of OCR programs in Texas, of OCR programs in Texas, evaluation 2014 Foundation’s In the Hogg

304 307,308 = 13) Black (46 percent) or White (32 (SD = 13) Black (46 percent) a 38- year-old was the typical participant (63 schizophrenia with percent) male (72 percent) diagnosed percent) single (87 a felony charge criminal disorder (21 percent) and whose percent) or bipolar not was homeless. of participants were percent). In addition, 28 percent (60 Texas added another eight OCR programs between 2011 and 2013, now constituting constituting now and 2013, 2011 between eight OCR programs another added Texas individuals as country and serving roughly 1,700 of OCRs in the system the largest of 2016. year to support expanding the number of OCR pilot sites beyond the initial four. the initial sites beyond OCR pilot the number of expanding year to support More recent research on OCR programs across the country concluded that OCR concluded recent research on OCR programs across the country More program low rates, outcomes in terms of high restoration “promising programs have savings.” cost and substantial failure rates, Source: Hogg Foundation for Mental Health. (July 2015). 2015). (July Health. Mental for Foundation Hogg Source: In addition to avoiding the high cost of hospitalization, OCR can reduce costs to of hospitalization, OCR can reduce costs the high cost In addition to avoiding remain in jail reducing the length of time individuals jails and local communities by to an available of transporting an individual long distances and eliminating the cost programs found that evaluation of OCR 2014 Foundation’s hospital bed. The Hogg in an lengths of stay increased with greater of restoration likelihood a person’s longer mark, lengths of 21-week threshold. After the OCR program, up to a 21-week of restoration. with greater likelihood associated were not stay of forensic commitments in state psychiatric hospitals. For the four pilot sites, the sites, four pilot the For hospitals. psychiatric in state commitments of forensic $11,894 was 2012 in FY OCR through services restoration provide to cost average in a state restoration for inpatient of $50,520 cost average far less than the per case, hospital. In 2011, Rider 78 (82 In 2011, hospitalizations were shown to have a significant effect on a person’s likelihood to likelihood a significant effect on a person’s to have hospitalizations were shown who in an OCR program; individuals in OCR programs to competency be restored hospitalizations were percent) prior psychiatric or one (80.5 percent) had zero (86.0 than individuals who had two to competency to be successfully restored more likely prior hospitalizations. percent) percent) or three or more (68.7 (67.8 below shows some of the most important components of successful OCR programs. some of the most shows below Impacting Success of OCR Programs Factors Most Important 60. Figure states have shown a number of benefits to OCR, including: shown have states 156 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC percent ofthetotal U.S populationin2014. total of21.5millionAmericansover 12withasubstance age usedisorder—thatis8.1 between of12and18increasesthatnumberby theages another 1.3millionfora State agencies and organizations are increasingly using the term “behavioral and organizationsareincreasingly usingtheterm“behavioral State agencies exacerbate existing ones. the communityasawhole, anditcanboth creatementalhealthconditionsand Ultimately, substance usehasasignificant effectontheindividual,family, and persistent substance anddrugaddiction. usecanalsoleadtochemicaldependency impact behavior, judgment,mood,thoughtprocesses, andmemory. Continuedand potential toalteranindividual’s brainchemistry, cannegatively andlong-termusage Substance usecanresultinseriousbehavioral andemotional —ithasthe challenges America struggled withsubstance usedisordersin2014. Health (SAMHSA),anestimated ServicesAdministration 20.2 millionadultsin tothemost up-to-datestatisticsAccording fromSubstance Abuse andMental S treating defendants who are not restored to competence and are transferred to the state hospital for additional restoration services. stay and cost per individual for the community- and jail-based programs**The do not reflect length of theadditional time and cost of *Percentage is for cumulative success rate for FY 2008-2013. Figure 61. Competency Comparison Restoration of Programs** restoration program. costs andwithhighersuccessratesthantheSanBernardino jail-basedcompetency 61, Texas’s outpatientcompetency restoration programsprovide treatmentatlower based oncost, lengthofstay, andrestoration successrate.Asdemonstrated inFigure Figure 61comparesthethreedifferenttypesofcompetency restoration programs compared toinpatientcompetency restoration. In Texas, OCRcosts anaverage of$21,208lessperindividualrestored tocompetency · · · with moresevere needsand/or riskfactors. benefit ofreducingforensic waitlists andfreeup state hospitalbedsforindividuals inpatient competency restoration programsintoOCRcanalsohave the Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

ration Jail-Based Competency Resto- Type Program of State Psychiatric Hospital ration Outpatient Competency Resto- 2012) program, FY 2012) ubst Total cos An averag An average rateof70 percent competency restoration (77 percent in Texas); 319 318 (San Bernadino, CA (FY 2013) a t of OCRaveraged $215per individual perday ($140 inTexas). nce e of149 days to be restored to competency (70days in Texas); and 317 U (FY se S $229 otPrDyAvg. Length of Cost Per Day $421 $278 ervices 128 days Stay 120 days 63 days

320 315 314 Diverting individualsfrom $29,312 Individual Served Avg. Total Cost per $50,520 $17,514 319 Theadditionofchildren charges dropped* improved with 58% restored or Success Rate 75% restored 45% restored 313 Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 157 321 324 to help individuals successfully integrate into their into integrate successfully individuals help to

323 services; 322 atment services with a recovery-oriented approach; and approach; recovery-oriented a with services atment works to reduce tobacco-related health problems. The program program The problems. health tobacco-related reduce to works

, Garcia/Naishtat), the Outreach, Screening, Referral and Screening, the Outreach, , Garcia/Naishtat), Peer-support Peer-support tre Aligning supports community Expanding communities. th

While a full evaluation of the 22 pilot projects is still underway, over 10,000 individu- 10,000 over ofevaluation full a While underway, still is projects pilot 22 the ofhours 35,000 than more received have ofals as services support recovery February to ability participants’ increase help services these show that reports initial and 2016, abstinence. and employment, housing, maintain division This Addresses the client’s psychosocial and family systems to understand appropriate appropriate understand to systems family and psychosocial client’s the Addresses based, evidence are services Treatment needs. treatment dependency or use substance These of ofcontinuum the coordination emphasize and across care need. holistic, DSHS. by funded programs outpatient and inpatient both services include pilot Service Support Recovery began organizations different 22 ofMay In 2014, commu- six programs, use treatment substance 14 including Texas, across programs Support Recovery The organizations. recovery peer-run two and programs, nity-based ofgoal the have pilots Services areas: three on focus increasing · · · Includes OSAR, which operates much like LMHAs by serving as the first point of point first the as serving by LMHAs like much operates contact which OSAR, Includes an with appointment an After use. substance for treatment seeking individuals for otheror treatment, outpatient treatment, inpatient for made are referrals OSARcounselor, - test offers: also program SAI the services, OSAR Besides needed. as services appropriate assuch females for services specialized HIV, with persons for management case and ing interven- border rural the as such initiatives special and outreach, pregnant/postpartum ofrisk high at persons for program tion issues. use substance developing Goals and Services Provided Services and Goals community families, and youth for training skills education, include Services regional as serve that (PRCs) Centers Resource Prevention 11 and coalition-building, resources. up-to-date and data disseminate to clearinghouses information focuses on preventing tobacco initiation, supporting cessation efforts, eliminating eliminating efforts, cessation supporting initiation, tobacco preventing on focuses maintain- and tobacco, to access youth reducing disparities, health tobacco-related goals. these out carry to the state throughout infrastructure the ing A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Tobacco Prevention and Prevention Tobacco Control Recovery Support Services Support Recovery Substance Treatment Abuse Substance Abuse Substance Prevention Abuse Substance Interven- tion Program The HHS System provides substance use services for eligible youth and adults use services for substance provides The HHS System and Social treatment. The Medical to deliver service providers and contracts with policies regarding is responsible for creating and implementing Services Division Within that treatment outcomes. optimal use services and defining substance (SAPIT) and Treatment Intervention, Prevention, Abuse division, the Substance use services for substance supports and primary goal is to provide Program’s major the program’s and treatment. Figure 62 describes intervention, prevention, use. to substance activities relating health” in place of “mental health” to more accurately represent the co-occurrence co-occurrence the represent more accurately to health” of “mental in place health” integrated to improve an effort In use conditions. substance and health of mental integrate better LMHAs can on how increased focused has also been care, there LMHAs. by typically provided services the mental health use services with substance of SB 1507 (84 As a result Assessment (OSAR) providers responsible for substance use screenings and referrals and use screenings substance for responsible providers (OSAR) Assessment of Texas. across all with LMHAs co-located services are now use for substance Figure 62. Major Programs within Substance Abuse Prevention, Intervention, Intervention, Abuse Prevention, within Substance Major Programs 62. Figure (SAPIT) and Treatment 158 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC by state-funded substance useproviders, including theNorthSTAR program. adults livingbelow 200percentofFPLwithchemical dependencewereserved appropriate services. InTexas inFY2013, 18,088 (or10.4 percent) ofthe174,730 Only asmallportionofindividualsneedingsubstance usetreatmentreceive the ACCESS TO SUBSTANCE USESERVICES Source: Texas Health and Human Services. (2016, October 12). Personal Communication: Available Substance Use Treatment Services. Figure 63. Available HHSCSubstanceUse Treatment Services NorthSTAR; thismeansthemajority ofchildrenlivinginpoverty withsubstance use 200 percentofFPLwith chemical dependencereceived servicesthroughDSHSor Additionally, only47,086 (or38.4 percent) ofthe122,580childrenlivingbelow Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Co-occurring psychiatric & substance use conditions use & psychiatric substance Co-occurring therapy substitution Opioid Group Individual female) services (specialized Outpatient Psychiatrist consultation Family support Family counseling support Adolescent Group Female Individual services Outpatient HIV residential detox Ambulatory (specialized female) detox Ambulatory detox (specializedResidential female) detox Residential children) (women and Residential supportive female) (specialized supportive Residential supportive Residential children) (women and Residential intensive (specialized female) Residential intensive intensive Residential Referral Assessment Screening Type Service of Adults Only Adults Only or Both) (Adult-Only, Youth-Only, Both Adults only Adult Adult Adult Youth Only Youth Only Youth Only Youth Only Both Both Both Both Adults Only Adults Only Adults Only Both Both Both Both Both Both Both Both Both Target Population 325

Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 159 The LBB’s The LBB’s 329 As a part of Exceptional Exceptional Request Items 2019 328 legislative legislative th 327 Exceptional Exceptional Items Request 2018 Requested Requested 2019 Requested 2018 Budgeted 2017 Legislative session about the high costs of treating substance session about the high costs Legislative st Estimated 2016 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation

$153,660,796 $205,627,295 $189,826,370 $187,024,788 $187,024,787 $11,734,183 $11,734,183 Expended 2015 326 Strategy Substance Abuse Prev/Inter- vention/ Treatment the legislation authorizing coverage of these services, the Legislative Budget Board (LBB) the Legislative of these services, the legislation authorizing coverage substance covering analysis to see whether effectiveness to conduct a cost mandated was spending for those clients. Medicaid use treatment for adults increased overall * It should be noted that these figures don’t include figures be noted that these * It should use service utilization for substance of FPL) 200 percent below (i.e., not living in poverty who are the number of individuals use services due to their state-funded substance accessing trouble but may still have pay to resources for and not having the financial gap falling coverage in the Medicaid scale. services on a sliding USE SERVICES SUBSTANCE FUNDING FOR sufficient to address use services is not of public funding for substance The level to address state is attempting barriers to treatment. The need, creating significant use treatment delivery expanding the capacity of the substance these concerns by Budget Board (LBB). the Legislative by established beyond the level system $25 million, including over by use funding increased substance legislators In 2013, use reimbursement rates for substance nearly $11 million to increase provider into the service providers and competitive new to attract services in an attempt aimed to incentivize service providers The introduction of competitive system. During the 84 rates. treatment, and recovery higher service quality, ELIGIBILITY FOR SUBSTANCE USE SERVICES USE SERVICES FOR SUBSTANCE ELIGIBILITY concerns in the 81 Following Source: Data captured from HHSC and DSHS Legislative Appropriations Request for FY 2018/19, September 2016. September 2018/19, FY for Request Appropriations Legislative DSHS and HHSC from captured Data Source: Figure 64. Funding Trends for Substance Use Services Trends Funding 64. Figure treatment needs did not receive state-funded treatment services.* This discrepancy This services.* treatment state-funded receive not did needs treatment use providers, shortages from could result and utilization need substance of between for drug seeking services surrounding stigma for services, lists waiting funding, low and a general enforcement, to law drug use reported about having use, worries use substance over precedence take health priorities that mental perception priorities. use disorders, adults with substance use disorders who are on Medicaid began having use disorders who are on Medicaid adults with substance use disorders, to inpatient and outpatient services (e.g., assessment, 1, 2010) access (on September and counseling, inpatient treatment, medication therapy, ambulatory detoxification, use disorders free of cost. specialized services for women) to treat substance session, DSHS received a $9.5 million increase for Substance Abuse Prevention, Prevention, Abuse million increase for Substance a $9.5 session, DSHS received biennium. and Treatment services for the 2016-17 Intervention 160 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC and addictive disordersareeligiblefortreatmentservices. Additionally, 13to17whomeet youthage theDSM-V criteriaforsubstance-related considered: occurring psychiatric andsubstance usedisorders, the following scenariosshouldbe addresses both conditions in concert.Whenexaminingtherelationshipofco- and policiesthatsupportdualdiagnosistreatment —integrated treatmentthat The highprevalenceofthesecomorbiditiesdemonstrates theneedforinterventions · · · time. Lookingatnationaldatafrom2014: Mental illnessandsubstance usedisorderscommonly occurinpersonsatthesame CO-OCCURRING MENTAL HEALTH AND SUBSTANCE USEDISORDERS anyone else,inthefollowing orderofpriority: Three populationsreceive priorityforadmissiontosubstance useservicesbefore PRIORITY POPULATIONS greater than200percent,individualswillbeassessedafeeonslidingscale. of FPLareeligibleforfullyfundedsubstance useservices. Iftheiradjusted incomeis substance useproviders. Individualswhoseadjusted incomeisatorbelow 200percent use servicesmust complete afinancialassessmentbeforebeginningserviceswiththe individuals whoarenot eligibleforMedicaid butareseekingstate-funded substance Similar tothefinancialeligibilityprocessformentalhealthservicesatLMHAs, the resultsofthissecond,morecomplete evaluation. continuation offundingforsubstance usetreatmentunderMedicaid willbedependenton isplanningtoreplicatetheLBBcost analysiswithmorecomplete($818). HHSC dataand overall costs toMedicaid beforesubstance usetreatment($900)andafter due todatalimitations, buttheLBB’s initialresultsindicatea9.1 percentreductionin analysis ofthecost effectiveness ofpaying forsubstance usetreatment was incomplete Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas needs, experiences, developmental level, andbehavior. be admitted toayouthtreatmentprogramdependingontheindividual’s specific

7.9 million adults had bo and 12.3 million adults hada subs 35.6 million adults had · ·

· · · 3) 2) 1)

18.2 percent of individuals 39.1 percent of individuals substances.

risk factors. Drug useand mentalillnesscanbethe resultofother independentcommon Mental illnesscanlead todruguse;and Drug usecanleadtomental illness; Intravenous Pregnant substance Pregnant, intrav 336 335 drug users enous substance users a mentalhealth diagnosis and no substance usedisorder; th a mentalhealth and substance usediagnosis, ofwhich: users tance use disorder andnomentalhealthdiagnosis; using substances hada mental healthdiagnosis;and with amental health diagnosis also used 332

330,331 334 333 Adults ages 18to21may ages Adults Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 161 8,193 9,034 10,516 10,119 10,624 $1,617 $1,582 $1,617 $1,764 $1,766 31,627 31,206 31,303 32,816 32,250 $89 $71 $60 $116 $182 123,914 141,299 167,032 95,896 82,227 $16 $16 $15 $13 $19 468,054 468,054 492,957 784,257 601,399 2011 2012 2013 2014 2015 In FY 2015, 3,772 individuals were served through served individuals were 3,772 In FY 2015, 337 338 Annual cost per adult per cost Annual Annual cost per adult per cost Annual Annual cost per adult per cost Annual A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation http://www.dshs.texas.gov/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590002694 Total number ofnumber list wait a on adults Total treatment use substance for Treatment programsTreatment year per Number Intervention programsIntervention year per served Number Prevention program Prevention year per served Number COPSD programs. . slides] [PowerPoint quarter fourth 2015, FY book, data health Behavioral (2016). ofDepartment Services. Health State Texas Source: from Retrieved SUBSTANCE USE SERVICES: UTILIZATION AND COSTS AND COSTS UTILIZATION USE SERVICES: SUBSTANCE use services; of substance costs the utilization and two figures show The following Figure 66 is for children and adolescents. information for adults and Figure 65 details Use Services Adult Substance for and Costs Utilization 65. Figure The Texas HHS System supports the integration of substance use and mental health health mental use and substance of integration the supports HHS System Texas The The goal of co- disorders. of co-occurring treatment simultaneous for the services is to provide (COPSD) services abuse disorder substance and psychiatric occurring the in conjunction as are treated conditions wherein both services, coordinated contracts with 488 Services Division and Social condition. The Medical primary treatment facilities and 160 residential facilities use treatment substance outpatient service. for this specialty 162 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC slides]. Retrieved from http://www.dshs.texas.gov/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590002694 Sources: Texas State Health Services. Department of (2016). Behavioral health data book, FY 2015, fourth quarter [PowerPoint Figure 67. Care SelectedQualityof Measures for Adult SubstanceUseServices services andFigure68shows thesame forchildrenandadolescentservices. Figure 67shows someofthemeasurestracked onaregularbasisforadultsubstance use monitorsqualityandperformanceinseveral areasbasedontheTRRframework. HHSC SUBSTANCE USESERVICES: QUALITY OFCARE MEASURES Retrieved from Source: Texas State Health Services. Department of (2016). Figure 66. Utilization andCosts forChild& Adolescent SubstanceUseServices Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas wait list for substance use treatment Total children and adolescents on a number of programs Treatment programs Intervention program Prevention Percentage adults completing a program not arrested of who have gainful employment at discharge Percentage unemployed adults completing a program of abstinence at discharge Percentage adults completing a program who report of Percentage adults completing a program per year of Program: All Of Adults Entering a Substance Use Treatment http://www.dshs.texas.gov/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590002694 Annual cost per youth Number per year Annual cost per youth Number served per year Annual cost per youth Number served per year 1 0 5 1 438 512 753 809 612 373$,4 326$,9 $3,630 $3,693 $3,246 $3,645 $3,713 ,1 ,8 ,4 ,4 4,760 4,941 4,848 4,886 5,418 17$5$4$8$228 $98 $44 $55 $127 6595,0 8971,1 7,025 16,519 68,977 58,903 26,519 1 1 1 1 $15 $13 $13 $14 $14 ,4,6 ,2,2 ,3,0 ,7,4 1,716,359 1,875,143 1,939,809 1,920,024 1,843,263 0121 0321 2015 2014 2013 2012 2011 Behavioral health data book, FY 2015, fourth quarter [PowerPoint slides]. 0%10 0%10 100% 51% 100% 58% 92% 100% 59% 91% 100% 53% 56% 100% 90% 49% 52% 89% 52% 89% 53% 56% FY 2013 FY 2012 FY 2011 2014 FY 2015 FY Intellectual and Medical and Developmental Disabilities Behavioral Health

HHSC Social Services Division & Behavioral Health Services Services 163

343 Care for youth with intensive Care for youth with intensive ROSC is an organizational 342 341 The purpose of the multi-phase 339 FY 2011 FY 2012 FY 54%2013 FY 2014 FY 52%2015 FY 89% 52% 89% 44%83% 90% 51% 77% 89%99% 75% 91% 99% 75% 99% 78% 99% 99% In order for a delivery system to be recovery-oriented, it must it must recovery-oriented, to be system In order for a delivery 340 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation TRI and the ROSC framework underscore the significance of community 344 Percentage of treatment use substance completing youth Percentage year per programs of treatment use substance completing youth Percentage discharge at abstinence reporting programs of treatment use substance completing youth Percentage year per follow-up at status school positive with programs of treatment use substance completing youth Percentage arrested not programs support needs is coordinated across agencies, private and public organizations, private and public organizations, support needs is coordinated across agencies, them from the barriers that prevent and families so that children can overcome of Care (SOC) System Consortium was accessing the services they need. The Texas of mental health services for youth with the delivery to improve in 2013 established expanding the SOC by services throughout the state. high needs in Texas [PowerPoint [PowerPoint quarter fourth 2015, FY book, data health Behavioral (2016). ofDepartment Services. Health State Texas Sources: http://www.dshs.texas.gov/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590002694 from Retrieved slides]. INITIATIVE TEXAS RECOVERY THE AND OF CARE SYSTEMS with the goal (TRI) began in 2007 Initiative of ensuring that Recovery The Texas to support individuals and resources are available needed person-centered services use disorder. from a substance in their recovery Figure 68. Selected Quality of Care Measures for Youth Substance Use Services Substance Youth for Measures of Quality Selected Care 68. Figure TRI and the ROSC/SOC the philosophical and organizational approach provide of planning and delivery systematic framework that is essential for the collaborative, for over in practice and research Established child and family mental health services. approach nationally to be a cost-effective been proven of care have systems 25 years, and increased access to services and child and family outcomes resulting in better supports. TRI is “to gather information and recommendations for designing protocols that recommendations for designing protocols TRI is “to gather information and use within the behavioral models of care for recovery-oriented implement holistic, health community.” be person-centered, multi-disciplinary, and use coordinated treatment plans and be person-centered, multi-disciplinary, individuals receiving services to take of services that allows array a comprehensive recovery. responsibility for their own of Care Oriented System the Recovery is supported by Initiative Recovery The Texas and supports services, (ROSC) framework, which coordinates “multiple systems, the to meet readily adjust and designed to that are person-centered, self-directed, to recovery.” chosen pathway needs and individual’s framework for mental health and social services that is strength-based and social services that is strength-based framework for mental health and cultural An SOCcollaborative. to the youth and their family’s framework is sensitive highly individualized services such as and delivers preferences and linguistic the supports to reduce youth admissions into hospitals, wraparound and YES waiver and the child welfare system. system, justice juvenile 164 Intellectual and Behavioral Health Developmental Disabilities Medical and Services & Behavioral Health Services Social Services Division HHSC giving communitiesmoreconcrete steps ofSOC. toachieve thegoals Moving framework tofocusmoreon forward, surveys indicateaneedfortheSOC have established frameworks. orareintheprocessofactively establishing SOC frameworks. Denton, andMidland)thatare“communitiesofinterest” forfutureSOC established Texas communityexpansionsites, SOC andthreecounties(McLennan, frameworkstoserve familiesintheircommunity,SOC 13countiesthathave There arecurrently43countiesinTexas thathave implementedfederally-funded · · · frameworkinlocalmunicipalitiesby: to initiatetheROSC and recovery skills. management DSHSiscurrentlyassisting communitiesstatewide services aimtoenhanceindividuals’strengths andfunctioningby buildingresilience organizations, andfaith-basedentities. By providing continualsupport,ROSC partnerships andcollaborationsbetween federalandlocalgovernments, nonprofit · · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas agencies andbetteragencies collaborationbetween providers andyouththeirfamilies. frameworkreporthaving improvedimplemented theSOC coordinationacross philosophy andapproachtoservices.familiar withtheSOC Communitiesthathave Surveys inearly2016 indicatethatcommunitiesacrossthestate arebecomingmore dshs.texas.gov/sa/texasrecoveryinitiative/ abuse/ROSC/ andalist ofupcomingTRImeetings inthestate canbefoundatwww. acrossTexasA fulllist ofROSCs canbefoundatwww.dshs.texas.gov/substance-

Assisting withdevelopment andtraining aweek-long educationaltrack Adding Participating in person Providing telephone for achieving recovery; them with the development of the initial phase ofthis systems approach change Conducting on-site informational Health Institute; and meetings; 346 Asofspring2015, over halfofTexans arelivingincommunitiesthat and email technical assistance regarding the ROSC concept; and emailtechnical assistance regarding theROSC and via teleconferencing in local ROSC community and viateleconferencing in localROSC trainings to organize communitiesand assisting on recovery during theTexas Behavioral of recovery coaches. 345 349

347

348

Intellectual and Intellectual and Medical and Developmental Disabilities Developmental Disability

HHSC Social Services Division & Behavioral Health Services Services Department 165

h 352

Further, reports Further,

350 ls wit bilities 351 a a is D l a ndividu Additionally, community services community Additionally, I

355 f 40 percent of persons with intellectual of persons 40 percent or developmental disability (IDD) along with a (IDD) along disability or developmental ely to have experienced traumatic events including traumatic events experienced have ely to e a dual diagnosis or who present behavioral behavioral or who present a dual diagnosis e tween HHSCtween after transition during and divisions eeds o N including emergency respite evelopment the HHSCprocess transformation

While many individuals with IDD have known histories histories known with IDD have individuals While many in SSLCs D for community-based services for community-based h 353 l/ lt a a

implementation of trauma-informed care, positive behavior behavior care, positive trauma-informed of implementation

ychiatric services in state supported living centers and community- supported ychiatric services in state A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 356 oncerns 354 cts C l He a a st F st ent indicate that individuals who have IDD are three to five times more likely to have a to have times more likely three to five IDD are who have that individuals indicate general the than health condition mental co-occurring population. emotional, physical, and sexual abuse, neglect, and maltreatment when compared and maltreatment neglect, and sexual abuse, physical, emotional, to able-bodied peers. Children with IDD are more lik with IDD are more Children based supports to as a dual diagnosis. referred is sometimes illness mental supports, and person-centered recovery-focused practices recovery-focused and person-centered supports, of restraint Reduction an intellectual of The coexistence process Access crisis services to System-wide ps Improved wait time Significant Addressingwith disabilities of individuals health needs the mental be of services Coordination during delivery Service disabilities are diagnosed with a mental health condition. a mental are diagnosed with disabilities It is estimated that as many as 30 to that as many It is estimated and supports are frequently incapable of meeting the behavioral health needs of behavioral the of meeting are frequently incapable and supports when transitioning into the outcomes to less successful leading individuals, these community. of abuse (some research suggesting nearly 30 percent), the rate may be higher the rate may 30 percent), nearly suggesting research (some of abuse family and other recognition by of or lack underreporting of because in reality caregivers. Individuals with IDD who hav Individuals to be last and are often the “challenges”institutionalized to be likely are more setting. to a community-based released olicy a ntellectu

· M I existing (IDDs) can often overshadow disabilities Intellectual and developmental and family members caregivers, Professionals, mental health or medical conditions. an individual through the lens of their disability to seeing who are accustomed health conditions, be associated with mental that may behaviors can misinterpret trauma. or past acute medical conditions, distress, · · · · F · · · · · Intellectual and Developmental Disability Developmental and Intellectual DepartmentServices ( Services) Aging and Disability of the Department through provided formerly P · · 166 Intellectual and Intellectual and Developmental Disability Developmental Disabilities Medical and Services Department & Behavioral Health Services Social Services Division HHSC in theirlifetime, increasing thelikelihood ofdeveloping amental healthcondition. nearly 75percentofparticipantswithIDDexperienced at least onetraumaticevent and other population.Inonestudy, typesoftraumaatrateshigherthanthegeneral disabilities experienceabuse,neglect,institutionalization, abandonment,bullying, disabilities,Adults andchildrenwith itissignificantandrequiresattention. While traumaisnot inpeoplewith theonlycauseofmentalhealthchallenges intellectual disabilities arediagnosedwithamental healthcondition. population. ofmentalhealthconditionsatrateshigherthanthegeneral experience thefullrange to able-bodiedpeers. emotional, physical, andsexualabuse,neglect, maltreatmentwhencompared Children withIDDaremorelikely tohave experiencedtraumatic events including in theresearch andtheyoftendon’t receive quality mentalhealthtreatment. mental health needsofpeoplewithintellectual disabilities areroutinely overlooked often experiencesignificant disparitiesintheirabilityto access needed services. The population, at ahigherriskofhaving mentalhealthconditionsthan the general and requireaccesstoquality mentalhealthservices. People withdisabilities, while Individuals withdisabilities canexperiencealltypes ofmentalhealthconditions embedded inacultureofhopeandresilience. health conditionscanbenefitfromrecovery-focused interventions thatare recovery intoitsculture. IndividualswithIDDandolderadultswhohave mental health system, theHHSenterprisehasnot yet incorporatedtheprinciplesof Further, whileDSHShasintegrated recovery-focused interventions intoitsmental because ofunderreportingorlackrecognitionby familyand other caregivers. abuse (someresearchsuggesting nearly30percent),theratemay behigherinreality illness. are frequentlyusedtocontrolbehaviors, whichaddressesthesymptoms butnot the Often, thefirst lineof“treatment”ispsychopharmacological; psychotropic drugs is targeting thebehavior andnot theactualmentalhealthormedicalcondition. or theuseofmedicationstocontrolbehaviors. Inboth cases, thetreatment often beenthedevelopment planstopromote ofbehavior management compliance medical conditions, orpast traumacausethebehaviors. Thefocusoftreatmenthas managing behaviors, withoutconsideringwhether underlying mentalhealth, Many systems ofcareforpeoplewithIDDcontinuetofocusoncontrollingand to acommunity-based setting. aremorelikely tobeinstitutionalized“challenges” andareoftenthelast tobereleased Individuals withIDDwhohave adualdiagnosisorwhopresentbehavioral mental illnessisonetypeofdualdiagnosis. The coexistence ofanintellectualordevelopmental disability (IDD)alongwitha DISABILITIES PREVALENCE OFMENTAL HEALTH CONDITIONS FORPEOPLE WITH Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas have adualdiagnosis(withpsychiatric disability)population. thanthegeneral reports indicatethatindividualswhohave IDDarethreetofive timesmorelikely to leading tolesssuccessfuloutcomeswhentransitioningintothecommunity. frequently incapableofmeeting thebehavioral healthneedsoftheseindividuals, 357 Thissignificantlyreducesopportunitiesforrecovery. 359 Itisestimated thatasmany as30to40percentofpersonswith 364 Whilemany individualswithIDDhave known histories of 362 Additionally, communityservicesandsupportsare 358 Individualswithintellectualdisabilities 360

Further, 363

367 361

365

366

Intellectual and Intellectual and Medical and Developmental Disabilities Developmental Disability

HHSC Social Services Division & Behavioral Health Services Services Department 167 The 374 368, 369 368, An 373 However, However, 376 ns a 378 ex T Many health professionals mistakenly health professionals mistakenly Many Aging Aging 377 f 372 eeds o N

h This group is one of fastest growing populations in Texas, populations in Texas, growing of fastest This group is one 371 nvironment lt

E a 370 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation l He a 375 nging ent conclude that depression is a consequence of these problems, leaving the condition leaving of these problems, conclude that depression is a consequence among older adults. widely unrecognized and undertreated and is expected to more than triple between 2010 and 2050. By 2050, this group is 2050, By 2050. and 2010 more than triple between and is expected to to 12 million. expected to grow Cha Department plan, the Texas Prior to the implementation of the HHS transformation long-term responsible for providing was (DADS) Services of Aging and Disability people with physical the age of 60, over for Texans services and supports (LTSS) (IDD). disabilities developmental and people with intellectual and other disabilities residential and community services) help individuals receive (including both LTSS communities of choice. DADS needed care and services to remain in their homes and the state’s and administering of LTSS also had responsibility for regulating providers guardianship program. As a result of the HHSC as a separate transformation, DADS agency will be abolished and the programs and services incorporated into the HHSC services more information on the transition of DADS For organizational structure. section of this guide. see the DADS It is important to know that depression is not a normal part of aging. that depression is not It is important to know Aging Texans require mental health and substance use services that meet their use services that meet require mental health and substance Aging Texans and under-treated under-recognized who are aging experience People unique needs. population has 20 percent of the older Approximately health conditions. behavioral commonly depression, a substance health condition, most some form of behavioral symptoms. or psychiatric or dementia-related behavioral use disorder, M Census According to a large is home to the U.S. number of aging individuals. Texas age60 or older (15 percentof million people in Texas there were 3.8 Bureau, in 2010 population). the total Over the past decade, evidence has also shown a high prevalence of mental health of mental health a high prevalence has also shown decade, evidence the past Over Recent research disorder (ASD). autism spectrum in people with conditions had at least living with autism years old of children 10-14 that 70 percent indicates or more mental had two percent mental health condition, and 41 one co-occurring health diagnoses. The higher prevalence of mental health conditions among people with disabilities disabilities with people among conditions health of mental higher prevalence The isolation, social to a disability, related stress psychological to also be linked may factors. and other self-esteem, low bullying, institutionalization, trauma, depression often co-occurs with other serious illnesses, such as heart disease, stroke, such as heart disease, stroke, serious illnesses, depression often co-occurs with other disease. Parkinson’s and cancer, diabetes, estimated two million seniors in the United States have serious mental illness. have two million seniors in the United States estimated suicide rate among older Texans (over age 55) is higher than the rate among younger (over suicide rate among older Texans groups. 168 Intellectual and Intellectual and Developmental Disability Developmental Disabilities Medical and Services Department & Behavioral Health Services Social Services Division HHSC Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Medicaid caretoprovide managed services topeoplewithdisabilities. TheSB7 implemented inthecomingyear. Many inSB7involved ofthechanges expanding more detailed thathave informationonthechanges occurredandthosethatwillbe services andsupports(LTSS) topeoplewithdisabilities. section for SeetheHHSC inthe delivery ofbothSB 7requiredmajorchanges acutecareand long-term Supports of SSLCsandICFs wentintoeffectonSeptember 1,2015. may beprovided throughonlinetraining.Trainingrequirementsfornewemployees individuals withIDDinSSLCsandIntermediateCareFacilities (ICFs). Thetraining to develop oradopt trauma-informed caretrainingforemployees whoworkwith HB 2789(84 rapid responseteamscanvisitthosefacilities. including long-termcarefacilities, andexpandsthecircumstances underwhich Among other provisions, thebillprovides forthemonitoringofcertainfacilities, the institution; or3)assist withtherelocationofresidents toanother institution. of atrustee tooperatetheinstitution; 2)assist withobtaining anewoperatorfor corrective action.Ifalicenseisrevoked, DADS can:1)request theappointment serious injury, harm,impairment,ordeathtoaresident,necessitatingimmediate facility’s non-compliancewithoneormorerequirementscauses, orislikely tocause, exploitation, orneglectwithinatwo-year period.Aseriousviolationoccurswhena nursing homefoundtohave threeormoreseriousviolationsrelatedtoabuse, executiveSB 304requiresthattheHHSC commissionerrevoke thelicenseofa facilities asaresultofHB2789(84 welfare andthejuvenile justice systems, aswellwithinsomeLTSS programsand behavior andhave statutorily mandatedtrauma-informed caretraininginthechild Texas have policymakers recognizedthe impactoftraumaondevelopment and and ICFs The HB1(84 for People withIDD HB 1(84 SB 304(84 SB 7(83 2017, pleaseseeourLegislative SummaryinAppendixX. For information onDADS ridersintheappropriated budget forFY2016 andFY edu/mhwidd. Disabilities (MHW-IDD). Thetrainingisavailable onlineat:https://tango.uthscsa. course, MentalHealthWellness IndividualswithIntellectualandDevelopmental for Informed CareforIndividualswithIDD”asonemoduleinacomprehensive online DADS andDSHScollaboratedtocreateanonlinetrainingmoduletitled“Trauma by theSunset Commissionfor$7.5 millionfortenadditionalteams. federal fundsover the2016-17 biennium. the community. Appropriationswillprovide anadditional$18millioninstate and crisis intervention teamstoprovide increasedsupportstopeoplewithIDDlivingin rd th , Nelson/Raymond) – Acute Care and Long-term Services and CareandLong-termServices , Nelson/Raymond) –Acute , Otto/Nelson) -AdditionalFunding forCrisisIntervention Teams th th , Schwertner/Raymond)- “ThreeStrikes Rule” th , Otto/Nelson) set asidefundsinthestate budgettohelpDADS expand , Raymond/Zaffirini)- Trauma-InformedCarewithinSSLCs th , Raymond/Zaffirini). HB2789required DADS 379 Thistotal exceeds therecommendation 381 AsaresultofHB2789, 380

Intellectual and Intellectual and Medical and Developmental Disabilities Developmental Disability

HHSC Social Services Division & Behavioral Health Services Services Department 169 The 382 385 HB 3523 clarifies that DADS that HB 3523 clarifies 383 , Raymond/Perry) IDD System Redesign Advisory Committee Advisory Redesign IDD System , Raymond/Perry) A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation , Zaffirini/Perez) – Employment First Task Force Task First – Employment , Zaffirini/Perez) th rd , Zaffirini/Naishtat) Employment Assistance and Supported Assistance , Zaffirini/Naishtat) Employment Further, the bill requires additional analysis of provisions required additional analysis of provisions the bill requires Further, rd 384 by SB 7. The required analyses must inform future transition activities, including inform future transition activities, The required analyses must SB 7. by LTSS, of acute care and quality LTSS, these activities effect access to evaluation how housing, etc. options, service coordination, employment outcomes, can contract with IDD waiver service providers to deliver basic attendant and and attendant basic to deliver service providers IDD waiver can contract with DADS that and specifies Choice[CFC]) (Community First habilitation services of CFC in the delivery those providers authority over oversight has regulatory and services. SB 45 (83 IDD System Redesign Advisory Redesign HHSC is helping System IDD Committee service future develop disabilities. with individuals serve can better that systems delivery (84 HB 3523 bill also changes the start date of the IDD pilot to September 1, 2017 and removes and removes 2017 1, to September IDD pilot date of the bill also changes the start that managed as well as clarifies two years, at least last the pilot requirements that can participate in the pilot. care organizations HB 3523 reinforces the role of the IDD System Redesign Advisory that of the IDD System reinforces the role HB 3523 Committee Living Home Texas the transition of HB 3523 delays through SB 7. established was IDD the transition of other and delays 1, 2018, September one year to by (TxHmL) 1, 2021. until September one year, to managed care by and ICFs waivers Employment Services Employment SB 45 required the programs, waiver Medicaid standardize the In an effort to services in all of the and supported employment assistance inclusion of employment waiver PLUS the STAR and waivers home and community-based 1915(c) Medicaid help individuals with IDD find is intended to assistance Employment in the 1115. and individualized needs. preferences individual’s and secure a job according to the only with job placement, but not services is meant to assist Supported employment the longevity and successfulness tasks to improve also with daily job orientation and adaptations including employment of individuals with IDD in their employment, and supervision. SB 1226 (83 SB 1226 created the Employment First Task Force to advise the state on its efforts to advise the state Force Task First SB 1226 created the Employment The bill for individuals with disabilities. employment competitive to promote as the desired outcome for people employment competitive further established as the employment competitive The bill further established with disabilities. public who receive desired outcome for working-age people with disabilities is considered to be work in the labor market employment Competitive benefits. for setting that is performed on a full-time or part-time basis in an integrated less than minimum wage, but not at or above which the individual is compensated or similar work for the same an employer and usual wage paid by the customary First The Employment a disability. have who do not individuals performed by agency representatives employers, is comprised of self-advocates, Force Task competitive of integrated and providers and DADS), DARS, (including TEA, HHSC, to increase who would like stakeholders other services and employment in competitive to find employment opportunities for individuals with disabilities As a result of the task force, HHSC (on behalf of all HHS agencies), TEA, and settings. Among its recommendations, philosophy. First an Employment all adopted TWC 170 Intellectual and Intellectual and Developmental Disability Developmental Disabilities Medical and Services Department & Behavioral Health Services Social Services Division HHSC Figure 69. LTSS Funding Trends andRequests limited tofundingformentalhealthservices. governments. Thesefiguresincludefundingforanarray of LTSS servicesandnot Funding forLTSS programandservicescomesfromboth thefederalandstate Funding task-force. texas.gov/services/disability/employment/employment-first/employment-first- most up-to-dateinformationontaskforceactivitiesand meetings athttps://hhs. The taskforcereleasedareportinOctober2014 with72recommendations. Findthe segregated employment workforpeoplewithdisabilities. andsub-minimumwage into thecurrentdiscussionaboutinclusive employment services, aswelltoend the taskforcewishestobringneedsofindividualswith moresevere disabilities Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Living Waiver Texas Home Disabilities Multiple Deaf-Blind tance Living Assis- Community Services nity-based Commu- Home and – IDD care Facilities Intermediate Hospice ing Facility Skilled Nurs- Medicare Payments Facility Nursing Services & Health Day Activity Strategy 93312$11035$27760$22322$31680$373,608 $13,166,800 $12,283,292 $12,777,600 $11,190,335 $9,393,172 $271,202,479 $234,983,319 $272,048,636 $255,232,852 $256,600,233 , $8,658,115 $7,886,545 2015 Expended 6,5,4 171557$0,5,7 9,2,7 9,2,8 1,9,5 $46,521,754 $12,197,155 $96,626,880 $90,722,978 $105,559,272 $117,145,547 $61,057,640 254348$3,2,7 267433$246,048,017 $266,704,373 $238,826,476 $225,443,448 $1,211,979,830 $1,079,856,374 $947,217,383 $269,018,597 $269,727,154 $265,432,662 $299,250,636 $297,199,523 $1,357,454,134 5,8,4 5,8,2 3,4,2 $57,069,377 $38,943,225 $50,387,328 $59,489,743 2016 Estimated 292851$4,8,3 232625$2,000,078 $263,216,275 $241,885,837 $269,298,561 $117,471 $9,458,542 $8,826,868 $8,822,412 2017 Budgeted 2018 Requested 1204118$,4,6,9 $190,545,882 $1,241,063,894 $1,200,481,108 2019 Requested 244800$75,006,330 $264,498,000 $2,506,131 $315,486,226 2018 Request Items tional Excep- 0 0 2019 Request Items Exceptional $674,818 $184,876,052 $528,959,887 $2,002,733 0 0 $1,221,484 $121,402 Intellectual and Intellectual and Medical and Developmental Disabilities Developmental Disability

HHSC Social Services Division & Behavioral Health Services Services Department 171

Exceptional Exceptional Items Request 2019

h $8,069,057 $18,488,767 Excep- tional Items Request 2018 Requested Requested 2019 eople wit P or 0 0 Requested 2018 f o-occurring o-occurring C onditions ve C

Budgeted Budgeted 2017 a h ervices lt S o H a Estimated Estimated 2016 nd Wh a l He a A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation ms $37,531,672 $41,507,058 $45,237,024 $44,277,843$88,644,809 $44,372,116 $92,299,005 $6,733,111 $93,595,371 $6,761,197 $3,945,067,864 $3,172,820,601 $3,324,818,306 $3,051,990,717 $3,242,783,480 $332,304,722 $830,976,881 $684,111,674 $702,396,976 $689,157,263 $668,105,568 $666,622,891 $34,755,899 $41,348,787 Expended Expended 2015 a vior bilities a ha is e rogr Medically Dependent Children’s Program All-Inclusive All-Inclusive Elderly – Care (PACE) Strategy - Sup State Living ported Centers Total LTSS programs serve persons who are aging, people with physical disabilities, and disabilities, who are aging, people with physical persons serve programs LTSS including those who disabilities, developmental people with intellectual and other and supports are provided Services health conditions. co-occurring behavioral have The services programs. institution-based and of community-based through a variety funding sources. are funded through various federal and state AND SUPPORTS SERVICES LONG-TERM COMMUNITY HHSC responsible for services, is now waiver Medicaid and In addition to Medicaid The majority long-term services and supports. of community the administration of Many setting. services in a community-based receive with disabilities of Texans and co-occurring needed services to people with disabilities these programs provide the medical criteria for nursing meeting Older Texans health challenges. behavioral HHSC services funded by if be eligible for community-based home services may criteria. Some of the major community service financial eligibility they also meet programs are described below. SERVICES WAIVER 1915(C) MEDICAID Services and Community-based Home 1915(c) Medicaid HHSC administers now which are designed to through DADS), programs (previously administered waiver P D B Source: Data captured from HHSC and DADS Legislative Appropriations Request for FY 2018/19, September 12, 2016. 12, September 2018/19, FY for Request Appropriations Legislative DADS and HHSC from captured Data Source: section. Medicaid the in provided appropriation Medicaid total in the included is figure this in reflected funding The Note: unavailable. is programs these in services health behavioral for costs on Data Note: to the transition of these services is due payments facility The reduction in nursing into managedof 3/1/15. care as 172 Intellectual and Intellectual and Developmental Disability Developmental Disabilities Medical and Services Department & Behavioral Health Services Social Services Division HHSC Services forpeoplewithDisabilities Figure 70. Community-Based Waiver EligibilityandBehavioral Health-Related waivers forpersonswithintellectualandother developmental disabilities. Figure 70provides basicinformationabouteligibilityandservicesforthree primary from threetomorethan10years. (i.e., fundedwaiver slots). Thewait timeforservicesvariesby programbutranges appropriations determine thenumberofpeoplereceivingservicesintheseprograms entitlement andeachprogramcurrentlyhasasignificant interest list. Legislative As opposedtoinstitution-based care,accesstothesewaiver servicesisnot an services andsupports. institutionalization ofpeoplewithdisabilities by providing appropriatecommunity care (i.e.,nursingfacilitiesorintermediatefacilities). Thesewaivers prevent the provide communitysupportsandservicestoindividualseligibleforinstitutional Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Program Supports and Services (CLASS) ea oeLvn THL Individuals with an IQ below 70 or a Texas Home Living (TxHmL) C based Services (HCS) Home and Community- ommunity Living Assistance ommunity Eligibility tal income is not considered. no more than $2,000.resources of Paren- the SSI limit and countable to 300% of requirements including income limit up services. Must meet financial eligibility that qualify for intermediate care facility life. Must have functional limitations the person’s ability to function in daily that originated before age 22 and affects disability other than intellectual disability any age with a primary Individuals of eligibility for children. income when determining financial is the only waiver that considers parental no more than $2,000.resources of This the SSI limit and countable to 300% of requirements including income limit up services. Must meet financial eligibility qualify for intermediate care facility Must have functional limitations that related condition with an IQ below 75. Parental income is not considered. no more than $2,000.able resources of the SSI limit and count- up to 300% of requirements including income limit services. Must meet financial eligibility that qualifyforintermediatecare facility 75. Must have functional limitations related condition and an IQ score below Must have an IQ score below 70 or a tual disability diagnosed before age 22. any age with an intellec- Individuals of · · · · · · addition to Medicaid state plan services) Behavioral Health Services Provided (in · · · · · · · · · · · · · · · · · · · · · · ·

work and psychology services music, recreational Behavioral support, Case management Specialized therapies Supported employment Employment services Respite Community support Habilitation Day habilitation Behavioral support Case management Specialized therapies Supported employment Employment services Nursing services Respite Habilitation Psychological and Case management residential support supervised living (gr foster/companion care supported home living Residential as Supported employment Employment services Nursing services Respite Day habilitation sistance including: behavioral support including social oup home) such as aquatic, Intellectual and Intellectual and Medical and Developmental Disabilities Developmental Disability

HHSC Social Services Division & Behavioral Health Services Services Department 173 adaptive aids adaptive care services and recreational recreational and snacks Case management Case support Behavioral habilitation Day habilitation Residential living Assisted services Nursing services Employment employment Supported services Chore and Noon meal personal and Nursing rehabilitation Physical educational Social, Transportation activities

Behavioral Health Services Provided (in Provided Services Health Behavioral services) plan state Medicaid to addition · · · · · · · · · · · · · · Retrieved from http://www.dads.state.tx.us/ from Retrieved 2015. Guide Reference Retrieved from http://www.dads.state.tx.us/ from Retrieved sheets. fact and FAQs Website 386 Individuals with a functional disability disability functional a with Individuals physi- a diagnosis, medical a to related supervision, or care requiring order cian’s more or one with help need who and eligibility meet Must tasks. care personal XIX Title get (to Medicaid for criteria income specified exceed not or services) services. XX Title limits to get and resource Eligibility one and deaf-blindness with Individuals eligi- meet who disabilities other more or facilities. care intermediate for bility A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Activity and Health Health and Activity Day Services (DAHS) (DAHS) Services Deaf/Blind/Multiple Disabili- Deaf/Blind/Multiple (DBMD) ties Program LIDDAs are responsible for program eligibility, waiver program enrollment, and waiver program eligibility, are responsible for LIDDAs the or a related condition as part of establishing of intellectual disability determination serviceIDD priority population. Additional responsibilities include developing LIDDA for Lists maintaining Interest targeted case management providing (TCM) services, plans, conducting Preadmission Screening and Resident Review (PASRR) waivers, IDD Medicaid providing evaluations for persons with IDD seeking admission to a nursing facility, Information Process the Community Living Options continuity of care, and completing are also responsible for permanency LIDDAs (CLOIP) for persons residing in SSLCs. planning for individuals less than 22 years of age in intermediate care facilities, who live and HCS group homes. nursing facilities, supported living centers, state website serving a specific location, please refer to the LIDDA identify the LIDDA To https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-careproviders/local-idd-authority-lidda. Sources: Texas Department of Aging and Disability Services. (2015). (2015). ofDepartment Services. Disability and Aging Texas Sources: news_info/budget/docs/fy15referenceguide.pdf (n.d.). ofDepartment Services. Disability and Aging Texas services/faqs-fact/index.html DISABILITY AND DEVELOPMENTAL INTELLECTUAL ROLE OF LOCAL SERVICES WAIVER TO PEOPLE IN CONNECTING (LIDDA) AUTHORITIES in authorities (LIDDAs) disability developmental There are 39 local intellectual and for long-term services as the front door and serve all 254 counties that cover Texas disabilities with intellectual and developmental and support programs for people While co-occurring mental health conditions. (IDD), including those who also have the co-locate with local mental health authorities across the state, may the LIDDAs LIDDAs the same. authorities and are not separate administrative two entities have which includes services and supports, connect individuals with IDD to long-term Services (HCS) and Community-based supported living centers (SSLCs), Home state and services, net safety programs, waiver Medicaid Living (TxHmL) Home and Texas (CFC). Choice Community First 174 Intellectual and Intellectual and Developmental Disability Developmental Disabilities Medical and Services Department & Behavioral Health Services Social Services Division HHSC Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 2014, therewere1,224 licensednursingfacilitiesinTexas. disabilities whosemedicalconditionrequiresskilledlicensednursingservices. InFY Texas nursingfacilitiesprovide institutional careforolderTexans andpeople with Skilled Nursing Facilities comparisonpurposes. is includedinthissectionfor the SSLCs willnotbeincludedintheMedicalandSocialServicesDivision,information ICF services as a Medicaid benefit, those services become an entitlement to all those ICF servicesas aMedicaid benefit,those servicesbecomeanentitlement toallthose (ICF) servicesintheirMedicaid state plans. However, onceastate choosestoinclude The federalgovernment gives states theoption to includeintermediatecarefacility Community Intermediate Care Facilities · · · tothePASRRchanges included: program.Threemajorchanges In 20 · · Division ofHHSCbySeptember1 currently administered through DADS willtransition totheStateOperated Facilities services isprovided primarilythroughMedicaid. Thestatesupportedlivingcenters experience co-occurringbehavioral healthconditions. Funding fortheseresidential intermediate carefacilities, state-operated orinlarge supportedlivingcentersoften Persons withdisabilities residinginnursingfacilities, privatelyoperated Institutional Long-Term andSupports Services · facility. PASRR screeningisintendedtoidentifythefollowing: and ResidentReview(PASRR) Level 1screeningpriortoadmissionanursing governmentidentified andaddressed,thefederal mandatesPreadmissionScreening In ordertoensurethatthementalhealthneedsofnursing homeresidentsare professionals. health servicesareprovided by psychiatrists andother medicalandbehavioral health equipment, over-the-counter drugsandpersonalneedsitems. Skilledbehavioral Nursing facilitiesprovide roomandboard,socialservices, medicalsuppliesand program thatprovides both acutecareandlong-term servicesandsupports. facility serviceswereintegratedintoSTAR+Plus, aTexas Medicaid care managed facilities alsohave co-occurringmentalhealthconditions. InMarch2015, nursing facilities requiremedicalnecessityforadmission,many individualsresiding innursing

a Resident Review isrequired. Requiring an automated communication admission; and Requiring specific, specializedservices tobeidentified PASSR Evaluation; process by introducing local authorities (LA) asthe party thatwillcomplete the Eliminating the role of nursingfacilities Eligibility for specialized services The appropriateness of placement in thenursing Individuals who hav developmental disability (also known as related conditions); 13, theCentersforMedicare andMedicaid ServicesdirectedTexas tomake e amental illness, an intellectual disability, orother st 389 , 2016.Whilethatchangehasnotyet occurred and in the PASRR Evaluation determination to local authorities that is triggered when to local authorities thatistriggered facility; and 387 before nursingfacility WhileMedicaid nursing 388 Intellectual and Intellectual and Medical and Developmental Disabilities Developmental Disability

HHSC Social Services Division & Behavioral Health Services Services Department 175 - These FY 2019 FY (Pro jected) 390 - , 2017) FY 2018 FY (Pro jected) st An HHSC report 392 - legislative session legislative th FY 2017 FY (Pro jected) Although the SSLC

391 - (Pro jected) 394 Further, maintaining the SSLCs’ dilapidated infrastructure maintaining the SSLCs’ dilapidated infrastructure Further, 393 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 4,207 3,993 3,756 3,547 3,362 3,186 3,075 2,931 2,787 2,643 . state to the more cost adds even revealed that delivering services to a person in an SSLC costs $856.70 per day, totaling per day, $856.70 costs services to a person in an SSLC that delivering revealed year. per $360,000 over As part of a 2009 settlement agreement with the U.S. Department of Justice over over Department of Justice the U.S. agreement with As part of a 2009 settlement and quality of care for health, safety, agreed to improve DADS conditions at SSLCs, to psychiatric consumers living in them. The agreement includes increased access policy and practices to reduce of as well as improved services, care and psychological to visit and Independent monitors were assigned in mid-2014 the use of restraints. State Supported Living Centers Long-Range Plan May 2016. Long-Range Supported Living Centers State May). Department ofAging and Disability Services (2016, Texas Source: https://www.dads.state.tx.us/services/SSLC/draft-sslc-planningreport-5-16.pdf from Retrieved Figure 71. State Supported Living Center Enrollment Trends and Projections, and Projections, Trends Enrollment Living Center Supported State 71. Figure 2010-2019 Years Fiscal meeting eligibility criteria. Community-based ICFs can be licensed to provide services to provide licensed can be ICFs Community-based criteria. eligibility meeting to as referred disabilities, developmental or other disabilities intellectual with to people in Texas. ICFs were 833 licensed there 2016, As of September related conditions. population has declined significantly over the past decade, any discussion related to discussion decade, any the past over population has declined significantly opposition. legislative with strong has been met closure or consolidation of facilities the 84 significant debate around the SSLCs during There was facilities provide residential services similar to the state supported living centers but are living centers supported to the state services similar residential provide facilities beds to in size from six ICF facilities vary Community and operated. owned privately fewer beds. with eight or are small, ICFs community-based 160 beds; most over 1 to HHSC by September (will transfer Centers State Supported Living due to the DADS Sunset Recommendations to close six SSLCs, including closing the to close six SSLCs, Recommendations Sunset due to the DADS ultimately the legislature As mentioned earlier, of 2017. September SSLC by Austin only the SSLCs operational. In Texas, SSLC and all other the Austin to keep voted supported living center. legislature can direct closure of a state Texas as the census in these of aging facilities, and the deterioration costs Due to fixed increase. According Commission the per person costs to the Sunset facilities declines, involving state-run facilities is costly, of system final report, maintaining the large of $661.9 million a year. and a budget employees more than 13,900 State supported living centers (SSLCs) are large institutions that provide 24-hour that provide centers (SSLCs) are largeState supported living institutions service that must health treatment is a required Behavioral residential services. andowned and certified ICFs The SSLCs are licensed facilities. the by be provided SSLCs operate in 13 are privately owned). ICFs (community the state operated by Lufkin, Lubbock, Paso, El Denton, Christi, Brenham, Corpus Austin, locations: Abilene, Rio Grande State Center and San Antonio. Angelo, Richmond, Rio Grande, San Mexia, and serving persons with intellectual hospital, psychiatric is also a licensed inpatient Individuals seeking placement in an and mental illness. disabilities developmental financial and functional eligibility requirements. both meet SSLC must individuals reside in these facilities. 3,145 Approximately 176 Intellectual and Intellectual and Developmental Disability Developmental Disabilities Medical and Services Department & Behavioral Health Services Social Services Division HHSC Figure 72. InstitutionalCare EligibilityandBehavioral Health-Related Services by institutional providers ofLTSS services. Figure 72presentsinformationontheeligibilityrequirements andservicesprovided report onconditionsatall13SSLCs. psychiatric serviceswhowerenot makingprogressormaintainingstability.” The 2015 monitoringreportalsoidentifiedinstances of“individualsreceiving Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas toward psychiatric andnot goals maintainingpsychiatric stability. psychiatric andpsychological services, including individualresidentsnot progressing Other monitoringreportsin2015to identifieddeficienciesatalloftheSSLCsrelated monitoring reportfortheAustin SSLCcontinuedtoidentifysignificantdeficiencies. and Related Conditions viduals with Intellectual Disabilities Intermediate Care Facilities for Indi- Nursing Facilities Program · · · · · STAR+PLUS. and their long-term services through health services through Medicare care (dual-eligible) receive their basic People who get Medicaid and Medi- term services through STAR+PLUS. health services (acute care) and long- a nursing facility receive their basic are covered by Medicaid and living in Beginning May 1, 2015, people who · Eligibility

Have a primary Have a full-scale Have a diagnosis Have a medical Be eligible for an ICF.tial setting of in the 24-hour supervised residen- from the active treatment provided Be in need AND with moderate to extreme deficits, IQ and an adaptive behavior level licensed physician regardless of before age 22) diagnosed by a related condition (manifested deficits, or ior level with mild to extreme 22 years), and an adaptive behav- condition (manifested before age a related a licensed physician of below and a primary diagnosis by extreme deficits, or behavior level with mild to below 70 and an adaptive of disability with a full-scale IQ score nurse on a regular basis. a licensed requires the skills of 395 Despitethe2009agreement,June 2015 of and able to benefit of SSI or Medicaid. diagnosis of a diagnosis of condition that IQ score of 75 or IQ score of of intellectual of · · · · that include: 24-hour residential care and services · · · · · · · · · that include: 24-hour residential care and services services) (in addition to Medicaid state plan Behavioral Health Services Provided

Skilled nursing Medication management Behavioral he PASRR (see above) between Services to maintain connections therapies Occupational, physical Skills training Nursing Medication management Behavioral he Physician services Rehabilitative ther Specialized therapies/services lies/natural support systems 398 residents and their fami-

alth services alth services apies 397 and speech

396

Intellectual and Intellectual and Medical and Developmental Disabilities Developmental Disability

HHSC Social Services Division & Behavioral Health Services Services Department 177 services connections alth services alth FY 2015 FY BH Diag- BH nosis % ograms and employ- and ograms http://www.dads.state.tx.us/ ment fami- their and residents between systems support lies/natural Physician and nursing nursing and Physician he Behavioral training Skills therapies Occupational pr Vocational maintain to Services

Behavioral Health Services Provided Provided Services Health Behavioral plan state Medicaid to addition (in services) · 24-hour residential care and services services and care residential 24-hour include: that · · · · · - require devel- develop- BH Diag- BH nosis % Enrolled FY2014 . Retrieved from from Retrieved 2015. Guide Reference or profound profound or be unable to provide provide to unable be a substantial risk ofrisk substantial a 399 Enrolled 5,011 1,105 22.05% 5,222 1,169 22.39% 22,265 8,568 38.48% 25,331 9,320 36.79% 189 25 13.23% 263 32 12.17% 6,462 1,987 30.75% 6,626 2,014 30.40% 6,928 1,859 26.83% 9,078 2,580 28.42% 6,101 1,897 31.09% 5,961 1,348 22.61% 3,715 1,745 46.97% 3,475 1,455 41.87% ments. severe Have and intellectual Have and intellectual Have Represent adult, an As physi- personal basic most the for needs. cal Meet ICF/ID eligibility eligibility ICF/ID Meet developmental and intellectual or disabilities, be and disabilities opmental or fragile, medically behavioral and disabilities mental or challenges, selfto physical injury others. or

· Eligibility · · · · · % 22.37 % 22.37 38.32 % 38.32 10.13 % 10.13 38.80 % 38.80 25.38 % 25.38 41.09 % 41.09 56.13 % 56.13 BH Diag- BH nosis A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation FY2013 93,032 56,227 60.44% 92,844 58,983 63.53% 86,140 58,560 67.98% 3,912 2,196 Program Enrolled

Program State Supported Living Centers Living Supported State CLASS 4,828 1,080 HCS 21,404 8,201 DBMD 158 16 MDCP 6,407 2,486 TxHmL 5,997 1,522 ICFs/ID 6,169 2,535 Nursing Facilities SSLCs Source: Department of Aging and Disability Services. (2016, October 3). Data Request: People enrolled in DADS programs in DADS enrolled People Data Request: October 3). (2016, Department ofAging and Disability Services. Source: news_info/budget/docs/fy15referenceguide.pdf Average per person costs vary greatly between the long-term services programs. the long-term services programs. vary greatly between per person costs Average that per person it should be noted costs, are average above shown While the costs of need of the on the level within each program can also vary greatly depending costs Services requires that each waiver and Medicare individual. The Center for Medicaid neutral in the aggregate. program be cost years of the number of individuals in three the past the trends over Figure 73 shows program with a co-occurring mental health condition. 1915(c) waiver each Medicaid with a Behavioral Programs in DADS Enrolled of People Percentage 73. Figure Diagnosis Health Source: Texas Department of Aging and Disability Services. (2015). (2015). ofDepartment Services. Disability and Aging Texas Source: 178 Intellectual and Intellectual and Developmental Disability Developmental Disabilities Medical and Services Department & Behavioral Health Services Social Services Division HHSC Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Health, Developmental, and Independence Services 179

404 More More In FY 2015, the In FY 2015, 405 402 nit U Services within the o promote self-sufficiencyo promote 400 ervices S 403 l a oci S nd a tive a elopmental Services elopmental A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation In FY 2015, 6,159 individuals received services under a plan or waiver services under a plan or waiver individuals received 6,159 In FY 2015, 401 bilit ha Independent Living Programs Living Independent and Supports Services Rehabilitative Guardianship Health & Dev & Health Rehabilitative & Social Services & Social Rehabilitative e

information on these programs can be found in the TWC section of this guide. section information on these programs can be found in the TWC for Independent The Independent Living Services Program partner with Centers CILs are private, nonprofit, These Living (CILs) located around the state. programs. of independent living an array nonresidential centers that provide and community-based CILs partner with HHSC DADS (formerly with DARS), There federal funds. and organizations and are funded either privately or with state These 27 CILs DARS. 15 of which are funded by are currently 27 CILs across Texas, Angleton, Amarillo, counties and are located in: Abilene, out of 254 Texas 157 serve average monthly cost per consumer was $437. per consumer was average monthly cost from independent living centers. An additional 121,423 individuals without a plan An additional 121,423 from independent living centers. services from a Center for Independent Living. received or waiver However, the Independent Living Services for Older Individuals Who are Blind the Independent Living Services for Older Individuals However, programs for individuals along with other 1, 2016, on September transferred to TWC Blind and Visually Rehabilitation Services, who are blind including the Vocational Program. of Texas and the Business Enterprises Impaired Services, Sunset legislation required both the blind and general independent living services both legislation required Sunset Program within HHSC. programs to be combined into one Independent Living INDEPENDENT LIVING SERVICES PROGRAM LIVING SERVICES INDEPENDENT Program is intended t The Independent Living Services · · disabilities. for individuals with one or more significant Services R programs and services and Social Services Unit includes The Rehabilitative The programs in this unit offering services to to HHSC. transferred from DARS include: individuals living with mental illness · and Independenceand include two units: This department · · Health, Developmental, Developmental, Health, Independent Living (IL) Program seek to provide the individual with “consumer seek to provide Independent Living (IL) Program self- equal access and self-determination, control, peer support, self-help, advocacy.” Austin, Beaumont, Belton, Bryan, Crockett, Corpus Christi, Dallas, Denton, El Paso, Fort Worth, Houston, Laredo, League City, Lubbock, McAllen, Odessa, Palestine, Plano, Round Rock, San Angelo, San Antonio, San Marcos, Sugarland, and Tyler.406

Eligibility In order to be eligible for independent living services, an individual must be certified by a counselor to have a significant disability that results in substantial impediment to the person’s ability to function independently in the family or community. There must also be a reasonable expectation that assistance will result in the person’s ability to function more independently.407

Services Independent living services may include:

· Counseling and guidance · Training and tutorial services · Adult basic education · Rehabilitation facility training · Telecommunications, sensory and other technological aids for people who are hearing-impaired · Vehicle modification · Assistive devices such as artificiallimbs, braces, wheelchairs, and hearing aids to stabilize or improve function · Other services as needed, such as transportation, interpreter services, and maintenance, in order to achieve independent living objectives. 408

SERVICES FOR INDIVIDUALS LIVING WITH BLINDNESS AND VISUAL IMPAIRMENTS

Figure 74 lists the programs and services formerly provided by DARS to achieve increased quality of life outcomes for Texans who are blind or have visual impairments. Figure 74 also provides an overview of the programs and services moving to HHSC.

Figure 74. Services for Individuals Who Are Blind and Visually Impaired Services

Average Cost Per Program Name Services Number Served Individual

Blind Children’s Vocational Assists children and youth up to 22 Discovery and Development years old in developing the confidence 4,053 $112409 Program and competence to become fully active members of their community. Blindness Education, Screening Program goal is to prevent blindness. and Treatment Program Also assists uninsured adults with paying for urgently needed eye-medi- 3,353 $104410 cal treatment. Deaf and Hard of Hearing Provides a variety of services including: 68,270411 n/a* Services communication access services, issuing equipment and service vouchers, issuing interpreter certificates, educating consumers and interpreters.

180 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Health, Developmental, Medical and and Independence

HHSC Social Services Division Services 181 http://www.dars.state. (Note: this is the most (Note:

419 415 417 CRS also had 333 successful CRS also had 333 414 Retrieved from from Retrieved 2015. Report Annual In FY 2015, a total of 983 individuals a total In FY 2015, 413 CI) 416 CI 418 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation The program is intended to ensure that consumers who have TBIs and/or and/or TBIs who have to ensure that consumers The program is intended 412 62% Traumatic Brain Injury (TBI) (S Cord Injury 32% Spinal and S TBI 6% both

updated information available on DADS guardianship services available at print date) services available guardianship on DADS updated information available Resources Code Section The purpose of the guardianship program under Human to: guardianship services is to provide 161.101 The DADS self-evaluation submitted to the Sunset Commission in 2013 indicates that indicates in 2013 Commission Sunset to the submitted self-evaluation The DADS 913 individuals receiving guardianship services from there were, on average, in 2012 of $432 per adult individual. monthly cost at an average DADS GUARDIANSHIP PROGRAM GUARDIANSHIP services to people referred guardianship provides The Guardianship Services program a court under limited or by Services, and Protective Department of Family the Texas by of guardianship Code. The court appointment as described in the Estate circumstances for adults whom the courts deem protection an individual is intended to provide over is appropriate and works as intended, ensuringincapacitated. Often guardianship manageguardians effectively of older adults and people with disabilities the affairs decision- Guardianship profoundly limits a person’s and appropriately. honestly, fairly, include, Guardianship may be considered carefully. making rights and therefore must or institutional arranging for community services, overseeing limited to, but is not In order for HHSC and making medical decisions. to placement, managing estates, an be available; not must alternatives lesser restrictive guardianship services, provide available and willing to serve; be not appropriate and qualified alternate guardian must to fund the services, resources available have the individual under guardianship must an expectation that guardianship will meet including long-term care; and there must needs. the person’s CRS moved from DARS to HHSC to 1, 2016. from DARS on September CRS moved *The Deaf and Hard of Hearing Services Program provides a wide variety ofvariety wide a provides Deaf and devices communication including services *The of Hard and Program Services Hearing of variety wide the due to this program for individual per cost average accurate an not is There certificates. interpreter issuing offered. services SERVICES REHABILITATION COMPREHENSIVE have people who Services (CRS) program serves Rehabilitation The Comprehensive spinal cord injuries traumatic brain injuries (TBIs) and/or experienced traumatic (SCIs). Source: Texas Department of Assistive and Rehabilitative Services. (2016). (2016). Services. Rehabilitative and of Department Assistive Texas Source: tx.us/reports/annual2015/annualreport2015.pdf SCIs receive individualized services to improve their functioning within the home their functioning within the home SCIs to improve individualized services receive independence. promote and community to case closures, with 93 percent of individuals living at home or with family at time of of individuals living at home with 93 percent case closures, per individuals is $3,840. cost monthly closure. The average · were served, with 669 new applications received. with 669 new applications were served, conditions: the following have consumers Within CRS, · · 182 Health, Developmental, and Independence Medical and Services Social Services Division HHSC without someonemakingthosedecisionsonbehalfofthe adultwithadisability. understand theoptions, responsibilities, andconsequencesoftheirlifedecisions, Peña). Supporteddecision-makingisassistance inhelpinganadultwithadisability The operatingbudget forECIinthe2016-2017 bienniumwas $140,691,606. revenue fundsarerequiredtodrawgeneral down federalfunding forECIprograms. early intervention program for infants and toddlers ages zerotothree. early intervention programforinfantsandtoddlersages (IDEA); Part Cisafederal grantprogramthatassists states inoperatingastatewide ECI isauthorizedby Part CoftheIndividualswithDisabilities EducationAct support totheirspecialneedschildren,andcounterenvironmental riskfactors. development canreducethecost ofspecialneedsservices, enablefamiliestoprovide not addressed.Providing in servicestofamiliesandchildrenatanearlystage delays thatcanleadtolaterphysical, cognitive, when andbehavioral challenges Early interventions have the potential tomitigatetheimpactofdevelopmental EARLY CHILDHOODINTERVENTION (ECI)SERVICES He making agreements:HB39(84 During thelast legislative session,twobillspassedthatincludedsupporteddecision- · · · stakeholders preferandconsidermorerespectful. bylanguage changingtheterm“ward” to“personunderguardianship,” whichmany The 84 exploreallalternatives toguardianshippriorappointingaguardian. judges Additionally, anumberofrelatedbillswereadopted ensuringthatattorneys and Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

Future Steps: Lea Next Steps:ECIServices Getting Started A Child’s Journey throughECI: Incapacitated individuals referred directly capacity;and protecting the person is available and thereissome indication theindividuallacks in which abuse, neglect, or exploitation was confirmed,andno other meansof Protectivewho were referred by Adult Services (APS) following aninvestigation 65orolder Incapacitated adults age conservatorship; Incapacitated children upon reaching authority under certain criteria established in statute or rule. a 7. 4. 6. 5. 3. 2. 1.

th legislative sessionprovided nomovement toward utilizingperson-first Children must transition outofECIby theirthirdbirthda Review ofChild’s Progress ECI ServiceDelivery Begins Service PlanDevelopment Individualized Family ServicePlanMee Evaluation andAssessment First Visit Referral h

a nd ving ECI D evelopment th , Smithee/Zaffirini)andSB1881(84

, orbetween of18-65withadisability, the ages the age of 18whohavethe age beeninCPS a to the program by acourtwith probate l ting andIndividualizedFamily S ervices 420 y. th 425 , Zaffirini/ 423 State 424

422 421

Health, Developmental, Medical and and Independence

HHSC Social Services Division Services 183

429

http://

428 auditory or visual impairments auditory or visual 427 delays. For a list of diagnoses that a list For delays. Page. 38. Retrieved from from Retrieved 38. Page. 2015. Report Annual DARS

430 ECI is a cost share program, meaning that share program, ECI is a cost 431 function in one or more areas of development. areas of more function in one or A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 426 http://www.dars.state.tx.us/ecis/resources/diagnoses.asp. ECI see http://www.dars.state.tx.us/ecis/resources/diagnoses.asp. qualify for Education Agency Texas (TEA). the by as defined Auditory or visual impairments: Children with Auditory 25 at least of delays developmental Children with delays: Developmental affect that percent Children with medical diagnoses that have a have diagnoses that with medical Children condition: diagnosed Medically resulting in developmental high probability of

Based on the results of this evaluation, ECI professionals and the child’s family work and the child’s Based on the results of this evaluation, ECI professionals include a an individualized family service plan. The plan may as a team to develop range counseling, therapy family of services such as evaluation, service planning, and nutrition services, and speech therapy), services (such as occupational, physical, work services. and social psychological ECI evaluates a child for developmental delay using the Battelle Developmental Developmental using the Battelle delay ECI evaluates a child for developmental delays. social and emotional which includes an assessment of the child’s Inventory, Source: Texas Department of Assistive and Rehabilitative Services. (2016). (2016). Services. Rehabilitative and ofDepartment Assistive Texas Source: www.dars.state.tx.us/reports/annual2015/annualreport2015.pdf · · Eligibility for Services for Eligibility from professionals two least of at a team ECI services, for eligibility determine To abilities. a child’s evaluation of a comprehensive disciplines performs different three one of following at least a child meeting by is determined eligibility Generally, criteria: · Figure 75. Reasons for Eligibility for X Programs/Services Programs/Services X for for Eligibility Reasons 75. Figure families with the ability to pay are expected to contribute financially to the cost are expected to contribute financially to the cost families with the ability to pay all ECI services free of charge. receive In Texas, Children on Medicaid of services. Services, Utilization, and Costs Services, and level Eligible children can participate in ECI regardless of their income certain ECI services are free of charge, including evaluation and assessment, case Service Plan (IFSP), and management, of an Individualized Family development services. translation and interpreter 184 Health, Developmental, and Independence Medical and Services Social Services Division HHSC expand toAustin, CorpusChristi, ElPaso, andSanAntonio. Worth. 3through8 ontheautismspectruminHoustonto childrenaged andDallas/Fort to extend treatmentservices, therapy, includingAppliedBehavior Analysis(ABA) The DARS Autism Programstarted asapilot projectinFY2008andwas intended in theUnitedStatesarebornwithordevelop Autism SpectrumDisorder(ASD). The CentersforDiseaseControlandPrevention (CDC)estimate that1in68children CHILDREN’S AUTISMPROGRAM children receive multipleservices. No · · · · · · · · services was: In FY2015, thepercentag · · · evenly groups, splitamongthethreekey age asfollows: In FY2015, thedistribution ofenrollmentintheECIprogrambywas fairly age state.tx.us/reports/annual2015/annualreport2015.pdf Source: Texas Assistive Department of and Rehabilitative Services. (2016). * basedoncomprehensive services Figure 76. IndividualsutilizingECIServices Characteristics of 65 percentofchildrenreceivingECIservicesarerecipients ofMedicaid. not beturnedaway duetoaninabilitypay. forECIservices.account whenarrivingatamaximummonthlycharge Families will the child’s foster carestatus, andpublicprivatehealthinsurancearetaken into families pay forECIservicesonaslidingscalebasis. Family income,familysize, Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

Average monthly cost per child Total children who received comprehensive services Total children referred Audiology: 2 percent Vision services:2percent Psychological/ Nutrition: 8 percent Physical therap Occupational therapy: 30percent therap Speech language Developmental services: 82 percent 25 to36months:30percent 13 to 24 months:34percent 0 to12 months: 37 percent te: Total planned servicetypessumtomorethan100percentbecausemany 437 Increasesinfundingfrom theTexas Legislature allowed theprogramto 435 social work:4percent y: 26percent e ofenrolledchildrenusingeachthemajortypes y: 59 percent

$440 50,634 73,488 FY 2015 433 DARS Annual Report 2015. 434 438 InFY2015, 288children Retrieved from 432 http://www.dars. Other 436

Health, Developmental, Medical and and Independence

HHSC Social Services Division Services 185

441 448 http://www.dars.state.

h Legislature approved approved Legislature th Percent ofPercent Total 71% 32%* The 84 The 439 eople wit The increased funding allowed the funding allowed The increased ns P . Retrieved from from Retrieved . Annual Report-2015 440 a The Children’s Autism Program now Program now Autism The Children’s ex or 444,445 T f 449 ms a

with Disabilities Number ofNumber Children 204 93 Services nd Aging nd Aging rogr eals a P ersonal Attendant Services Attendant ersonal The program aims to serve over 1004 children in FY 2016 – – 1004 children in FY 2016 over The program aims to serve l 447 a A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation In FY 2015, a total of 288 children were served through the Children’s through the Children’s were served of 288 children a total In FY 2015, Focused ABA a few specific improve are intended to target and services Focused 446 442 Legislature required the expenditures for comprehensive ABA the expenditures for comprehensive Legislature required treatment Legislature also required other changes directing the program, including other to also required Legislature Comprehensive ABA Comprehensive including a full range services address of life skills, bilities th th 443 a Emergency Response Care Family M Delivered Home Persons Special Services to Adult Foster Care Adult Foster ManagedClient P is Comprehensive Applied Behavioral Comprehensive Analysis Applied Analysis Behavioral Focused

services only be used for children enrolled in the program before August 31, 2015. All 31, 2015. before August for children enrolled in the program services only be used ABA treatment Focused are limited to 1, 2015 on or after September children enrolled services. the phasing out of the Comprehensive ABA treatment services by August 31, 2017. 2017. 31, ABA the Comprehensive the phasing out of August by treatment services The 84 Autism Program. Autism 59 in Comprehensive ABA services and 945 in Focused ABA services. ABA59 in Comprehensive services and 945 in Focused serves children across the state ages 3 to 15 and includes parent participation, child agesparent participation, child state 3 to 15 and includes children across the serves the treatment training requirements along with and additional staff attendance, services. Figure 77. Children Who Received Services in FY 2015 Services in FY Received Who Children 77. Figure · tx.us/reports/annual2015/annualreport2015.pdf direct programs providing funded HHSC non-Medicaid several administers These include: long-term services and supports to individuals with disabilities. · · · · · Addition D SERVICES NON-MEDICAID *Children may have received both Comprehensive and Focused ABA services during the year. the during services ABA Focused and Comprehensive both received have may *Children (2016). Services. Rehabilitative and ofDepartment Assistive Texas Source: and Social Medical to HHSC’s from DARS Program moved Autism The Children’s 1, 2016. Services Division on September communication, sociability, and self-care. sociability, communication, were served through the Children’s Autism Program. Autism the Children’s through served were outcomes including addressing certain behaviors and improving social and adaptive social and adaptive and improving addressing certain behaviors outcomes including skills. program to expand to the following areas: Tyler, Round Rock, Brownwood, Bryan, Rock, Brownwood, Round Tyler, areas: following to expand to the program and Edinburg. Lubbock, Denton, Midland, San Angelo, Waco, Texarkana, a total of $14 million to the Children’s Autism Program for the FY 2016-17 biennium, 2016-17 the FY for Program Autism to the Children’s million of $14 a total biennium. FY 2014-15 $9 million in the up from The 84 186 Health, Developmental, and Independence Medical and Services Social Services Division HHSC and SSLCs)back intotheircommunities. with disabilities move from institutional settings (includingnursingfacilities, ICFs, participate inthisfederal demonstration designedtohelp older adultsorpersons first of30 states chosentoparticipateinMFPD 2007. Asof June 2016, 43 states known asMoney Follows thePerson Demonstration (MFPD).Texas was among the conditions, Texas participatesinafederallyfundednationaldemonstration program initiativesAmong themany affecting individualswithco-occurring HHSC Money Follows the Person Program health care(seeDSHSsectionformoreinformation). other institution inproviding of17bedsormorewhichisprimarilyengaged mental individuals between of22through64yearsinahospital,nursingfacility, theages or mental diseaseexclusion.” Thisexclusion prohibitstheuseofMedicaid fundingfor Balanced Incentive Programprojectweredeniedby CMSduetothe“institutions of to individualsleaving state psychiatric facilities. Efforts toaddressthisgapthrougha to community-based services. Similarrelocationservicesarenot currentlyavailable transition teamsareavailable toassist nursingfacilityresidents intheirtransition In addition,statewide relocationassistance, housingopportunities, andcommunity including theMoney Follows thePerson programfornursinghomeresidents. available tohelpindividualsremaininorreturn totheircommunities ofchoice, As partofthePromoting IndependenceInitiative, anumberofsupportsare · · · · (including mentalhealthconditions)underthefollowing circumstances: ruled thatstates must provide community-based servicesforpersonswithdisabilities response totheU.S. SupremeCourtrulinginOlmsteadv. L.C. , inwhichthecourt The Texas Promoting IndependenceInitiative beganinJanuary 2000indirect Promoting IndependenceInitiative More informationisprovided below. federal andstate authorityhasbeengrantedtodevelop thisprogramifstates opt in. funds arenot aBetter available fortheAchieving LifeExperience(ABLE)initiative, initiative andtheMoney-Follows-the-Person Initiative. Additionally, whilefederal Federal fundsarecurrentlyavailable throughthePromoting Independence ADDITIONAL FEDERALLY FUNDEDPROGRAMS DADS FY2015 AnnualReferenceGuide. For moreinformationontheseprogramsandtheservices offered,pleaserefertothe · · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

services. to thestate andthe needs of others who are receiving state-supported disability The placementcan be reasonably accommodated The affected person agreestoreceiv appropriate; The state’s treatment The person would otherwise beentitled Intellectual Disability In-Home and Family SupportProgram 451

professionals deem community-based placement to be Community Services e community-based services; and 452 to institutional services;

given theresourcesavailable 450 Health, Developmental, Medical and and Independence

HHSC Social Services Division Services 187

456 ms

a 454 rogr P nd a , Perry/Burkett). The federal , Perry/Burkett).

th 453 rtners Pa In 2014, FQHCs served nearly 1.2 million patients. served FQHCs In 2014, 455 ystem ystem S

S These reimbursements are designed to cover the additional These reimbursements are designed to cover 457 l HH a A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation The Texas ABLE program will be operated through the Comptroller’s office. office. Comptroller’s ABLE program will be operated through the The Texas Prepaid as needed to the Texas assistance The Advisory will provide Committee office during the creation of and Comptroller’s Higher Education Tuition Board ABLE program, visit updated information on the Texas the most the program. For texasable.org. Achieving a Better Life Experience (ABLE) Program Life Achieving a Better ABLE Program (ABLE) program and the Texas Life Experience The Achieving a Better Advisory created through SB 1664 (84 were Committee ABLE act was signed into law in December 2014 making these programs optional for making these programs optional 2014 in December signed into law ABLE act was implementation statewide its own pass legislation to create must Each state states. created to support the financial was of the ABLE program. The ABLE program aside them to set allowing by with disabilities independence of certain individuals eligibility for services in secured accounts without affecting their personal savings including the Anyone, Medicaid. or such as SSI, SSDI, they are qualified to receive contribute to an ABLE account. can family members and friends, individual’s Addition partners and encompass a number many HHSC program have the Medicaid and The following services in Texas. and provide of subprograms to help administer or and partnerships that help to administer subprograms sections highlight several mental health services in Texas. provide CENTERS HEALTH QUALIFIED FEDERALLY healthcare services to provide Health Centers (FQHCs) Qualified Federally or uninsured. FQHCs who are under- including Texans communities, underserved Services Act grants through Section 330 of the Public Health federal and playreceive health care services to people with comprehensive an important role in providing as well as to people who are and CHIP, public health insurance such as Medicaid with nearly 450 in Texas and uninsured. There are 72 FQHCs low-income otherwise sites statewide. service delivery MFPD provides federal grant funding as well as funding from Medicaid matching matching from Medicaid funding as well as funding grant federal provides MFPD the to institutions from individuals in moving states to assist savings cost in federal funding $16 million the HHSC over receive will FY16, In community. used are also Funds settings. out of institutional transition to help individuals the remain living in help individuals supports that health behavioral to provide leads which integrated employment, opportunities for andenhance community accessible of affordable, availability the and increases self-sufficiency, to greater the housing. The age Follows advantage span of individuals taking the Money of ranges program than 100 years old. from less than one year to more Person transition from institutional individuals 10,000 MFPD has helped over Since 2008, transitioned since 2003 34,598 individuals Another services. to community-based Independence initiative. Promoting under the Texas While FQHCs receive grant funding from the federal government, they also receive they also receive the federal government, grant funding from receive While FQHCs to individuals receiving Medicaid services enhanced reimbursements for providing services. and Medicare 188 Health, Developmental, and Independence Medical and Services Social Services Division HHSC also qualifyforMedicaid. covers theexpenseofemployer-sponsored healthcarepremiumsfor familieswho The Texas Health InsurancePremium Payment program(HIPP)isathat TEXAS HEALTH INSURANCE PREMIUMPAYMENT PROGRAM enrolled inMedicaid throughTMHPbefore theycanbecredentialed andpartofan Medicaid enrollmentactivities. AllMedicaid careproviders managed must first be to administer thestate’sHHSC Medicaid fee-for-service claimspayments andall Accenture, whichcontractswith subcontractors operating undertheconsultingfirm The Texas Medicaid andHealthcare Partnership (TMHP)isagroup of TEXAS MEDICAID AND HEALTHCARE PARTNERSHIP employer-sponsored plan. solely covered underHIPPareresponsibleforcost-sharing defined by termsinthe Program. employer-provided insuranceortheTexas Health InsurancePremiumPayment Cost-sharing isbasedonincome,thenumberofpeopleinfamily, andaccessto Most familiesarerequiredtopay monthlypremiums, co-pays, ordeductibles. disability 18oryounger, whoisage aU.S. citizenorlegalresident,andnot married. Texas Medicaid buy-in forchildrenisavailable tofamilieswhohave achildwith who areworkinganddonot live inastate institution ornursinghome. The Texas Medicaid buy-in programforadultsisavailable topersonswithadisability Medicaid program. premium. Thehealthcareservicesprovided arethesame asinthetraditional Participants must meet certainincomecriteriaandmay berequiredtopay amonthly to enrollinMedicaid whentheirincomelevels exceed normaleligibilitylimits. The Texas Medicaid buy-in programsallow adultsandchildrenwithdisabilities MEDICAID BUY-IN PROGRAMS Medical Homes (PCMHs). As of2014, 54percentofFQHCs nationallywererecognizedPatient-Centered multiple chronicconditions, includingmentalhealthandsubstance usedisorders. medical homestoimprove thecoordinationandintegrationofcareforclientswith many FQHCs aretransformingtheirpracticestohealthhomesorcomprehensive Act, funded patients. fromtheAffordableCare Asaresultof2010 changes policy costs associatedwithproviding comprehensive caretoboth uninsuredandpublicly Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas obtain insurance. cost-sharing whenreceivingservicesfromwithintheMedicaid network. to HIPP. Families covered underboth Medicaid andHIPParenot responsiblefor to beHIPP-eligible, thenthefamilywillautomaticallybetransferredfrom STAR remain enrolledinboth STAR andHIPP. IfafamilyonSTAR appliesandisfound may remainenrolledinboth plans. However, familieseligibleforSTAR cannot effective. Families eligibleforboth theSTAR+PLUS Medicaid programandHIPP mustMedicaid deemtheemployer-sponsored eligibleandHHSC cost policy In ordertoqualifyfortheprogram,atleast onememberofthe familymust remain may beeligibletoreceive employer-sponsored premiumassistance fromHIPP. 461

463 Family memberswhowouldotherwise beineligibleforMedicaid 462 458 HIPPmay helppeoplewhootherwise wouldbeuninsured 464 459 Families The The 460

Health, Developmental, Medical and and Independence

HHSC Social Services Division Services 189 A

468 470 466 469 The HHS Enterprise offers Texas veterans services veterans Texas The HHS Enterprise offers 471 TMHP does not process claims for services provided by managed by provided for services claims process not does TMHP HHSC oversees the project, DSHS provides day-to-day project day-to-day HHSC project, DSHS provides the oversees A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 465 467 management, and the Institute for Child Health Policy at the University of Florida at the University Policy Health for Child management, and the Institute The study technical assistance. and provides conducts the program evaluation in the analysis phase. and the project is now period concluded in December 2015 final program evaluation report is due to CMS in late 2016. final program evaluation report is through several agencies including but not limited to the Department of State agenciesthrough several including but not Workforce and Texas Commission (TVC), Veterans Services (DSHS), Texas Health section can be found in the TVC information on veterans More Commission (TWC). of this guide. VETERAN SERVICES DIVISION VETERAN SERVICES Services Division within HHSC to coordinate, created in 2013 was The Veteran focus The division’s agencies. services across state and enhance veteran strengthen, engage the charitable and nonprofit is to review and analyze current programs, and create public-private partnerships to benefit these programs. communities, TEXAS WELLNESS INCENTIVES AND NAVIGATION PROJECT AND NAVIGATION INCENTIVES WELLNESS TEXAS Disease” of Chronic for the Prevention Incentives won a “Medicaid Texas In 2011, Services (CMS). The and Medicaid Centers for Medicare grant from the federal efficacy project evaluating the of providing is a national demonstration initiative Texas received behaviors. healthy beneficiaries to adopt to Medicaid incentives $10 grant period (and approximately year of the five-year first $2.7 million in the trial conduct a randomized, controlled of the project) to the lifetime million over health managementon the efficacy in improving of personal wellness incentives with severe services among individuals of preventive and increasing utilization mental illness. MCO network. MCO care organizations (MCOs), but it does collect encounter data from MCOs to use for to from MCOs data encounter collect it does but (MCOs), organizations care managedand utilization of of quality the evaluation care services. The Veterans Services Division is an active participant in the Texas Coordinating Coordinating participant in the Texas Services Division is an active The Veterans Services. Council for Veterans 190 Health, Developmental, and Independence Medical and Services Social Services Division HHSC Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Access and Eligibility Services 191

) 473 DDS ervices ( S tion a

474 472 etermin D A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation SSDI is governed by rules set out in Title II of the Social Security Act out in Title II of the Social Security rules set by SSDI is governed bility 475 a is and covers workers age 18 to 65 who have a disability, widows/widower of worker of worker widows/widower a disability, age workers 18 to 65 who have and covers D disability Services Division (DDS) makes Determination The Disability DDS works with individuals disabilities. for individuals with severe determinations federal Social Security who apply for benefits through the (SSA) to Administration who meet adults and children for both available Benefits for daily needs. help pay Insurance (SSDI) and Supplemental Disability eligibility include Social Security Security Income (SSI). Services Access and Eligibility and Access SOCIAL SECURITY DISABILITY INSURANCE (SSDI) DISABILITY SECURITY SOCIAL for individuals who can no longerSSDI is available work due to a medical condition, one year or result in at least that is expected to last including mental illness, death. Both SSI and SSDI are cash assistance programs administered by SSA. HHSC by staff programs administered SSI and SSDI are cash assistance Both SSI. applying for SSDI and/or for Texans determination initial disability the makes in FY 2015. cases were determined disability 323,550 Approximately Some people with serious mental health conditions will qualify for either or both for either or both Some people with serious mental health conditions will qualify same time is called SSDI and SSI benefits at the SSDI and SSI. Qualifying for both not common, they are possible are While concurrent benefits “concurrent benefits.” the required enough at some point in his or her life to have if an individual worked number of work credits. with a disability, and adult children (with a disability) of workers with sufficient work histories.476 People become eligible for SSDI throughout their working lives by paying social security taxes.477Approval for SSDI payments results in eligibility for Medicare coverage after a two-year waiting period.478 Approximately a third of individuals receiving SSDI assistance qualify on the basis of a mental health diagnosis.479

SUPPLEMENTAL SECURITY INCOME (SSI)

Supplemental Security Income (SSI) is governed by rules set out in Title XVI of the Social Security Act. SSI provides monthly stipends to qualifying low-income adults who have a disability, are blind, or are over the age of 65.480 Children who have a disability or are blind may also qualify for SSI. Unlike SSDI, SSI is not based on an individual’s work history.481 The monthly maximum amount for 2016 are $733 for an eligible individual and $1,100 for an eligible individual with an eligible spouse.482 Once approved for SSI, participants are eligible for Medicaid.483

Figure 78 below details the disability claims process to receive SSI or SSDI benefits.

Figure 78. Disability Claims Process for SSI and SSDI Benefits

Source: Texas Department of Assistive and Rehabilitative Services. (n.d.). Disability Determination Services. Retrieved from http://www. dars.state.tx.us/services/ddsClaimsProcess.shtml

192 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Medical and Access and Eligibility

HHSC Social Services Division Services 193 487 To be eligible for To 490

491 489 Disability determinations for SSDI on the basis determinations Disability s decisions by judges at the administrative hearing judges at the administrative by s decisions ther psychotic disorders psychotic ther 488 disability examiner and medical team reviewsand examiner the disability elopmental disorders elopmental Claimants may present witnesses and evidence at a and evidence present witnesses may Claimants earing: 484 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Of those who appealed their denial, 2 percent of applicants were their denial, 2 percent of applicants Of those who appealed 485 A new report is scheduled to be released in November 2016. 2016. in November A new report is scheduled to be released A hearing at the federal court level; very few cases very court level; at the federal Court: A hearing ederal District 486 Other pervasive dev pervasive Other Anxiety-related disorders Anxiety-related disorders Somatoform disorders Personality use disorders Substance Spectrum Disorder Autism Organic mental disorders Organic and o paranoid, Schizophrenic, disorders Affective disability Intellectual Review SSA Council Hearing: level. F U.S. level. reach this Another Another Reconsideration: H Administrative judge. law administrative with an private hearing formal, case to determine if the decision was proper. Claimants may submit additional submit may Claimants proper. was the decision if determine case to their case. to support evidence

subsequently granted benefits at the reconsideration state and 11 percent through a the reconsideration subsequently granted benefits at hearing. of a mental health condition are categorized as: · · · · · · · · · · Each of these categories includes a set of criteria that must be satisfied in order to in order be satisfied of criteria that must Each of these categories includes a set benefits for SSDI are dependent on the social security qualify for SSDI. Monthly There is no minimum SSDI monthly benefit; the earnings record of the worker. monthly maximum benefit depends on the age left the workforce at which a worker the final admission decision on eligibility The SSA makes due to his or her disability. of eligibility criteria. set after consideration of a more exhaustive According to a 2015 report by the SSA, mental health conditions constitute about a about constitute the SSA, mental health conditions According report by to a 2015 third of national SSDI diagnoses. According to a report by the SSA that tracked SSDI outcomes from 2004–2013, from 2004–2013, SSDI outcomes According SSA that tracked the to a report by averaged upon initial review who were granted awards the number of applicants percent. 24 · · People who disagree with their SSI or SSDI determination have a legal right to a legal have SSDI determination SSI or with their disagree who People of appeal: four levels are There the decision. appeal · · ELIGIBILITY that an the determination SSDI and SSI is conditioned on Eligibility for both physical serious his or her ability to work. Like that prevents individual has a disability an individual to allow and may mental health conditions can be disabling conditions, Initial disability other eligibility criteria. they meet access SSDI or SSI cash benefits if officers within the DDS Division. disability are made by determinations SSI, adults and children must meet strict financial and functional criteria in addition financial and functional criteria in strict meet SSI, adults and children must (including mental health conditions). a disability to having 194 Access and Eligibility Medical and Services Social Services Division HHSC Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas DDS MOVED FROM DARS TO HHSC ON SEPTEMBER 1,2016.DDS MOVED ON SEPTEMBER DARS FROM TO HHSC annualreport2015.pdf Annual Report2015.Retrieved fromhttp://www.dars.state.tx.us/reports/annual2015/ Sources: Texas DepartmentofAssistive andRehabilitative Services. (2016). DARS Figure 79. DisabilityDetermination Servicesin Utilization of Texas Figure 79provides informationonapplicationsforbenefits Texas in2015. UTILIZATION Social Securitywebsiteathttp://www.ssa.gov. informationoneligibilitycriteriaandhow toapplycanbefoundonthe Additional Accuracy with regards to ultimate SSA decision Average initial case process time (in days) Total cases determined 2015 95.5% 73.4 323,550 492 HHSC 195 Texas Texas th Reg. Sess., art. II. (Tex. 2015). 2015). II. (Tex. art. Reg. Sess., th Retrieved from https://www.sunset. Retrieved Legislature. from https://www.sunset. , 6. Retrieved Legislature th th tee Report, 2015 Leg., 84 tee Report, 2015 Texas Medicaid and CHIP: Senate Bill 760, 84 Bill 760, Senate Medicaid and CHIP: Texas Retrieved from https://www. Retrieved . 17-18 Pages Legislature. from https://www. . Retrieved 122-123 Pages Legislature. th th Reg. Sess., recapitulation – all art. and art. II. (Tex. 2015). 2015). (Tex. and art. II. – all art. recapitulation Reg. Sess., 16). Personal communication; North Texas Behavioral Behavioral communication; North Texas 16). Personal of the Health and 15). Status update on the reorganization plan. transition 16). Health and Human Services system from . Retrieved Committee Health Advisory 16). Behavioral Presented at responses. HHSC stakeholder 16). Draft 16). Personal communication. 16). Personal Health and Human Services system transition transition 16). Health and Human Services system tenth edition. Medicaid and CHIP in perspective 15). Texas Preliminary Medicaid Enrollment by Month (XLS) Medicaid Enrollment 16). Preliminary . tenth edition and CHIP in perspective Medicaid 15). Texas th ealth Resources and Service Administration. (2016). Health Administration.ealth Resources and Service (2016). 15 Leg., 84 15 Leg., 15). Report to the 84 15). Report to the 84 200. Retrieved from http://www.capitol.state.tx.us/BillLookup/ Retrieved Senate Bill 200. Retrieved Retrieved adequacy. – Medicaid HMO network 15). TMA testimony: SB 760 Retrieved from http:// Nelson et al. Retrieved SB 200, ). Bill analysis: ouse Research Organization. (2015 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation dvisory Commission. (2015). Report to the 84 dvisory Commission. (2015). dvisory Commission. (2015). Report to the 84 dvisory Commission. (2015). -2. Total Medicaid MCO Spending (Timeframe: Total (2016). Facts. State Health Foundation, aiser Family ., Jessee, G., & Vasquez, A., Texas Health and Human Services Commission. (March, 2016). and Human Services Commission. (March, 2016). Health A., Texas G., & Vasquez, ., Jessee, 53. Retrieved from https://hhs.texas.gov/sites/hhs/files/documents/about-hhs/transformation/final- Retrieved 53. Retrieved from http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017.pdf Retrieved Texas Sunset A Sunset Texas H.B. 1, Conference Committee Report, 20 Report, Committee 1, Conference H.B. . Retrieved from http://www. . Retrieved on Human Services: Medicaid managed care. to the House Committee Presentation al., ; Price et hhsc.state.tx.us/reports/2016/house-human-services-medicaid-managed-care-charge-03-0816.pdf from http://www. et al.. Retrieved Schwertner SB 760, Bill analysis: Research Organization. (2015). House Texas hro.house.state.tx.us/pdf/ba84r/sb0760.pdf#navpanes=0 . Retrieved from http://www.ntbha. health services. Retrieved Local plan for (2016). indigent behavioral Authority. Health Systems. & LifePath Texas ; Collin County, org/docs/NTBHA_IBH_Revised_Plan_Submission_1-15-16.pdf from http://www.lifepathsystems.org/wp- health services. Retrieved Local plan for(2015). indigent behavioral content/uploads/2016/04/CollinCo_FinalLocalPlan_NStransition_9-30-15-Complete.pdf Slides]. September 18, 2015 [Powerpoint Human Services system, Page transformation-plan.pdf https://hhs.texas.gov/about-hhs/leadership/advisory-committees/behavioral-health-integration-advisory- . committee Bill Research Organization. (2015). House ; Texas from https://www.texmed.org/Template.aspx?id=33658 at http://www.hro.house.state.tx.us/pdf/ba84r/sb0760. al. (Price). Retrieved et Schwertner analysis: SB 760, pdf#navpanes=0 with advocate. from personal communication Retrieved Meeting. Managed Holder Care Stakeholder Medicaid C Traylor, and Human Services Commission. (n.d.). Health Texas Texas Medical Association. (20 Medical Texas and Human Services Commission. (20 Health Texas sunset.texas.gov/public/uploads/u64/Report to the 84th Legislature.pdf sunset.texas.gov/public/uploads/u64/Report and Health ; Texas sunset.texas.gov/public/uploads/u64/Report%20to%20the%2084th%20Legislature.pdf communication. Personal Human Services Commission. (2016). and Human Services Commission. (20 Health Texas and Human Services Commission. (20 Health Texas and Human Services Commission. (20 Health Texas www.hro.house.state.tx.us/pdf/ba84R/SB0200.pdf and Human Services Commission. (20 Health Texas and Human Services Commission. (20 Health Texas Price et al. Texas H al. Texas Price et AdvisorySunset Commission. (20 Ibid. and Human Services Commission. (20 Health Texas AdvisorySunset Commission. (20 Texas Legislature Online. (2015). Legislature Online. (2015). Texas Ibid. and Human Services Commission. (20 Health Texas 1 Ibid., Pages Texas Sunset A Sunset Texas texas.gov/public/uploads/u64/Report to the 84th Legislature.pdf texas.gov/public/uploads/u64/Report to the 84th Legislature.pdf texas.gov/public/uploads/u64/Report History.aspx?LegSess=84R&Bill=SB200 from https://hhs.texas.gov/sites/hhs/files/documents/about-hhs/transformation/final- plan. Retrieved transformation-plan.pdf from https://hhs.texas.gov/sites/hhs/files//pinkbook.pdf Retrieved to 7-13. 7-11 Pages Retrieved from https://datawarehouse.hrsa.gov/topics/ Sites Data. Retrieved and Look-Alike Service Delivery Center and Service Administration. Resources Health and Human Services, US Department of Health hccsites.aspx; from http://bphc.hrsa.gov/uds/datacenter. Data. Retrieved Comparison Grantee 2014 Program (2016). aspx?year=2014&state=TX&compare=Nat Retrieved from http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017.pdf Retrieved 2016) [XLS 2011 – March (September https://hhs.texas.gov/texas-medicaid- from data file]. Retrieved 1, 2010 April of the Resident Population: Annual Estimates Bureau. (2016). ; US Census enrollment-statistics Estimates [XLS – 2015 Population – July 1, 2015 from http://www.census.gov/popest/data/ data file]. Retrieved state/totals/2015/index.html from https://hhs.texas.gov/sites/hhs/files//pinkbook.pdf Retrieved and 1-3. 1-2 Pages from http://kff.org/other/state-indicator/total-medicaid-mco- table]. Retrieved [online interactive 2014) spending/ Commit 1, Conference Act,General Appropriations H.B. Henry J. K J. Henry H and Human Services, US Department of Health Texas Health and Human Services Commission. (20 Human Services Commission. and Health Texas (20 Human Services Commission. and Health Texas Retrieved from http://www.hhsc.state.tx.us/medicaid/managed-care/SB760-implementation. Retrieved Legislature.

7 Endnotes 1 26 20 21 22 23 24 25 16 18 17 19 14 11 13 8 9 10 12 15 6 2 3 4 5 196

HHSC 42 39 38 37 36 35 34 33 32 31 30 29 28 27 50 49 48 47 46 45 44 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 41 40 51 43

General Appropriations Act, H.B.General AppropriationsAct, 1,ConferenceCommit fy18-19-lar.pdf Retrieved from https://hhs.texas.gov/sites/hhs/files/documents/about-hhs/communications-events/news/ Session, agencysubmission, version 1,AutomatedBudgetandEvaluation System ofTexas (ABEST)[Datafile]. 84 Hogg Foundation analysisofGeneralAppropriations A sunset.texas.gov/public/uploads/u64/Final%20Results%20of%20Sunset%20Reviews%202014_2015.pdf Commission.(20 Sunset Advisory Ibid. with%20Final%20Results.pdf 1. Retrieved from https://www.sunset.texas.gov/public/uploads/files/reports/DADS%20Staff%20Report%20 Sunset Commission.(2015). with%20Final%20Results.pdf 3. Retrieved fromhttps://www.sunset.texas.gov/public/uploads/files/reports/DADS%20Staff%20Report%20 Sunset Commission.(2015). aspx?fileticket=5F9NH12OjmM%3D&tabid=371 of People withSeriousMentalIllness. Retrievedhttp://www.bazelon.org/LinkClick. from Judge Da Possibilities.aspx Reports/2009/Preventing-Mental-Emotional-and-Behavioral-Disorders-Among-Young-People-Progress-and- Behavioral Disorders AmongYouth People: Progress andPossibilities. Retrievedhttp://www.iom.edu/ from Institute ofMedicine oftheNationalA www.nimh.nih.gov/health/publications/treatment-of-children-with-mental-illness-fact-sheet/index.shtml National Institute ofMental H dars.state.tx.us/reports/annual2014/2014AnnualReport.pdf Texas DepartmentofRehabilitative Services Texas Health andHumanServicesCommission.(20 Efficiency%20Report%202009.pdf#Abuse_Treatment from http://www.lbb.state.tx.us/Documents/Publications/GEER/Government%20Effectiveness%20and%20 Legislative Budge methodology-for-substance-use-disorder-cost-effectiveness.pdf of substanceusedisorder. Page Texas Health andHumanServicesCommission.(20 advocate. Medicaid CareStakeholder Holder Managed Meeting. Retrieved frompersonalcommunicationwithhealthcare Texas Health andHumanServicesCommission.(20 shtml General Appropriations Act, H.B.General AppropriationsAct, 1,ConferenceCommit Ibid. behavioral healthinitiatives. Retrieved fromhttps://hhs.texas.gov/docs/cabhi.pdf Texas Health andHumanServicesCommission,OfficeofM aspx?LinkIdentifier=id&ItemID=8590005752 Health andHumanServicesCommission.Retrieved fromhttps://dshs.texas.gov/WorkArea/linkit. Gaines, S., &Kirch,L.(F https://hhs.texas.gov/services/health/mental-health-substance-abuse/office-mental-health-coordination Texas Health andHumanServicesCommission.(n.d.). files/documents/about-hhs/transformation/051816-tloc-update.pdf May 2016:HealthandHumanServicessystem transition plan. Retrieved fromhttps://hhs.texas.gov/sites/hhs/ Texas Health andHumanServicesCommission.(20 Ibid. Appropriations_Act_2016-2017.pdf 2013 Leg.,83 Appropriations_Act_2016-2017.pdf S.B.; andGeneralAppropriationsAct, 1,ConferenceCommittee Report, state.tx.us/Documents/Publications/Fiscal_SizeUp/2939_Fiscal_Size-up_2016-17.pdf. General_Appropriations_Act_2014-15.pdf Texas Health andHumanServicesCommission.(20 Texas Legislative Budg 84 Hogg Foundation analysisofGeneralAppropriations A [XLS data file].Retrieved fromhttp://www.census.gov/popest/data/– July1,2015 Population Estimates[XLS enrollment-statistics; andUSCensusBureau.(2016). AnnualEstimatesoftheResidentPopulation: April1,2010 datafile].Retrieved fromhttps://hhs.texas.gov/texas-medicaid-(September 2011–March 2016)[XLS Texas Health andHumanServicesCommission. (20 2017.pdf (Tex. 2015). Retrieved fromhttp://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016- Appropriations_Act_2016-2017.pdf all art.andII.(Tex. 2015). Retrieved fromhttp://www.lbb.state.tx.us/Documents/GAA/General_ th th Reg.Sess., art.II.(Tex. 2015). Retrieved fromhttp://www.lbb.state.tx.us/Documents/GAA/General_ Reg.Sess., art.II.(Tex. 2015). Retrieved fromhttp://www.lbb.state.tx.us/Documents/GAA/General_ vid L.BazelonCenterforMental Health Law. (n.d.).Employment andUnemployment rd Reg.Sess., art.II(Tex. 2013). Retrieved fromhttp://www.lbb.state.tx.us/Documents/GAA/ t Board.(2009). Texas stategovernment andefficiency.Pages effectiveness 173-181. Retrieved et Board.(2016). Fiscal size-up 2016-17biennium,163. Retrieved fromhttp://www.lbb. ebruary 2016). Presentationtohouseselectcommittee onmentalhealth.Texas Department ofAgingandDisabilityServicesStaffReportwith Final Results.Page Department ofAgingandDisabilityServicesStaffReportwith Final Results.Page , 1.Retrieved fromhttp://www.hhsc.state.tx.us/reports/Rider44-evaluation- ealth. (n.d.).Treatment ofChildren withMentalIllness. Retrieved fromhttp:// 15) Final ResultsofSunsetReviews 2014-2015.Retrieved from https://www. cademies. (March12,2009). Preventing Mental,Emotional,and . (2015). DARS AnnualReport2014.Retrievedhttp://www. from 16). Personal communication. 15). Evaluation costeffectiveness methodologyreport for 16). Draft HHSCstakeholder responses. Presentedat 16). Reporttothetransition legislative oversight committee, 2A. Summaryofbaserequest bystrategy,16). 2A. 85 Preliminary Medicaid Enrollment by Month (XLS) 16). Preliminary MedicaidEnrollment byMonth(XLS) The OfficeofMentalHealth Coordination. Retrieved from ct, H.B. 1,ConferenceCommittee Report,2015 Leg., ct, H.B. 1,ConferenceCommittee Report,2015 Leg., tee Report,2015 Leg.,84 tee Report,2015 Leg., 84 ental Health Coordination.(n.d.).Cross-agency th th Reg.Sess., art.IXsec.10.04. Reg.Sess., recapitulation- th Regular HHSC 197 Reg. Sess., art. II. (Tex. 2015). 2015). art. II. (Tex. Reg. Sess., th 9. Retrieved from http://www.lbb. Retrieved 9. tee Report, 2015 Leg., 84 Leg., tee Report, 2015 . Health and Human Services system consolidated budget budget consolidated Services system and Human Health tance Abuse and Mental Health Services Administration. Health and Mental tance Abuse Texas Medicaid and CHIP in perspective tenth edition. Medicaid and CHIP in perspective 15) Texas Texas Medicaid and CHIP in perspective tenth edition. Medicaid and CHIP in perspective 15). Texas tenth edition. Medicaid and CHIP in perspective 15) Texas tenth edition. Medicaid and CHIP in perspective 15). Texas tenth edition. Medicaid and CHIP in perspective 15) Texas tenth edition. Medicaid and CHIP in perspective 15) Texas Attempted Renewals, 15). Statewide CHIP Enrollment, Texas Medicaid and CHIP in perspective tenth edition. Medicaid and CHIP in perspective 15) Texas Texas Medicaid and CHIP in perspective tenth edition. tenth edition. and CHIP in perspective Medicaid 15). Texas 16). CHIP state program information. https://www. 16). CHIP state ., Agazzi, H., Nunez, A., & Gieron-Korthals, M. (2012). Chapter 3: Psychopathology 3: Psychopathology Chapter M. (2012). A., & Gieron-Korthals, ., Agazzi, H., Nunez, Enrollment under the Medicaid under the Enrollment Services Administration. (2014). ental Health Medicaid under the Enrollment Services Administration. (2014). ental Health Fiscal size-up 2016-17 biennium. 2016-17Page size-up Fiscal Board. (2016). et A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Total Medicaid MCO Enrollment MCO Enrollment Medicaid Total (2016). Facts. Health State Foundation, aiser Family 11 to 2-13. 10. -3 to 1-4, 2-2 to 2-4. -3 to 1-4, -14. -6. -3. Children’s health coverage: Medicaid, CHIP, and the ACA. Medicaid, CHIP, health coverage: Children’s (2014). Foundation. aiser Family aiser Family Foundation, State Health Facts. (2016). Medicaid Income Eligibility for (2016). Adults as a Facts. State Health Foundation, aiser Family Federal Medical Assistance Percentage (FMAP) Percentage Medical Assistance Federal (2016). Facts. State Health Foundation, aiser Family Retrieved from https://hhs.texas.gov/sites/hhs/files//pinkbook.pdf Retrieved Retrieved fromhttps://hhs.texas.gov/sites/hhs/files//pinkbook.pdf . Retrieved Retrieved from https://hhs.texas.gov/sites/hhs/files//pinkbook.pdf . Retrieved Retrieved from https://hhs.texas.gov/sites/hhs/files//pinkbook.pdf . Retrieved Retrieved from https://hhs.texas.gov/sites/hhs/files//pinkbook.pdf .Retrieved Retrieved from https://hhs.texas.gov/sites/hhs/files//pinkbook.pdf from . Retrieved Medicaid financing: How the FMAP formula works and why it the FMAP falls short. The George(2008). Medicaid financing: How works formula , C. 1-3 9-3 and ; US Department of Health from https://hhs.texas.gov/sites/hhs/files//pinkbook.pdf . Retrieved 3-11 9-10 1-2 Retrieved from http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017.pdf Retrieved and Human Services Commission. (20 Health Texas Page 9-13. Ibid. 1, Conference Commit General Appropriations Act, H.B. Retrieved from https://hhs.texas.gov/sites/hhs/files//pinkbook.pdf . Retrieved to 15-15 15-14 Pages Page medicaid.gov/chip/state-program-information/chip-state-program-information.html Page Page guidelines. Poverty Evaluation. (2016). for Planning and Secretary Office of the Assistant Human Services. from https://aspe.hhs.gov/poverty-guidelines Retrieved Page 9 Ibid., Page 9 Ibid., Page and Human Services Commission. (20 Health Texas by Month (XLS) and Disenrollment Renewals, from https://hhs.texas.gov/chip-enrollment- [data file]. Retrieved statistics K J. Henry from http://kff.org/health-reform/issue-brief/childrens-health-coverage-medicaid-chip-and-the- Retrieved aca/#footnote-106009-1 Texas Health and Human Services Commission. (20 Health Texas and Human Services Commission. (20 Health Texas and Human Services Commission. (20 Health Texas Ibid., Page 1 Ibid., Page and Human Services Commission. (20 Health Texas 91. Ibid., Page (20 and Human Services. US Department of Health US Substance Abuse and M Abuse US Substance and M Abuse US Substance and Human Services Commission. (20 Health Texas Texas Health and Human Services Commission. (20 Health Texas Page 1 Ibid., Pages 2-4. Ibid., Page K J. Henry from http:// data table]. Retrieved [interactive 1, 2016) (Timeframe: January Level Poverty of the Federal Percent kff.org/health-reform/state-indicator/medicaid-income-eligibility-limits-for-adults-as-a-percent-of-thefederal-poverty-level/#note-12 from https://store.samhsa.gov/shin/content/PEP13- Retrieved Exchanges. Insurance and Health expansion BHPREV-ACA/NSDUH_state_profile_Texas.pdf from https://store.samhsa.gov/shin/content/PEP13- Retrieved Exchanges. Insurance and Health expansion BHPREV-ACA/NSDUH_state_profile_Texas.pdf Peters from http://nhpf.org/library/issue-briefs/IB828_ Retrieved D.C. Washington, University: Washington FMAP_12-11-08.pdf K J. Henry from http://kff. for data table]. Retrieved [interactive and 2017) and Multiplier (Timeframe: FY 2016 Medicaid org/medicaid/state-indicator/federal-matching-rate-and-multiplier/ Armstrong, K.H., Hangauer, J K.H., Hangauer, Armstrong, Subs and Human Services, US Department of Health Budg Legislative Texas Texas Health and Human Services Commission. (20 Human Services Commission. and Health Texas 2- Ibid., Pages 2- Ibid., Page K J. The Henry from http://kff.org/other/state-indicator/total- Retrieved table]. [online interactive March, 2016) (Timeframe: medicaid-mco-enrollment/ of Childhood and Adolescence: A In Psychopathology Disabilities. of Intellectual and Developmental 27-51. NY, Inc.: New York, Springer (ed). Davis Publishing Company, Andrew S. Approach, Neuropsychological state/totals/2015/index.html (n.d.). Commission. Services and Human Health Texas Page 1-1 2010-2020. for mental and substance use disorders, of treatment of national expenditures Projections (2014). from http://store.samhsa.gov/shin/content//SMA14-4883/SMA14-4883.pdf Retrieved . state.tx.us/Documents/Publications/Fiscal_SizeUp/2939_Fiscal_Size-up_2016-17.pdf Retrieved from https://hhs.texas.gov/about-hhs/budget-planning Retrieved 2016-2017. foryears fiscal

82 75 81 69 73 79 80 71 74 76 77 78 70 72 63 65 66 67 68 61 62 64 56 57 58 52 54 55 59 60 53 198

HHSC 108 105 104 103 102 101 100 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 84 83 109 107 106 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

Pilot Program Substance Abuse andM Substance Abuse and M legislative/2016Reports/JBCRpilto3rdQtrFY16.pdf Program: Third QuarterFiscal Year 2016.Retrieved fromhttp://dshs.texas.gov/ConsumerandExternalAffairs/ Texas DepartmentofStateHealth Services Pilot Program Texas Departmentof StateHealth Services Texas Adminis legislative/2016Reports/JBCRpilto3rdQtrFY16.pdf Program: Third QuarterFiscal Year 2016.Retrieved fromhttp://dshs.texas.gov/ConsumerandExternalAffairs/ Texas Department of StateHealth Services Summary_Final_2015.docx Health-Related Legislation.Retrieved fromhttp://hogg.utexas.edu/wp-content/uploads/2015/11/Legislative- Hogg Foundation forM aspx?LinkIdentifier=id&ItemID=8590004028 Texas DepartmentofStateHealth Services Association ofCaliforniawebsite:http://www.fmhac.net/Assets/Documents/2013/Handouts/Rice.pdf Restoration ofCompetency (ROC)PilotProgram [PowerPoint slides].Retrieved fromForensic Mental Health Rice, K.,&Hazelwood,L.(2013). J based+restoration+of+competency from http://www.dshs.state.tx.us/layouts/contentpage.aspx?pageid=35959&id=8589979768&terms=jail- Texas DepartmentofStateHealth Services from https://dshs.texas.gov/mhsa/SB1507/SB-1507.aspx Texas DepartmentofStateHealth Services dshs.texas.gov/ConsumerandExternalAffairs/legislative/2016Reports/NorthSTARTransitionReport.pdf Texas DepartmentofStateHealth Services http://www.ntbha.org/docs/NTBHA_LSAP_SFY16-17.pdf North Texas Behavioral H Summary_Final_2015.docx Health-Related Legislation.Retrieved fromhttp://hogg.utexas.edu/wp-content/uploads/2015/11/Legislative- Hogg Foundation forM History.aspx?LegSess=84R&Bill=SB200 Texas LegislatureOnline.(2015). Retrieved from http://www.ntbha.org/docs/Collaborative_Report_12-23-15.pdf (December 23, 2015). ACollaborative ReportofNorthSTAR System Performance andTrending Data : Slide3. Texas DepartmentofStateHealth Services Update.pdf Plan. Page 21.Retrieved fromhttp://www.hhsc.state.tx.us/hhs-transformation/docs/Transformation-Plan- Texas Health andHumanServicesCommission.(A Ibid., Pages 20and46 transformation/final-transformation-plan.pdf Transition Plan.Pages 4and20. Retrieved fromhttps://hhs.texas.gov/sites/hhs/files/documents/about-hhs/ Texas Health andHumanServicesCommission.(A tloc-transition-plan-033116.pdf Plan. Page 20. Retrieved fromhttps://hhs.texas.gov/sites/hhs/files/documents/about-hhs/transformation/ Texas Health andHumanServicesCommission.(March20 History.aspx?LegSess=84R&Bill=SB200 Texas LegislatureOnline.(2015). Ibid. 9eba-67b14f00ad22.PDF Retrieved fromhttp://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e- Presentation totheSelectCommittee onMentalHealth:TheBehavioral HealthSystem [PowerPoint Slides] Hellerstedt, J SB1507/2016MeetingFiles/022216-meeting-files/JCAFS-SHSForensics.pdf on Access andForensic Services[PowerPoint slides].Retrieved fromhttps://dshs.texas.gov/mhsa/ Boyd, T. (F continuing-challenges-and-sensible-strategies and SensibleStrategies. Retrieved fromhttp://hogg.utexas.edu/project/the-texas-mental-health-worforce- Hogg Foundation forM Growth. Retrieved fromhttp://www.prb.org/Publications/Articles/2015/us-3-states-account.aspx Mather, M.,Population ReferenceBureau.(20 table/PST045215/48 United StatesCensusBureau.(2016). QuickF Support. Retrieved fromhttp://www.samhsa.gov/section-223/care-coordination/person-family-centered aspx?LinkIdentifier=id&ItemID=8590004028 readtac$ext.ViewTAC?tac_view=5&ti=25&pt=1&ch=416&sch=C&rl=Y ebruary 22,2016). Forensics intheStateHospitalSystem: Presentation totheJoint Committee . &LacefieldLewis, L., Texas DepartmentofState Health Services. (February 18, 2016).

Fir Fir trative Code,Title24, Part I,Chapter 416, Subchapter C, https://texreg.sos.state.tx.us/public/ st QuarterFiscal Year 2016.Retrieved fromhttp://dshs.state.tx.us/WorkArea/linkit. st QuarterFiscal Year 2016.Retrieved fromhttp://dshs.state.tx.us/WorkArea/linkit. . ental Health. (2016). TheTexas Mental Health Workforce: ContinuingChallenges ental Health. (June 22,2015). Texas 84th Mental Legislative Session Summaryfor ental Health. (June 22,2015). Texas 84th Mental Legislative Session Summaryfor ental Health (2016). ServicesAdministration. NationalRegistry ofEvidence-based ental Health (2016). Services Administration. Person- and Family-centered Care andPeer ealth Authority. (2015). LocalArea ServicePlanSFY2016&2017.Retrieved from Senate Bill200. Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ Senate Bill200. Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ ail-based competencyrestoration: Findings from LibertyHealthcare’s 2-year . (May 2016). ReportontheJail BasedCompetency Restoration Pilot . (December2015). ReportontheJail BasedCompetency Restoration . (May 2016). ReportontheJail BasedCompetency Restoration Pilot . (December2015). Reportonthe . (2013). Jail-Based Competency Restoration Workgroup. Retrieved . (2016). Joint Committee onAccess andForensic Services.Retrieved . (May 2016). NorthSTAR Transition. Retrieved fromhttp://www. , NorthTexas Behavioral Health Authority, andValueOptions. acts: Texas. Retrievedhttp://www.census.gov/quickfacts/ from Three States Account for Nearly15). Three StatesAccountfor Half ofU.S. Population ugust 2016). HealthandHumanServicesSystem Transition ugust 2016). HealthandHumanServicesSystem 16). HealthandHumanServicesSystem Transition

Jail BasedC ompetency Restoration HHSC 199 Reg. Sess. (Tex. 2015) 2015) (Tex. Reg. Sess. th tee Report, 2015 Leg., 84 Leg., tee Report, 2015 Youth Empowerment Services: A Medicaid Services: A Medicaid Empowerment Youth tember 1, 2010). Presentation to the Select Committee on Mental Committee to the Select 16). Presentation ealth Services. (June 28, 2016). Personal communication: YES communication: Personal 2016). 28, (June ealth Services. YES Communication: Personal 2016). 28, (June ealth Services. Measuring recovery: A toolkit for mental health providers for A toolkit mental health providers Measuring recovery: (2013) , C. . (2014). Mental Health Outcomes and Accountability: Rider 78. . (2014). Youth Empowerment Services (YES). Empowerment Youth 2015). 24, . (November A Medicaid Services (YES) Empowerment Waiver: Youth 2015). . (May 2015 Mental Health Peer Support Re-entry Pilot. Support Health Peer 2015 Mental 2015). . (October, A Medicaid Services (YES) Empowerment Waiver: Youth 2015). . (May Sizing up the 2014-15 Texas budget: Mental health. Sizing up the 2014-15 Texas , (October 21, 2013). 126. Retrieved from http://www.capitol.state.tx.us/BillLookup/ Retrieved Senate Bill 126. 1. Retrieved from http://www.capitol.state.tx.us/tlodocs/84R/ House Bill 1. Retrieved e Director. (July 5, 2016). Personal Communication. Personal 2016). 5, (July e Director. ental Health Services Administration. (n.d.) Recovery and Recovery Support. Retrieved Support. Retrieved and Recovery Services Administration. (n.d.) Recovery ental Health Texas 84th Legislative Session Summary for Session Legislative Mental 84th Texas 22, 2015). (June ental Health. for Summary Session Legislative Mental 84th Texas 22, 2015). (June ental Health. Summary for Session Legislative Mental 84th Texas 22, 2015). (June ental Health. Proposed Amendment to Youth Empowerment Services (YES) Empowerment Retrieved Rule. Waiver Amendment to Youth 16). Proposed A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation State mental health agency per capita mental health services expenditures. State mental health agency per capita mental health services expenditures. oundation, (2013). ). Department of State Health Services Staff Report with Final with ). Department of State Health Services Staff Report 2015 dvisory Commission. (July . & Lacefield Lewis, L., Texas Department of State Health Services. (February 18, 2016). 2016). 18, (February Health Services. Texas Department of State L., . & Lacefield Lewis, : 41:20. Retrieved from http:// Retrieved on Mental Health: 41:20. to the Select Committee Testimony 2016). ebruary 18, : 44:02. Retrieved from http:// Health: 44:02. Retrieved on Mental to the Select Committee Testimony 2016). ebruary 18, . Australian Mental Health Health Mental . Australian measures Review of recovery & Rosen, A. (2010). T., Coombs, J., ., Pirkis, Kaiser Family F Family Kaiser Priorities Center for Public Policy Substance Abuse and M Abuse Substance P Burgess, K., & Williams Neils McDonald, Khanan, D., Retrieved from http://kff.org/other/state-indicator/smha-expenditures-per-capita/?currentTimeframe=0&sel Retrieved ectedRows=%7B%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D Retrieved from http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017.pdf Retrieved from http://www.amhocn.org/sites/default/files/publication_ Retrieved Outcomes and Classification Network. files/review_of_recovery_measures.pdf from https://www.pdffiller.com/ Hygiene. Retrieved and Mental Department of Health City. NYC in New York en/project/68205749.htm?form_id=100595557 from http://forabettertexas.org/images/2013_10__PP_Budget_MentalHealth.pdf Retrieved from http://www.samhsa.gov/recovery billtext/pdf/HB00001F.pdf#navpanes=0 Services Department of State Health Texas J Hellerstedt, Slides]. [PowerPoint Health System on Mental Health: The Behavioral to the Select Committee Presentation from http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e- Retrieved 9eba-67b14f00ad22.PDF 1, Conference Commit General Appropriations Act, H.B. Texas Legislature Online. (2013). Legislature Online. (2013). Texas A Sunset Texas from https://www.sunset.texas.gov/public/uploads/DSHS%20Final%20Results.pdf 31. Retrieved Results. Page Ibid. Legislature Online. (2015) Texas from https://www.dshs.texas.gov/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589980273 Retrieved Ita, R. (February 18, 20 18, Ita, R. (February Department of State H Texas Mark Catalano, Jessee, G. (March 22, 20 L. & Lacefield Lewis, Ibid. History.aspx?LegSess=83R&Bill=SB126 Texas Department of State Health Services Department of State Health Texas from https://www.dshs.state.tx.us/mhsa/yes/ Retrieved Department of State H Texas Mark Catalano, Program. Waiver Services Department of State Health Texas from http://www.txsystemofcare.org/ Retrieved Emotional Disorders. with Severe Children For Program Waiver wp-content/uploads/2015/01/YES-Clinical-Eligibility-Webinar_-cmb-edits-2.pptx from https://www.dshs.texas.gov/mhsa/yes/Proposed-Waiver-Amendments.aspx program. Waiver from http://www.dshs.texas.gov/WorkArea/linkit. Mental Health Services. Retrieved Health: Children’s aspx?LinkIdentifier=id&ItemID=8590006580 Texas Department of State Health Services Department of State Health Texas for M Foundation Hogg http://hogg.utexas.edu/wp-content/uploads/2015/11/Legislative- from Legislation. Retrieved Health-Related Summary_Final_2015.docx from https://www.dshs.state.tx.us/Legislative/reports/2015/MH-Peer-ReEntry-Program-100915.pdf Retrieved for M Foundation Hogg from http://hogg.utexas.edu/wp-content/uploads/2015/11/Legislative- Retrieved Health-Related Legislation. Summary_Final_2015.docx Commission. (Sep and Human Services Health Texas from http://www.dshs.texas.gov/ Retrieved Emotional Disturbance. for Severe with Children Program Waiver mhsa/yes/fy14/YES_Waiver_Manual_090613.pdf (F S. Gaines. tlchouse.granicus.com/MediaPlayer.php?view_id=37&clip_id=11770 from http://www. slides]. Retrieved [PowerPoint Disorders. Emotional with Severe Children For Program Waiver txsystemofcare.org/wp-content/uploads/2015/01/YES-Clinical-Eligibility-Webinar_-cmb-edits-2.pptx from http://hogg.utexas.edu/wp-content/uploads/2015/11/Legislative- Health-Related Legislation. Retrieved Summary_Final_2015.docx Ibid. (F S. Gaines. for M Foundation Hogg Services of State Health Department Texas Retrieved from http://nrepp.samhsa.gov/AdvancedSearch.aspx from Retrieved and Practices. Programs Executiv Bach, ViaHope Dennis tlchouse.granicus.com/MediaPlayer.php?view_id=37&clip_id=11770

138 134 136 137 135 131 133 129 130 132 127 128 121 122 123 124 125 126 114 115 116 117 118 119 120 112 110 113 111 200

HHSC 167 166 163 162 161 159 158 157 156 155 154 153 152 151 149 148 147 145 144 142 141 140 139 165 164 160 150 146 143 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

from http://www.txcouncil.com/userfiles/file/HOW/Integrated%20Care%20Community%20Solutions%20 Texas CouncilofCommunityCenters. (March20 Health Centers. Retrieved fromhttps://www.dshs.texas.gov/chpr/fqhcmain.shtm Texas DepartmentofStateHealth Services 04_17_2012%20FINAL.pdf http://www.txcouncil.com/userfiles/file/HOW/Integrated%20Care%20Community%20Solutions%20%20 Texas CouncilofCommunityCenters. (March20 Texas Associationof CommunityHealth Centers Centers forMedicare &Medicaid Services RuralHealthITtoolbox/Introduction/qualified.html What are Federally qualifiedhealthcenters (FQHCs)?. Retrievedhttp://www.hrsa.gov/healthit/toolbox/ from United StatesDepartmentofHealth andHumanServices, H Health Centers. Retrieved fromhttps://www.dshs.texas.gov/chpr/fqhcmain.shtm Texas Department of StateHealth Services Health Centers. Retrieved fromhttps://www.dshs.texas.gov/chpr/fqhcmain.shtm Texas Department of StateHealth Services Texas CouncilofCommmunityCenters. (March20 (2014). HealthCenter Fact Sheet.Page 2.Retrieved fromhttp://bphc.hrsa.gov/about/healthcenterfactsheet.pdf United StatesDepartmentofHealth andHumanServices, H Health Centers. Retrieved fromhttps://www.dshs.texas.gov/chpr/fqhcmain.shtm Texas DepartmentofStateHealth Services History.aspx?LegSess=84R&Bill=SB133 Texas LegislatureOnline.(2015). History.aspx?LegSess=84R&Bill=HB2186 Texas LegislatureOnline.(2015). http://www.dshs.state.tx.us/mhsa/lmha-list/ Texas DepartmentofStateHealth Services http://www.dshs.state.tx.us/mhsa/lmha-list/ Texas DepartmentofStateHealth Services view=4&ti=25&pt=1&ch=412 Texas Adminis History.aspx?LegSess=84R&Bill=SB1507 Texas LegislatureOnline.(2015). 9eba-67b14f00ad22.PDF Retrieved from: http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e- Presentation totheSelectCommittee onMentalHealth:TheBehavioral Health System [PowerPoint Slides]. Hellerstedt, J Texas Health andSafe History.aspx?LegSess=84R&Bill=SB1507 Texas LegislatureOnline.(2015). http://www.ntbha.org/docs/NTBHA_LSAP_SFY16-17.pdf North Texas Behavioral H txcouncil.com/userfiles/file/TexasCouncil%20Map%20201301web.pdf Texas CouncilofCommunityCenters. (20 Texas Health andSafe about_hhsc/AdvisoryCommittees/bhiac-docs/behavioral-health-carve-in.pdf Thyssen, M.(n.d.).SB58Behavior hhsc.state.tx.us/about_hhsc/AdvisoryCommittees/bhiac-docs/Wells-presentation-061114.pdf Care intoBehavioral AdultswithSPMI[PowerPoint HealthSettingsfor Slides].Retrieved fromhttps://www. Wells, R.( Medicaid.go Ibid. Census. go Behavioral%20Health%20System.pdf publicconsultinggroup.com/client/txdshs/documents/Analysis%20of%20the%20Texas%20Public%20 State HealthServices:Analysis oftheTexas publicbehavioral healthsystem. Retrieved fromhttp://www. Public ConsultingGroup. (2013). about_tachc MLNProducts/downloads/fqhcfactsheet.pdf Page 2.Retrieved fromhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ 04_17_2012%20FINAL.pdf http://www.txcouncil.com/userfiles/file/HOW/Integrated%20Care%20Community%20Solutions%20%20 Docs/HS/htm/HS.533.htm General PowersServices -SubchapterA: andDuties.(2016). Retrieved fromhttp://www.statutes.legis.state.tx.us/ Docs/HS/htm/HS.533.htm General PowersServices -SubchapterA: andDuties.(2016). Retrieved fromhttp://www.statutes.legis.state.tx.us/ information/by-topics/delivery-systems/managed-care/managed-care-site.html June 11,2014). PlannedComparative CaseStudyof1115MedicaidWaiver Projects Integrating Primary v. (n.d.)QuickFacts –Texas. Retrieved fromhttp://www.census.gov/quickfacts/table/PST045215/48 v. (2016). Managedcare. Retrieved fromhttps://www.medicaid.gov/medicaid-chip-program- . &LacefieldLewis, L., Texas DepartmentofState Health Services. (February 18, 2016 ). trative Code:https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_ ty Code,Title7, Subtitle A,Chapter 533:Power andDutiesofDepartmentStateHealth ty Code,Title7, Subtitle A,Chapter 533:Power andDutiesofDepartmentStateHealth ealth Authority. (2015). LocalArea ServicePlanSFY2016&2017. Retrieved from StateofTexas HealthandHumanServicesCommission Departmentof Senate Bill133. Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ House Bill2186.Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ Senate Bill1507. Retrieved from http://www.capitol.state.tx.us/BillLookup/ Senate Bill1507. Retrievedhttp://www.capitol.state.tx.us/BillLookup/ from al HealthIntegration. Retrieved fromhttp://legacy-hhsc.hhsc.state.tx.us/ 15). CommunityCentersofTexas Map. Retrieved fromhttp://www. . (February 2016). Federally QualifiedHealth Center Fact Sheet. . (2016). Texas — PrimaryCare Federally Office(TPCO) Qualified . (2016). Texas — PrimaryCare Federally Office(TPCO) Qualified . (2016). Texas — PrimaryCare Federally Office(TPCO) Qualified . (2016). Texas — PrimaryCare Federally Office(TPCO) Qualified . (2014). LocalMentalHealthAuthorities(LMHAs).Retrieved from . (2014). LocalMentalHealthAuthorities(LMHAs).Retrieved from . (2010). AboutTACHC. Retrieved fromhttps://www.tachc.org/ 12). Integrated Care: ACommunity Solution.Page 9. Retrieved 12). Integrated Care: ACommunity Solution.Retrieved from 12). Integrated Care: ACommunity Solution.Retrieved from ealth Resources and Services Administration. (n.d.). ealth ResourcesandServicesAdministration. ealth Resources and Services Administration. ealth ResourcesandServicesAdministration. HHSC 201 – Eligibility Criteria. Program Indigent Health Care 16). County Three States Account for Nearly Half of U.S. Population Population of U.S. Half States Account for15). Three Nearly . Retrieved from http://www.census.gov/quickfacts/ . Retrieved acts: Texas Retrieved from http://www. for Retrieved the future. Framework tember 2013). Presentation to Senate Health and Human Services Presentation April 14). . (2014, communication: LMHA waitlists. Personal April 29). . (2014, . (2013). FY 2014‐2015 SAMHSA Mental Health . (2013). Community Retrieved Retrieved Pamphlet. Program Indigent Health Care County . (2015). from www.dshs.state. – 83(R). Retrieved House Bill 3793 . (2014). Texas Resilience and Recovery ( and Recovery Resilience Texas . (2015). and Resiliency formerly Retrieved Information. Retrieved CHIP Program National Medicaid and . (2014). from https://www.medicaid.gov/ Retrieved Financing. . (2016). Retrieved from Status Report. Retrieved Advocate’s at 5 years: in Texas The ACA . (2016). Retrieved from http://www.capitol.state.tx.us/BillLookup/ Retrieved House Bill 3793. from http://www.capitol.state.tx.us/BillLookup/ Retrieved Senate Bill 7. State of Texas Health and Human Services Commission Department of Commission Health and Human Services State of Texas State of Texas Health and Human Services Commission Department of Health and Human Services Commission State of Texas Texas 84th Legislative Session Summary for Session Legislative Mental Health-Related 84th Texas (2015). ental Health. ty Code, tit. 7. subtit. A § 533.0354 (2014). Retrieved from http://www.statutes.legis.state. Retrieved (2014). A § 533.0354 subtit. ty Code, tit. 7. ty Code, tit. 7. subtit. B § 552.012. (1991). Retrieved from http://www.statutes.legis.state. (1991). Retrieved B § 552.012. subtit. ty Code, tit. 7. Retrieved from http://forabettertexas.org/ budget: Mental health. Retrieved Sizing up the 2014-15 Texas A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Status of state action on the Medicaid expansion decision. the Medicaid expansion Status of state action on (2016). Foundation. aiser Family trative Code, tit. 25. subtit. G § 412.314: https://texreg.sos.state.tx.us/public/readtac$ext. G § 412.314: subtit. Code, tit. 25. trative trative Code, tit. 25, part 1 § 412.106. Retrieved from https://texreg.sos.state. Retrieved 1 § 412.106. part Code, tit. 25, trative from https://texreg.sos.state.tx.us/public/ Retrieved 1 § 444.413. part Code, tit. 25, trative . Retrieved from fromhttps://www.medicaid.gov/medicaid-chip- . Retrieved CHIP in Texas Medicaid & (2016). v. Presentation to the Legislative Budget Board-Governor’s Office of Budget, Policy and Planning Office of Budget, Budget Board-Governor’s to the Legislative Presentation . L. (2012). Retrieved from http://hogg.utexas.edu/wp-content/uploads/2015/11/Legislative-Summary_ Legislation. Retrieved Final_2015.docx Ligon, K. (2013). for M Foundation Hogg D Lakey, Retrieved from http://www.prb.org/Publications/Articles/2015/us-3-states-account.aspx Retrieved Growth. Services Department of State Health Texas from http:// slides]. Retrieved health and substance abuse services [PowerPoint mental Overview Committee: www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589990636 Adminis Texas TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=25&pt=1&ch=412&rl=314 Services Department of State Health Texas images/2013_10__PP_Budget_MentalHealth.pdf Public Consulting Group. (2013). Public Consulting Group. Quick F United States Census Bureau. (2016). Reference Bureau. (20 M., Population Mather, Texas Legislature Online. (2013). Legislature Online. (2013). Texas Legislature Online. (2013). Texas Services Department of State Health Texas https://www.dshs.state.tx.us/WorkArea/linkit. Application. Retrieved & Substance Abuse Block Grant aspx?LinkIdentifier=id&ItemID=8589979882 from http://www. . Retrieved health system public behavioral of the Texas State Health Services: Analysis publicconsultinggroup.com/client/txdshs/documents/Analysis%20of%20the%20Texas%20Public%20 Behavioral%20Health%20System.pdf table/PST045215/48 Texas Department of State Health Services (20 Department of State Health Texas Services Department of State Health Texas Services Department of State Health Texas and Safe Health Texas tx.us/Docs/HS/htm/HS.533.htm#533.0354 History.aspx?LegSess=83R&Bill=HB3793 History.aspx?LegSess=83R&Bill=SB7 Texas Adminis Texas tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_ tac=&ti=25&pt=1&ch=412&rl=106. Adminis Texas readtac$ext.ViewTAC?tac_view=2&ti=25 from www.dshs.state.tx.us/cihcp/eligibility.shtm Retrieved from https://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589995983 tx.us/mhsa/hb3793 Retrieved from http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under- Retrieved the-affordable-care-act/ Services & Medicaid Centers for Medicare (Sep Council of Community Centers. Texas and Safe Health Texas tx.us/Docs/HS/htm/HS.552.htm#552.012 (2013). Public Consulting Group. Centers for Medicare & Medicaid Services & Medicaid Centers for Medicare from http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/Medicaid- and-CHIP-Eligibility-Levels-Table.pdf Priorities Center for Public Policy https://drive.google.com/file/d/0B-CM0KurzX_rZnh4OWJkNG56OVU/view?usp=sharing K J. The Henry affordablecareact/provisions/financing.html txcouncil.com/userfiles/file/HOW/Framework%20for%20the%20Future%20Final%209%205%202013.pdf from http://www. . Retrieved health system public behavioral of the Texas State Health Services: Analysis publicconsultinggroup.com/client/txdshs/documents/Analysis%20of%20the%20Texas%20Public%20 Behavioral%20Health%20System.pdf Ibid. Ibid. Ibid. Ibid. Medicaid.go %2004_17_2012%20FINAL.pdf Services Health of State Department Texas from https://www.dshs.texas.gov/mhsa/trr/ Retrieved or RDM). Management, Disease program-information/by-state/stateprofile.html?state=texas

198 193 194 195 196 197 190 191 192 187 188 189 182 183 184 185 186 177 180 175 176 178 179 181 170 171 172 173 168 169 174 202

HHSC 220 219 216 215 213 211 209 208 207 206 204 203 202 201 200 199 Texas DepartmentofStateHealth Services. (2016). Presentation toSelectCommittee onMentalHealth:The 218 217 214 212 210 205 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

Ibid, Page 1. ConsumerandExternalAffairs/legislative/2016Reports/JCAFSlegislativeReportForensicPlan2016.pdf of aComprehensive Forensic Planfor Services.Page 9. Retrieved fromhttp://dshs.texas.gov/ Joint Committee onA aspx?LinkIdentifier=id&ItemID=8590005945 Vernon Campus[PowerPoint slides].Retrieved fromhttps://www.dshs.texas.gov/WorkArea/linkit. Smith, J. E.,DepartmentofStateHealth Services Texas Legislative Budg Boyd, T. (December15 APS_pg_4800.asp Commitment &4810Emergency Detention.Retrieved fromhttp://www.dfps.state.tx.us/handbooks/aps/files/ Texas Department of Family Pro Court-Ordered-Involuntary-Mental-Health-Services.asp (HCPC): Court-Ordered/Involuntary MentalHealthServices.Retrieved fromhttp://www.mhmraharris.org/ Harris CenterforMental Health andIDD Texas Young La Mental_Health_Facilities_in_Texas_Diehl.pdf Primer. Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospitals- Texas Legislative Budg Texas Young La Mental_Health_Facilities_in_Texas_Diehl.pdf Primer. Retrieved from http://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospitals- Texas Legislative Budg Texas Young La Funding%20State%20Mental%20H primer. Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Primer/Managing%20and%20 Texas Legislative Budg Services%20SER%202013%2084%20Leg.pdf from https://www.sunset.texas.gov/public/uploads/files/reports/Department%20of%20State%20Health%20 Texas DepartmentofStateHealth Services ViewTAC?tac_view=5&ti=25&pt=1&ch=411&sch=J Texas Code,Title25 Admin aspx?LinkIdentifier=id&ItemID=8590002694 quarter [PowerPoint slides].Retrieved fromhttp://www.dshs.texas.gov/WorkArea/linkit. Texas DepartmentofStateHealth Services Maples, M.&LacefieldLewis, L.,T http://tlchouse.granicus.com/MediaPlayer.php?view_id=37&clip_id=11770 Gaines. S. (F projects. Retrieved from:http://www.dshs.state.tx.us/WorkArea/DownloadAsset.aspx?id=8589977842 Texas DepartmentofStateHealth Services Plan.pdf www.lbb.state.tx.us/Documents/Publications/Presentation/3190_Statewide_Behavioral_Health_Strategic_ 2016). Texas StatewideBehavioral HealthStrategic Plan:Fiscal Years 2017-2021. Page 21.Retrieved from http:// Texas Health andHumanServicesCommission.StatewideBeha tac=&ti=25&pt=1&ch=412&rl=403 sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_ handouts/C3822016021810001/5fc9614b-41a4-436e-9eba-67b14f00ad22.PDF Behavioral HealthSystem [PowerPoint slides].Retrieved fromhttp://www.legis.state.tx.us/tlodocs/84R/ Joint Hearing.Retrieved fromhttp://www.dshs.state.tx.us/WorkArea/DownloadAsset.aspx?id=70651 Mental_Health_Facilities_in_Texas_Diehl.pdf Primer. Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospitals- 12MeetingFiles/StateHospitalsSectionPresentation-JointCommitteeonAccessandForensicServices.pdf Services [PowerPoint slides].Slide23. Retrieved fromhttps://www.dshs.texas.gov/mhsa/SB1507/2015- committedtohealinginvoluntarycommitmentprocedures.pdf A3EB-6584-CA74-137E0474AE2C/attachments/AEDE810D-5686-4150-8E55-753ED82B9C41/ Involuntary Commitment Procedures. Retrieved fromhttp://texaslawhelp.org/files/685E99A9- committedtohealinginvoluntarycommitmentprocedures.pdf A3EB-6584-CA74-137E0474AE2C/attachments/AEDE810D-5686-4150-8E55-753ED82B9C41/ Involuntary Commitment Procedures. Retrieved fromhttp://texaslawhelp.org/files/685E99A9- committedtohealinginvoluntarycommitmentprocedures.pdf A3EB-6584-CA74-137E0474AE2C/attachments/AEDE810D-5686-4150-8E55-753ED82B9C41/ Involuntary Commitment Procedures. Retrieved fromhttp://texaslawhelp.org/files/685E99A9- SenateHHSdiversionForensicCapacity.pdf Slides]. Retrieved fromhttp://dshs.texas.gov/ConsumerandExternalAffairs/legislative/2016Reports/ and Forensic Capacity:Presentation totheSenateCommittee onHealthandHumanServices[PowerPoint

Texas Adminis ebruary 18, 2016). Testimony totheSelectCommittee onMentalHealth:1:03:30. Retrieved from wyers AssociationandtheStateBarofTexas. (n.d.).Committed toHealing: wyers AssociationandtheStateBarofTexas. (n.d.).Committed toHealing: wyers AssociationandtheStateBarofTexas. (n.d.).Committed toHealing: trative Code,tit.25, Part 1,ch.412,subch.I§412.403. (2016). Retrieved fromhttps://texreg. ccess andForensic Services. (June theCreation 2016). Recommendationsfor , 2015). Overview oftheStateHospital System: Joint Committee onAccess andForensic et Board.(April2016). StateHospitals:MentalHealthFacilities inTexas, Legislative et Board.(April2016). StateHospitals:MentalHealthFacilities inTexas, Legislative et Board.(2011). ManagingandfundingstatementalhospitalsinTexas: Legislative et Board.(April2016). StateHospitals:MentalHealthFacilities inTexas, Legislative , Part 1,Chapter 411,Subchapter Jhttps://texreg.sos.state.tx.us/public/readtac$ext. tective Services. (2009). DFPSProgram Handbooks: 4800MentalHealth exas DepartmentofStateHealth Services. (June 16, 2016). Diversion ospitals%20in%20Texas%20-%20Legislative%20Primer.pdf . (2016). TheUniversity ofTexas HarrisCounty Psychiatric Center . (2016). Behavioral healthdatabook,FY2015,fourth . (2013). Needsandcapacityassessment: Psychiatric emergency service . (September 2013). DSHS SunsetSelf-Evaluation Report.Retrieved . (n.d.).Overview ofNorthTexas StateHospital- vioral Health CoordinatingCouncil.(May

HHSC 203 ental Health and Substance Abuse Division. (July 8, 2016). 2016). 8, Division. (July Abuse and Substance ental Health Medicaid and Children’s Health Insurance Program (CHIP) Program Health Insurance Medicaid and Children’s . (2016). Medicaid and CHIP Managed Care Final Rule (CMS-2390-F): Final Medicaid and CHIP Managed Care . (2016). Diversion and Diversion 2016). 16, (June Services. Health exas Department of State and Fo- Diversion 2016). 16, (June Services. exas Department of State Health What Is Up With The Medicaid Emergency Psychiatric Psychiatric The Medicaid Emergency Up With What Is 2014). 14, July Analysis for the Ten-Year Plan for the Provision of Services to Persons to Persons of Services for Plan the Provision for Analysis Ten-Year the 14). ed from https://www.ssa.gov/OP_Home/ssact/title19/1905.htm New CMS rule could reshape Medicaid managed New CMS rule could reshape 2015). 30, (May Healthcare. ., Modern State Hospitals: Mental Health Facilities in Texas, Legislative Legislative in Texas, State Hospitals: Mental Health Facilities Board. (April 2016). et Legislative in Texas, State Hospitals: Mental Health Facilities Board. (April, 2016). et ). State Hospitals: Mental Health Facilities in Texas, Legislative Legislative in Texas, ). State Hospitals: Mental Health Facilities Board. (April 2016 et Presentation to the Select Committee on Mental Health: on Mental to the Select Committee Presentation 2016). 18, (February Board. et State Hospitals: Mental Health Facilities in Texas, Legislative Prim- Legislative in Texas, State Hospitals: Mental Health Facilities Board. (April 2016). et ccess and Forensic Services. (June 2016). Recommendations for 2016). the Creation (June Services. ccess and Forensic ccess and Forensic Services. (June 2016). Recommendations for 2016). the Creation (June Services. ccess and Forensic A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation . & Lacefield Lewis, L., Texas Department of State Health Services. (February 18, 2016). 2016). 18, (February Health Services. Texas Department of State L., . & Lacefield Lewis, . & Lacefield Lewis, L., Texas Department of State Health Services. (February 18, 2016). Presen- 2016). 18, (February Health Services. of State Texas Department L., . & Lacefield Lewis, Behavioral Health Challenges and Health Challenges Behavioral 2016). Association. (April 27, Hospital ., Texas Hellerstedt, J Hellerstedt, Slides]. [PowerPoint Health System on Mental Health: The Behavioral to the Select Committee Presentation from http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e- Retrieved 9eba-67b14f00ad22.PDF J Hawkins, from http://www.legis.state.tx.us/tlodocs/84R/handouts/ Hospitals. Retrieved Opportunities for Texas Texas Legislative Budg Legislative Texas on A Committee Joint http://dshs.texas.gov/ from 1. Retrieved Services. Page Plan for Forensic of a Comprehensive ConsumerandExternalAffairs/legislative/2016Reports/JCAFSlegislativeReportForensicPlan2016.pdf Texas Legislative Budg Legislative Texas from http://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospitals- Retrieved Primer. Mental_Health_Facilities_in_Texas_Diehl.pdf Ibid. on A Committee Joint from http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/3ea17faa- Retrieved Primer. 4c5b-4a15-9b2d-5af88e9cd4a9.PDF Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Party Related to Third and Revisions in Managed Care, CHIP Delivered Medicaid Managed Care, Programs; from https://www.federalregister.gov/articles/2016/05/06/2016-09581/medicaid-and- Retrieved Liability. childrens-health-insurance-program-chip-programs-medicaid-managed-care-chip-delivered Ibid. B & Herman, Dickson, V. from http://www.modernhealthcare.com/article/20150530/MAGAZINE/305309986 Retrieved care. Briefing. ( Open Minds Executive from http://dshs.texas.gov/ Retrieved 10 and 14. Services. Pages Plan for Forensic of a Comprehensive ConsumerandExternalAffairs/legislative/2016Reports/JCAFSlegislativeReportForensicPlan2016.pdf Social Security Act. Retriev Budg Legislative Texas from http://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospitals- Retrieved Primer. Mental_Health_Facilities_in_Texas_Diehl.pdf Services & Medicaid Centers for Medicare Services & Medicaid Centers for Medicare from https://www.openminds.com/market-intelligence/executive-briefings/ Retrieved Project? Demonstration medicaid-psychiatric-emergency-demonstration-project/ Ibid. Ibid. Budg Legislative Texas from http://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospitals-Men- Retrieved er. tal_Health_Facilities_in_Texas_Diehl.pdf Ibid. from https://www.medicaid.gov/medicaid-chip-program-information/by- Rule. Retrieved of the Final Overview topics/delivery-systems/managed-care/downloads/final-rule-overview.pdf Chad Pomerleau, Legislative Liaison for DSHS M Legislative Chad Pomerleau, T L., M. & Lacefield Lewis, Maples, Hellerstedt, J Hellerstedt, L., T Lewis, M. & Lacefield Maples, Communication. Personal 529-14-0066. for Services 83 RFP No. Rider DSHS Consulting (SPHs): Hospitals by State Psychiatric Served from https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=r- Retrieved 8. Page ja&uact=8&ved=0ahUKEwiS_9Oc3bzNAhVJNSYKHfDxBCkQFggeMAA&url=https%3A%2F%2Fwww.dshs. state.tx.us%2Fmhsa%2Freports%2FSPH-Report-2014.pdf&usg=AFQjCNHRuxYGyypPJiNrLNkxYGu4JIiax- Q&sig2=hqkU6VLGKbpSDDtmWMC8sQ&bvm=bv.125221236,d.eWE Budg Legislative Texas Retrieved and Funding. Overview Expenditures Plan and Coordinated Health Strategic Statewide Behavioral from http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/3738c396-61ed-4aae-8d75- a800bd306277.PDF Retrieved Slides]. [PowerPoint Health System on Mental Health: The Behavioral tation to the Select Committee from: http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e-9eba- 67b14f00ad22.PDF Slides]. and Human Services [PowerPoint on Health to the Senate Committee Presentation Capacity: Forensic from http://dshs.texas.gov/ConsumerandExternalAffairs/legislative/2016Reports/SenateHHSdiver- Retrieved sionForensicCapacity.pdf Slides]. Slide on Health and Human Services [PowerPoint Committee to the Senate Capacity: Presentation rensic from http://dshs.texas.gov/ConsumerandExternalAffairs/legislative/2016Reports/SenateHHSdi- 4. Retrieved versionForensicCapacity.pdf Texas Department of State Health Services (August 22, 2014) Personal communication: State Hospitals. State communication: Personal 22, 2014) Services (August Health of State Department Texas 20 (November CannonDesign.

245 244 240 241 243 236 237 238 242 234 239 229 230 231 232 233 235 227 223 224 225 226 228 221 222 204

HHSC 267 265 264 269 266 262 261 260 259 258 257 256 255 254 253 252 251 250 249 248 247 246 263 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 268

Texas Health andHumanServicesCommission.StatewideBehaiv Maples, M.&LacefieldLewis, L.,T Texas Departmentof StateHealth Services Texas LegislatureOnline. (2015). Maples, M.&LacefieldLewis, L.,T Boyd, T. (F SenateHHSdiversionForensicCapacity.pdf Slides]. Retrieved fromhttp://dshs.texas.gov/ConsumerandExternalAffairs/legislative/2016Reports/ and Forensic Capacity:Presentation totheSenateCommittee onHealthandHumanServices[PowerPoint History.aspx?LegSess=84R&Bill=SB1507 final.pdf Retrieved fromhttp://namitexas.org/wp-content/uploads/sites/12/2014/10/Budget-Summary-84th-Session- SB1507/2016MeetingFiles/022216-meeting-files/JCAFS-SHSForensics.pdf Access andForensic Services[PowerPoint slides].Slides3and4.Retrieved from https://dshs.texas.gov/mhsa/ from https://dshs.texas.gov/mhsa/SB1507/SB-1507.aspx National AllianceonMental Illness(NAMI)Texas Maples, M.&LacefieldLewis, L.,T SenateHHSinpatientMH.pdf Retrieved from https://www.dshs.texas.gov/ConsumerandExternalAffairs/legislative/2016Reports/ Partnerships: Presentation totheSenateCommittee onHealthandHumanServices[PowerPoint Slides]. Lakey, D Ibid. Ibid. Hospitals-Mental_Health_Facilities_in_Texas_Diehl.pdf Primer. Page 8. Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_ Texas Legislative Budg SB1507/2015-12MeetingFiles/1507_HospCapac_Hopkins_20151217.pdf Access andForensic Services[PowerPoint slides] . Slide10. Retrievedhttps://www.dshs.texas.gov/mhsa/ from Hopkins, L.(December15 ConsumerandExternalAffairs/legislative/2016Reports/JCAFSlegislativeReportForensicPlan2016.pdf of aComprehensive Forensic Planfor Services.Page 11.Retrieved fromhttp://dshs.texas.gov/ Joint Committee onA Ibid. SB1507/2015-12MeetingFiles/1507_HospCapac_Hopkins_20151217.pdf Access andForensic Services[PowerPoint slides] . Slide9. Retrievedhttps://www.dshs.texas.gov/mhsa/ from Hopkins, L.(December15 hospital-beds/ Tribune. Retrieved fromhttps://www.texastribune.org/2016/05/01/despite-state-spending-dearth-pysch- Walters, E.(Ma 67b14f00ad22.PDF from: http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e-9eba- The Behavioral HealthSystem [PowerPoint Slides].Texas DepartmentofStateHealth Services. Retrieved Hellerstedt, J 67b14f00ad22.PDF from: http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e-9eba- The Behavioral HealthSystem [PowerPoint Slides].Texas DepartmentofStateHealth Services. Retrieved Hellerstedt, J Retrieved fromhttps://www.texastribune.org/2015/03/25/hhsc-ditches-plan-privatize-terrell-state-hospital/ Langford, T. (March25, 20 http://www.correctcarers.com/mcmhtf/ Correct CareRecovery Solutions Plan.pdf www.lbb.state.tx.us/Documents/Publications/Presentation/3190_Statewide_Behavioral_Health_Strategic_ 2016). Texas StatewideBehavioral HealthStrategic Plan:Fiscal Years 2017-2021.Page 8. Retrieved fromhttp:// Texas Health andHumanServicesCommission.StatewideBeha C3822016042710001/8e344ac4-7ab4-4bf3-8a34-e84a804e2345.PDF TexasOpportunities for Hospitals..Retrieved fromhttp://www.legis.state.tx.us/tlodocs/84R/handouts/ Hawkins, J from https://dshs.texas.gov/legislative/2015/Rider83-State-Hospital-Long-Term-Plan.pdf Texas DepartmentofStateHealth Services C3822016042710001/8e344ac4-7ab4-4bf3-8a34-e84a804e2345.PDF SenateHHSdiversionForensicCapacity.pdf Slides]. Retrieved fromhttp://dshs.texas.gov/ConsumerandExternalAffairs/legislative/2016Reports/ and Forensic Capacity:Presentation totheSenateCommittee onHealthandHumanServices[PowerPoint Plan.pdf www.lbb.state.tx.us/Documents/Publications/Presentation/3190_Statewide_Behavioral_Health_Strategic_ 2016). Texas Statewide Behavioral HealthStrategic Plan:Fiscal Years 2017-2021. Page 26. Retrieved from http:// . (June 16, Improving 2016). Optionsfor theTexas MentalHealthHospitalsThoughAcademic ebruary 22,2016). Forensics intheStateHospitalSystem: Presentation totheJoint Committee on ., Texas Hospital Association.(April27, 2016). Behavioral HealthChallengesand . &LacefieldLewis, L.(February 18, 2016). Presentation totheSelectCommittee onMentalHealth: . &LacefieldLewis, L.(February 18, 2016). Presentation totheSelectCommittee onMentalHealth: y 1,2016). StateSpendingMore onMental Health Care,butWaitlist forBedsGrows. TheTexas ccess andForensic Services. (June theCreation 2016). Recommendationsfor et Board.(April2016). StateHospitals:MentalHealthFacilities inTexas, Legislative , 2015). DSHS HospitalCapacity:Presentation toSB1507Joint Committee on , 2015). DSHS HospitalCapacity:Presentation toSB1507Joint Committee on 15). Texas DitchesPlantoPrivatizeTerrell StateHospital. TheTexas Tribune . . (2014). MontgomeryCounty MentalHealthTreatment Facility. Retrieved from Senate Bill1507. Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ exas Department ofStateHealth Services. (June 16, 2016). Diversion and exas DepartmentofStateHealth Services. (June 16, 2016). Diversion exas DepartmentofStateHealth Services. (June 16, 2016). Diversion . (2016). Joint Committee onAccess andForensicRetrieved Services. . (January 2015). StateHospitalSystem Long-TermRetrieved Plan. . (2015). 84 th Legislative Session: BudgetSummary. Page 6. vioral Health CoordinatingCouncil.(May oral Health CoordinatingCouncil.(May HHSC 205

[PowerPoint slides]. [PowerPoint eating a Culture of Care: A Toolkit for a Trauma- Creating A Toolkit of Care: eating a Culture . Retrieved from http://www. . Retrieved Incompetency; Presumptions 003. Department of State Health Services efforts towards more more Department of State Health Services efforts. (2012). towards Retrieved Plan. Retrieved Long-Term State Hospital System 2015). . (January exas Department of State Health Services. (June 16, 2016). Inpatient Mental 2016). 16, (June Services. Health exas Department of State Retrieved from http://www.capitol.state.tx.us/BillLookup/ Retrieved Senate Bill 1129. Analysis for the Ten-Year Plan for the Provision of Services to Persons Served Served to Persons of Services Plan for the Provision for Analysis the Ten-Year 14). With state hospitals packed, mentally ill inmates wait in county jails that aren’t in county jails that aren’t mentally ill inmates wait state hospitals packed, With . Retrieved from . Retrieved Observer Texas wait. not rules mentally ill prisoners must Judge , 2012). Texas Outpatient Competency Restoration Programs: Evaluation Evaluation Programs: Restoration Outpatient Competency Texas (2015). ental Health. State Hospitals: Mental Health Facilities in Texas, Legislative Legislative in Texas, State Hospitals: Mental Health Facilities Board. (April 2016). et State Hospitals: Mental Health Facilities in Texas, Legislative Legislative in Texas, State Hospitals: Mental Health Facilities Board. (April 2016). et ccess and Forensic Services. (June 2016). Recommendations for 2016). the Creation (June Services. ccess and Forensic ealth_Facilities_in_Texas_Diehl.pdf wensmith, W.N., Frost, L.E., Speelman, D. & Therson, D. (2016). Lookin’ for (2016). beds in all the & Therson, D. L.E., Speelman, D. Frost, wensmith, W.N., Retrieved from http://tnoys.org/ Retrieved of care. a culture Creating (2014). outh Services. Retrieved from http://www.pbis.org/seclusion-restraint e Behavior Supports. Retrieved A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Considerations for seclusion and restraint use in for seclusion and restraint Considerations (PBIS). (2009). & Supports vioral Interventions . & Lacefield Lewis, L., Texas Department of State Health Services. (February 18, 2016). Presen- 2016). 18, (February Health Services. of State Texas Department L., . & Lacefield Lewis, ., 362 U.S. 402 (1960); Drope v. Missouri, 420 U.S. 162 (1975). Missouri, 420 U.S. 402 (1960); Drope v. ., 362 U.S. Forensics in the State Hospital System: Presentation to the Joint Committee Committee to the Joint Presentation in the State Hospital System: Forensics ebruary 22, 2016). Options for Improving the Texas Mental Health Hospitals Though Academic Mental the Texas Options for 2016). Improving 16, . (June Options for Improving the Texas Mental Health Hospitals Though Academic Partner- Mental Health Hospitals Though the Texas Options for 2016). Improving 16, . (June Texas Legislative Budg Legislative Texas Hospitals-Mental_H for M Foundation Hogg http://www.texasobserver.org/judge-rules-mentally-ill-prisoners-must-not-wait/ Ibid. (April 21, 2016). Grissom, B. Ibid. (F T. Boyd, from https://dshs.texas.gov/mhsa/ Retrieved slides]. Slide 9. Services [PowerPoint and Forensic on Access SB1507/2016MeetingFiles/022216-meeting-files/JCAFS-SHSForensics.pdf from http://hogg.utexas.edu/project/evaluation-outpatient-competency-restoration Retrieved 7. Report. Page Dusky v. U.S Dusky v. Go N., Gowensmith, Services Department of State Health Texas 30 Deprang, E. (January from http://trailblazersblog.dallasnews.com/2016/04/ Retrieved equipped for News. them. The Dallas Morning with-state-hospitals-packed-mentally-ill-inmates-wait-in-county-jails-that-arent-equipped-for-them.html/ from http://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_ Retrieved 8. Page Primer. New Logic Organizational Learning. (2011). Cr New Logic Organizational Learning. (2011). from www.dshs.texas.gov/cultureofcare/toolkit.doc Retrieved 6. Informed Page Environment. Legislature Online. (2015) Texas Code of Criminal Procedure article 46B. Texas statutes.legis.state.tx.us/Docs/CR/htm/CR.46B.htm patients determined incompetent to stand trial of timely treatment Lakey, D Lakey, Slides]. and Human Services [PowerPoint on Health to the Senate Committee Presentation Partnerships: from https://www.dshs.texas.gov/ConsumerandExternalAffairs/legislative/2016Reports/ Retrieved SenateHHSinpatientMH.pdf Beha Positive Positiv School-wide of Y Network Texas professional-program-development/creating-a-culture-of-care/ History.aspx?LegSess=84R&Bill=SB1129 Public Psychology, to modern problems. approach as a promising places: Outpatient competency restoration wrong from http://psycnet.apa.org/journals/law/22/3/293/ 22(3), 293-305. Retrieved & Law Policy Page 17. Retrieved from http://dshs.texas.gov/ Retrieved 17. Services. Page Plan for Forensic of a Comprehensive ConsumerandExternalAffairs/legislative/2016Reports/JCAFSlegislativeReportForensicPlan2016.pdf 1. Ibid., Page Ibid. Budg Legislative Texas Services Department of State Health Texas from https://dshs.texas.gov/legislative/2015/Rider83-State-Hospital-Long-Term-Plan.pdf Retrieved Retrieved Slides]. [PowerPoint Health System on Mental Health: The Behavioral tation to the Select Committee from: http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e-9eba- 67b14f00ad22.PDF D Lakey, from Slides]. Retrieved [PowerPoint on Health and Human Services to the Senate Committee ships: Presentation https://www.dshs.texas.gov/ConsumerandExternalAffairs/legislative/2016Reports/SenateHHSinpatientMH. pdf on A Committee Joint from http://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospitals- Primer. Retrieved Mental_Health_Facilities_in_Texas_Diehl.pdf Maples, M. & Lacefield Lewis, L., T Lewis, M. & Lacefield Maples, Ibid. J Hellerstedt, CannonDesign. (November 20 (November CannonDesign. slides]. Re- Services [PowerPoint on Health and Human Committee to the Senate Health Planning: Presentation http://www.dshs.texas.gov/ConsumerandExternalAffairs/legislative/2016Reports/SenateHHSin- from trieved patientMH.pdf [PowerPoint Slides]. Services [PowerPoint and Human on Health Committee to the Senate Presentation Capacity: Forensic from http://dshs.texas.gov/ConsumerandExternalAffairs/legislative/2016Reports/ Retrieved Slide 5. SenateHHSdiversionForensicCapacity.pdf Retrieved Retrieved 529-14-0066. Services for No. Rider 83 RFP DSHS Consulting Hospitals (SPHs): by State Psychiatric from https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0a- hUKEwiS_9Oc3bzNAhVJNSYKHfDxBCkQFggeMAA&url=https%3A%2F%2Fwww.dshs.state.tx.us%2Fmh- sa%2Freports%2FSPH-Report-2014.pdf&usg=AFQjCNHRuxYGyypPJiNrLNkxYGu4JIiaxQ&sig2=hqkU6VL- GKbpSDDtmWMC8sQ&bvm=bv.125221236,d.eWE

295 290 291 293 294 292 282 284 286 287 289 281 283 285 288 276 277 278 280 274 275 279 273 272 270 271 206

HHSC 323 322 318 317 316 315 314 312 311 310 309 308 307 306 305 304 303 301 300 299 298 297 296 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 321 320 319 313 302

Services%20SER%202013%2084%20Leg.pdf from https://www.sunset.texas.gov/public/uploads/files/reports/Department%20of%20State%20Health%20 9eba-67b14f00ad22.PDF Retrieved fromhttp://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e- Presentation totheSelectCommittee onMentalHealth:TheBehavioral HealthSystem [PowerPoint Slides]. Hellerstedt, J Substance Abuse andM Substance Abuse andM Taylor Heard, C. ( GEER/Government%20Effectiveness%20and%20Efficiency%20Report%202012.pdf Selected Issues andRecommendations.Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/ Texas Legislative Budg Ibid. Ibid. Ibid. Gowensmith, N., Go Ibid., Pages 4and2 Ibid. Report. Hogg Foundation forM Strategic_Plan.pdf http://www.lbb.state.tx.us/Documents/Publications/Presentation/3190_Statewide_Behavioral_Health_ 2016). Texas StatewideBehavioral HealthStrategic Plan:Fiscal Years 2017-2021. PageRetrieved E-3. from Texas Health andHumanServicesCommission.StatewideBeha restoration Evaluation Report.Page 4.Retrieved fromhttp://hogg.utexas.edu/project/evaluation-outpatient-competency- Hogg Foundation forM http://wwwprod.dshs.state.tx.us/legislative/82nd/DSHS-HHSC-combined-MHOverview.pdf Maples, M.D. (n.d.). aspx?pageid=35959&id=67427&terms=jail+diversion Continuity ofCare Task Force report. Retrieved fromhttp://www.dshs.state.tx.us/layouts/contentpage. Texas DepartmentofStateHealth Services GEER/Government%20Effectiveness%20and%20Efficiency%20Report%202012.pdf Selected Issues andRecommendations.Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/ Texas Legislative Budg Report. Page 7. Retrieved fromhttp://hogg.utexas.edu/project/evaluation-outpatient-competency-restoration Hogg Foundation forM Report. Page 11.Retrieved fromhttp://hogg.utexas.edu/project/evaluation-outpatient-competency-restoration Hogg Foundation forM Johnson, N. R.,&Candilis based+restoration+of+competency from http://www.dshs.state.tx.us/layouts/contentpage.aspx?pageid=35959&id=8589979768&terms=jail- Texas DepartmentofStateHealth Services Policy &Law 22(3),293-305.Retrieved fromhttp://psycnet.apa.org/journals/law/22/3/293/ wrong places:Outpatientcompetencyrestoration asapromising approach tomodernproblems. Psychology, Public Gowensmith, N., Go An-Overview.doc Retrieved fromhttp://www.dshs.texas.gov/mhsa/awareness/Outpatient-Competency-Restoration-Programs-- Texas DepartmentofStateHealth Services from https://www.sunset.texas.gov/public/uploads/files/reports/DSHS%20Staff%20Report_1.pdf Texas Sunset A SB1507/2015-12MeetingFiles/1507_HospCapac_Hopkins_20151217.pdf Access andF Hopkins, L.(December15, 2015). DSHS HospitalCapacity:Presentation toSB1507Joint Committee on Texas DepartmentofStateHealth Services Texas DepartmentofStateHealth Services www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf the UnitedStates:Resultsfrom the2014NationalSurvey onDrugUse andHealth.Page 23. Retrieved fromhttp:// www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf the UnitedStates:Resultsfrom the2014NationalSurvey onDrugUse andHealth.Page 32.Retrieved fromhttp:// trial-010312.pdf. LegislativeAnalyst’s Office. Retrieved from http://www.lao.ca.gov/reports/2012/hlth/ist/incompetent-stand- Policy &Law 22(3),293-305.Retrieved fromhttp://psycnet.apa.org/journals/law/22/3/293/ . wrong places:Outpatientcompetencyrestoration asapromising approach tomodernproblems. Psychology, Public 228.pdf of psychiatry, 5(2), 228. Retrieved fromhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4473494/pdf/WJP-5- , M.(Jan. 3, 2012). AnAlternativeApproach: Treating theIncompetenttoStand Trial.California Page 22.Retrieved fromhttp://hogg.utexas.edu/project/evaluation-outpatient-competency-restoration July 14, 2014). DSHSProgramSpecialist. Personal communication. orensic Services[PowerPoint slides].Slide7. Retrieved fromhttps://www.dshs.texas.gov/mhsa/ . &LacefieldLewis, L., Texas DepartmentofState Health Services. (February 18, 2016). dvisory Commission.(May 2014). DepartmentofStateHealthServices:StaffReport.Retrieved 4. wensmith, W.N., Frost, L.E.,Speelman,D. &Therson,D. bedsinallthe (2016). Lookin’for wensmith, W.N., Frost, L.E.,Speelman,D. &Therson,D. bedsinallthe (2016). Lookin’for Presentation: Overview ofthementalhealthsystem [PowerPoint Slides].Retrieved from et Board.(January 2013). Texas StateGov andEfficiencyReport: ernment Effectiveness et Board.(January 2013). Texas StateGovernment andEfficiencyReport: Effectiveness ental Health. (July 2015). Texas OutpatientCompetency Restoration Programs: Evaluation ental Health. (July 2015). Texas OutpatientCompetency Restoration Programs: ental Health. (2015). Texas OutpatientCompetency Restoration Programs: Evaluation ental Health. (2015). Texas OutpatientCompetency Restoration Programs: Evaluation ental Health (September ServicesAdministration. 2015). Behavioral HealthTrends in ental Health (September ServicesAdministration. 2015). Behavioral HealthTrends in , P. J. (2015). Outpatientcompetencerestoration: Amodelandoutcomes. World journal , (2013). Jail-Based Competency Restoration Workgroup. Retrieved . (2014). OutpatientCompetency Restoration Programs: AnOverview. . (2016). Recovery Suppor t ServicesPilotProject. Retrieved from . (September 2013). DSHS SunsetSelf-Evaluation. Retrieved Report . (2010). MentalHealthandSubstanceAbuseDivision vioral Health CoordinatingCouncil.(May HHSC 207 Retrieved from http://www.dshs.state.tx.us/ from Retrieved Evaluation Methodology Report for Cost Report for Methodology Cost 15). Evaluation Methodology Report for Cost 15). Evaluation Texas Recovery Initiative: Substance abuse service Initiative: Recovery Texas Retrieved Retrieved provisions. 13). Substance abuse additional general Combined Substance Abuse Block Grant Substance Abuse Block Grant FY2014-2015 Combined Texas . (2013). Behavioral health data book, FY 2015, fourth health data book, Behavioral . (2016). from http://www.dshs. Retrieved Initiative. Recovery Texas . (2016). from Retrieved (ROSC). of Care Systems Recovery-Oriented . (2016). Combined Substance Abuse Block Grant Substance Abuse Block Grant Combined FY2014-2015 Texas . (2013). Texas FY2014-2015 Combined Substance Abuse Block Grant Substance Abuse Block Grant Combined FY2014-2015 Texas . (2013). Presentation to Senate Health and Human Services to Senate Health and Presentation 2014). 14, . (August Retrieved from Sheet. Retrieved Fact Disorders: 13). Substance-Related and Addictive . Retrieved from . Retrieved drug abuse and mental illness in brief: Comorbid 11). Topics Retrieved from http://www.legis.state.tx.us/billlookup/ Senate Bill 421. Retrieved State of Texas Health and Human Services Commission Department of Health and Human Services Commission State of Texas State of Texas Health and Human Services Commission Department of Department Services Commission Health and Human State of Texas . Retrieved from . Retrieved of care The impact of system children: forA better future Texas Retrieved from http://www.txsystemofcare. Retrieved Communities. of Care 16). Map of System from http://www. Retrieved in Texas. Framework of Care the System 15). Expanding Behavioral Health Trends in Health Trends Behavioral 2015). Services Administration. (September ental Health Texas 84th Legislative Session Summary for Session Legislative Mental Health-Related 84th Texas (2015). ental Health. A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation . & Lacefield Lewis, L. (February 18, 2016). Presentation to the Select Committee on Mental Mental on Select Committee to the Presentation 2016). 18, L. (February Lewis, . & Lacefield The intersect of health reform and systems of care for with and youth of care children of health reform and systems The intersect (2011). . & Stroul, B. Texas Department of State Health Services Department of State Health Texas of Care. (20 System Texas org/texas-system-of-care-map/ of Care. (20 System Texas Texas Legislature Online. (2013). Legislature Online. (2013). Texas J Wotring, mental health and substance abuse conditions and their families (Issue Brief) DC: Georgetown . Washington, Mental for Children’s Center & National Technical Development Center for Child and Human University Health. Plan. Retrieved and Intended Use Health Assessment (MHBG) Behavioral (SABG) and Mental Health Block Grant from http://www.dshs.state.tx.us/WorkArea/DownloadAsset.aspx?id=8589979883 Texas Department of State Health Services (2008). Department of State Health Texas Services Department of State Health Texas Services Department of State Health Texas of Care. (n.d.). System Texas History.aspx?LegSess=83R&Bill=SB421 https://www.drugabuse.gov/publications/drugfacts/comorbidity-addiction-other-mental-disorders (2013). Public Consulting Group. Services Department of State Health Texas from http://www.dshs.texas.gov/WorkArea/linkit. Retrieved slides]. Slide 60. quarter [PowerPoint aspx?LinkIdentifier=id&ItemID=8590002694 from http://www.dshs.state.tx.us/sa/texasrecoveryinitiative/PDFs/TRI_DraftReview_ Retrieved redesign. November2008.pdf texas.gov/sa/texasrecoveryinitiative/ http://www.dshs.texas.gov/substance-abuse/ROSC/ http://www.txsystemofcare.org/wp-content/uploads/2013/02/TXSOC_outcomes.pdf Texas Department of State Health Services Department of State Health Texas and M Abuse Substance from http://www. and Health. Retrieved on Drug Use the 2014 National Survey the United States, Results from samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf (20 Drug Abuse. on National Institute Effectiveness of Substance Use Disorder: House Bill 1, General Appropriations Act, Article II, Health and Human Appropriations House Bill 1, General Use Disorder: Effectiveness of Substance https://hhs.texas.gov/sites/hhs/files//rider44-evaluation- from Rider 44. Retrieved Services Commission, methodology-for-substance-use-disorder-cost-effectiveness.pdf and Human Act, Article II, Health Appropriations House Bill 1, General Use Disorder: Effectiveness of Substance from https://hhs.texas.gov/sites/hhs/files//rider44-evaluation- Rider 44. Retrieved Services Commission, methodology-for-substance-use-disorder-cost-effectiveness.pdf Services (20 Department of State Health Texas from https://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589967362 Association. (20 American Psychiatric http://www.dsm5.org/documents/substance%20use%20disorder%20fact%20sheet.pdf Plan. Retrieved and Intended Use Health Assessment (MHBG) Behavioral (SABG) and Mental Health Block Grant from http://www.dshs.state.tx.us/WorkArea/DownloadAsset.aspx?id=8589979883 from http://www. . Retrieved health system public behavioral of the Texas State Health Services: Analysis publicconsultinggroup.com/client/txdshs/documents/Analysis%20of%20the%20Texas%20Public%20 Behavioral%20Health%20System.pdf Ibid. Services Department of State Health Texas 20 and Human Services Commission. (December Health Texas WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589990636 for M Foundation Hogg http://hogg.utexas.edu/wp-content/uploads/2015/11/Legislative-Summary_ from Legislation. Retrieved Final_2015.docx Commission. (December 20 and Human Services Health Texas Plan. Retrieved and Intended Use Health Assessment (MHBG) Behavioral (SABG) and Mental Health Block Grant from http://www.dshs.state.tx.us/WorkArea/DownloadAsset.aspx?id=8589979883 Texas Department of State Health Services of State Health Department Texas (2013). Group. Public Consulting http://dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590005709 http://dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590005709 J Hellerstedt, and Substance Abuse Services. Mental Health Overview Committee: from http://www. . Retrieved health system public behavioral of the Texas State Health Services: Analysis publicconsultinggroup.com/client/txdshs/documents/Analysis%20of%20the%20Texas%20Public%20 Behavioral%20Health%20System.pdf Behavioral Health System [PowerPoint Slides]. Texas Department of State Health Services. Retrieved Services. Retrieved Health of State Department Texas Slides]. [PowerPoint System Health The Behavioral Health: http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e-9eba- from 67b14f00ad22.PDF

347 345 346 344 337 339 340 341 342 343 336 329 332 333 334 335 338 330 326 328 331 324 327 325 208

HHSC 372 367 366 364 362 361 360 359 358 357 356 355 354 353 352 351 350 349 348 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 375 374 373 371 370 369 368 365 363

html https://www.dads.state.tx.us/news_info/publications/planning/stateplanonaging/2015-2017/attachmentd. Texas DepartmentofAgingandDisability Services Simonoff, E.,Pickles, A. C., Chandler Honey, A.,Emerson,E.,Llewellyn,G.,&K Substance Abuse andM Tomasulo, D experiences across span.TheJournal ofNervous thelife andMental Disease,197(3),182-186. health inadultswithmildandmoderate intellectualdisabilities:therole events andtraumatic ofrecent life Martorel, A.,Tsakanik Ibid. Keesler, J Ibid. Friedman, C., Lulinski,A.,&Rizzolo 16(1), 50–65. Retrieved from10.1080/15487768.2013.762306 in comorbid intellectualdisabilityandpsychosis: Acasestudy.AmericanJournal ofPsychiatric Rehabilitation, Allott, K.A.,F pubmed/25621184 Innovations inClinicalNeuroscience,11(11-12), 22–26. Retrieved fromhttp://www.ncbi.nlm.nih.gov/ Comorbidities inPersons withIntellectual/Developmental Disabilities:AnInitialProspective Analysis. Gentile, J. P., Gillig,P articles/PMC2710105/ mental illness/intellectualdisability. Psychiatry, 5, 49-57. Retrieved fromhttp://www.ncbi.nlm.nih.gov/pmc/ Gentile, J. &Jackson, C Disabilities. IntellectualandDevelopmental Disabilities, 53(4),257-270. and Community-Based Services1915(c)Waiv Friedman, C., Lulinski,A.,&Rizzolo Journal ofMentalHealthResearch inIntellectualDisabilities,6(2),74-105. Charlot, L.&Beasley, J Ibid. Disabilities. IntellectualandDevelopmental Disabilities 53(4),257-270. and Community-Based Services1915(c)Waiver People withIntellectualandDevelopmental Allocationfor Friedman, C., Lulinski,A.,&Rizzolo Ibid. of%20Trauma-Informed%20Care%20Among%20I%20DD%20Organizations.pdf from http://mha.ohio.gov/Portals/0/assets/Initiatives/TIC/Disabilities/A%20Call%20for%20Integration%20 Disability Organizations. Journal ofPolicy andPracticeinIntellectualDisabilities, 11: 34–42.Retrieved Keesler, J 16(1), 50–65. Retrieved from10.1080/15487768.2013.762306 in comorbid intellectualdisabilityandpsychosis: Acasestudy.AmericanJournal ofPsychiatric Rehabilitation, Allott, K.A.,F Innovations inClinicalNeuroscience,11(11-12), 22–26. Comorbidities inPersons withIntellectual/Developmental Disabilities:AnInitialProspective Analysis. Gentile, J. P., Gillig,P Disabilities. IntellectualandDevelopmental Disabilities, 53(4),257-270. and Community-Based Services1915(c)Waiver People withIntellectualandDevelopmental Allocationfor Friedman, C., Lulinski,A.,&Rizzolo Ibid. pdf Texas. Retrievedhttp://www.txsystemofcare.org/wp-content/uploads/2014/01/SOC-survey-report-final. from Texas System ofCare.(F txsystemofcare.org/wp-content/uploads/2012/05/Expansion-Model.pdf Administration onAging. (20 Administration Ibid. Ibid. Ibid. Journal Psychiatry, oftheAmericanAcademy ofChildandAdolescent 47, 921-929. autism spectrumdisorders: prevalence, comorbidity, andassociated factors inapopulation-derived sample. ofRehabilitation.RetrievedEncyclopedia fromhttp ://cirrie.buffalo.edu/encyclopedia/en/article/305/ and-assessment/PhysicalandCognitiveDisabilitiesQuickFacts.pdf Physical andcognitive disabilities. Retrieved fromhttp://media.samhsa.gov/co-occurring/topics/screening- Intellectual Disabilities, 18, 337-350. of%20Trauma-Informed%20Care%20Among%20I%20DD%20Organizations.pdf from http://mha.ohio.gov/Portals/0/assets/Initiatives/TIC/Disabilities/A%20Call%20for%20Integration%20 Disability Organizations. Journal ofPolicy andPracticeinIntellectualDisabilities, 11: 34–42.Retrieved Intellectual andDevelopmental Disabilities, 53(4),257-270. Community-Based Services1915(c)Waiver People withIntellectualandDevelopmental Disabilities. Allocationfor . M.(2014). theIntegration ACallfor ofTrauma-Informed Care AmongIntellectualandDevelopmental . M.(2014). theIntegration ACallfor ofTrauma-Informed Care AmongIntellectualandDevelopmental .J. (2014). Positive group psychotherapyfor adultswithintellectualdisabilities . Journal of modified rancey, S. M.,&Velligan, D. I.(2013). Improving functionaloutcomeusingcompensatorystrategies rancey, S. M.,&Velligan, D. I.(2013). Improving functionaloutcomeusingcompensatorystrategies . M.,Stinson,K.,&Jensen, J. (2014). Toward ImpactingMedicalandPsychiatric . M.,Stinson,K.,&Jensen, J. (2014). Toward ImpactingMedicalandPsychiatric os, E.,Pereda, A.,Gutierrez-Recacha, P., Bouras, N., &Ayuso-Mateo, J. L.(2009). Mental . (2013). IntellectualDisabilitiesandMentalHealth:UnitedStates-BasedResearch. .S. (2008).Supportive psychotherapy withthedualdiagnosispatient:co-occurring ental Health (n.d.).Co-occurring ServicesAdministration. disorder-related quickfacts: ebruary 2016). Current stateofchildservingsystem interagency collaboration across 12). Policy AcademyState Profile – Texas’ Population. Retrieved fromhttp://www. , M.C. (August 2015). Mental/Behavioral HealthServices:MedicaidHome , M.C. (August 2015). Mental/Behavioral HealthServices:MedicaidHome , M.C. (August 2015). Mental/Behavioral HealthServices:MedicaidHome , M.C. (2015 ). Mental/Behavioral HealthServices:MedicaidHomeand , S., Loucas, T., &Baird,G.(2008).Psychiatric disorders inchildren with ariku, M.(2012). Mentalhealthanddisability.International er Allocation for People withIntellectualandDevelopmental er Allocationfor . (2015). StatePlanonAging2015-2017 . Retrieved from

HHSC 209 https://hhs.texas.gov/ omoting Independence Advisory http://www.hhsc. from Rates. Retrieved Retrieved from https://www.dads. Retrieved summary. legislative th Diversion protocol: Targeted Home and Targeted protocol: Diversion . (2013). Local Intellectual and Developmental Disability Local Intellectual and Developmental . (2016). and Human Services on Health Senate Committee . (2015). Preadmission Screening and Resident Review . (2014). tember 2016). Intermediate Care Facilities for Individuals Intermediate Care Facilities tember 2016). 15). 84 High Level Summary of DADS Budget for Fiscal Years 2016- Years Budget for Fiscal of DADS Summary 15). High Level rt for Austin State Supported Living Center. rt for repo 15). Monitoring Austin State Supported Living Center. https://www. from Retrieved 15). Compliance Reports – SSLCs. ed from http://www.txsilc.org/assets/files/FY17-19%20 . Retrieved from Living Services. Retrieved Independent ging and Disability Services Staff Report with Final Results. ging and Disability Services Staff Report with . (n.d.). ). Plan for the Transfer of Vocational Rehabilitation Services and Other 15). Plan for of Vocational the Transfer Retrieved from https://hhs.texas.gov/ . (n.d.) Independent Living Services. Retrieved Retrieved from http://www.nimh. from Retrieved Mental Health. Adults and (n.d.) Older ealth. Page 37. 37. Annual Report 2015. Page (2016). Services. e and Rehabilitative Rehabilitation Services Comprehensive (2016). Services. e and Rehabilitative 42. Annual Report 2015. Page (2016). Services. e and Rehabilitative Page. 25. 25. Annual Report 2015. Page. (2016). Services. e and Rehabilitative Department of Aging and Disability Services Staff Report with Final Results. with Services Staff Report of Aging and Disability Department Retrieved from https://www.dads.state.tx.us/news_info/ Retrieved Regular Session. Legislature, th A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation -46. -46. . . Texas Health and Human Services Health Texas

Retrieved from http://www.dars.state.tx.us/drs/crs.shtml Retrieved Program. services/disability/independent-living-services from http://www.twc.state.tx.us/files/news/dars-transition-plan-twc. Retrieved 3. . Page Services and Programs pdf 40 Ibid., Page 42. Ibid., Page Department of Assistiv Texas Ibid. Department of Assistiv Texas Texas Health and Human Services Health Texas services/disability/independent-living-services Ibid. Ibid. Department of Assistiv Texas Texas Department of Assistiv Texas 46 Ibid., Page Ibid. State Plan for Independent Living. Retriev Texas Texas%20State%20Plan%20for%20Independent%20Living%20FINAL%20Submitted%2006-30-16.pdf Commission. (20 Workforce Texas Department of Aging and Disability Services. (20 Services. Disability Department of Aging and publications/legislative/84thlegislature-hb1.pdf (2015). Commission. Sunset from https://www.sunset.texas.gov/public/uploads/files/reports/DADS%20Staff%20 36h. Retrieved Page Report%20with%20Final%20Results.pdf Ibid. Ibid. (20 Services. of Aging and Disability Department aoa.gov/AoA_Programs/HPW/Behavioral/docs2/Texas.pdf H of Mental Institute National nih.gov/health/topics/older-adults-and-mental-health/index.shtml Bill 1-84 House 2017, http://www.dads.state.tx.us/providers/pi/piac/4-21-16-reports.pdf http://www.dads.state.tx.us/providers/pi/piac/4-21-16-reports.pdf from Retrieved Committee. state.tx.us/Rad/long-term-svcs/downloads/2015-09-icf-rates.pdf for State to a slots protocol individuals at imminent risk of admission Services (CBS) waiver Community-based https://www.dads.state.tx.us/handbooks/lidda/res/SSLC_ from (SSLC). Retrieved Supported Living Center Diversion_09-12-14.pdf https://www.sunset.texas.gov/public/uploads/files/reports/DADS%20Staff%20Report%20 from Retrieved with%20Final%20Results.pdf https://www.dads.state.tx.us/monitors/reports/austin-6-19-15.pdf from Retrieved (20 Services. Department of Aging and Disability dads.state.tx.us/monitors/reports/ Services Department of Aging and Disability Texas Health and Human Services Commission. (2015). ICF Enhancement Commission. (2015). and Human Services Health Ibid. (20 Services. Department of Aging and Disability 41 Ibid, Pages state.tx.us/news_info/publications/legislative/84thlegislativesummary.pdf from http://www.dads.state.tx.us/providers/la/index.cfm Retrieved Authority. https://www.dads.state. from Retrieved Presentation. and Disability Services. Powerpoint – Department of Aging tx.us/news_info/presentations/senatehhs-2-4-15.pdf http://www.dads.state.tx.us/providers/pasrr/index.cfm from Retrieved (PASRR). Ibid. (Sep Services. Department of Aging and Disability on September 23, Retrieved Resources. Provider (ICF/IID) with an Intellectual Disability or Related Conditions https://www.dads.state.tx.us/providers/icf/search/index.cfm. 2016 from Report to the Pr Commission. (April 2016). and Human Services Health Department of A (2015). Commission. Sunset Texas Department of Aging and Disability Services Department of Aging and Disability Texas Services Department of Aging and Disability Texas Services Department of Aging and Disability Texas Ibid. Ibid. Ibid. Ibid.

410 413 401 403 406 411 412 414 402 407 408 409 404 405 380 381 378 379 376 377 392 394 400 397 Ibid, Page 41. 397 Ibid, Page 398 393 396 399 395 382 387 388 389 390 391 383 384 385 386 210

HHSC 450 449 447 446 444 443 442 440 439 436 434 432 431 430 429 428 427 426 425 424 423 422 421 420 419 418 417 416 415 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 448 445 441 438 437 435 433

transformation-plan.pdf Page 22.Retrieved fromhttps://hhs.texas.gov/sites/hhs/files/documents/about-hhs/transformation/final- Program. Texas DepartmentofAssistiv Ibid. Program. Texas Health andHumanServicesCommission.(20 Autism Speaks. (n.d.) laws-regulations/handbooks/services/autism-program Texas Health andHumanServicesCommission.(20 Ibid. Program. Texas Health andHumanServicesCommission.(20 Legislative Budge tx.us/reports/annual2015/annualreport2015.pdf Texas Health andHumanServices Ibid. Texas DepartmentofAssistiv Centers forDiseaseControlandPrevention. (2016). Ibid., Page 39 Texas DepartmentofAssistiv cost-share Retrieved from https://hhs.texas.gov/services/disability/early-childhood-intervention-services/eci-family- Texas Health andHumanServices Texas DepartmentofAssistiv https://hhs.texas.gov/sites/hhs/files/basic_page/fcs_%20booklet_a.pdf Texas Health andHumanServices Ibid. Ibid. services/disability/early-childhood-intervention-services/eci-services-and-eligibility Texas Health andHumanServices http://ritter.tea.state.tx.us/rules/tac/chapter089/ch089aa.html Texas EducationAgenc services/disability/early-childhood-intervention-services/eci-services-and-eligibility Texas Health andHumanServices handbook services/disability/early-childhood-intervention-services/eci-public-awareness/eci-publications/eci-parent- Texas Health andHumanServices Texas DepartmentofRehabilitative Services ed.gov/explore/view/p/%2Croot%2Cstatute%2CI%2CC%2C U.S. DepartmentofEducation.(n.d.). early/2013/09/24/peds.2013-2305.full.pdf 132(4), 1073-1088. DOI:10.1542/peds.2013-2305. Retrieved fromhttp://pediatrics.aappublications.org/content/ IDEA Part CServices,andtheMedicalHome:Collaboration BestPractice for andBestOutcomes.Pediatrics, Adams, R.C tlodocs/84R/analysis/pdf/HB00039S.pdf#navpanes=0 Senate ResearchCenter. (2015). Retrieved fromhttp://www.dads.state.tx.us/providers/community_options.pdf Texas DepartmentofAgingandDisability Services and%20Disability%20Services%20SER%202013%2084%20Leg.pdf Retrieved fromhttps://www.sunset.texas.gov/public/uploads/files/reports/Department%20of%20Aging%20 Department ofAgingandDisability Services. (20 dads.state.tx.us/services/faqs-fact/guardianship.html Texas DepartmentofAgingandDisability Services transformation-plan.pdf Page 22.Retrieved fromhttps://hhs.texas.gov/sites/hhs/files/documents/about-hhs/transformation/final- Texas Health andHumanServicesCommission.(20 Ibid. Ibid. Olmstead v. L.C Texas Health andHumanServicesCommission. (20 Texas Health andHumanServicesCommission. (20 autism/treatment/applied-behavior-analysis-aba General_Appropriations_Act_2016-2017.pdf Committee ReportonHouseBillNo. 1.Pg IX-55. Retrieved fromhttp://www.lbb.state.tx.us/Documents/GAA/ dars.state.tx.us/autism/index.shtml Retrieved from http://www.cdc.gov/features/new-autism-data/index.html ., Tapia, C., &TheCouncilonChildrenwithDisabilities. (2013, September 30).Early Intervention, . ., 527U.S. 581(1999). t Board.(2015). General the2016-17Biennium,Text Appropriations Actfor ofConference Applied BehaviorAnalysis Retrieved (ABA). fromhttps://www.autismspeaks.org/what- y Chapter 89. forSpecialPopulations, Adaptations §89.1040 Retrieved (2007). from e andRehabilitative Services. (2016). AnnualReport2015.Page 36. e andRehabilitative Services. (2016). AutismProgram. Retrieved from http://www. e andRehabilitative Services. (2016). AnnualReport2015.Page 38. e andRehabilitative Services. (2016). AnnualReport2015.Page 38. CSHB 39BillAnalysis. Retrievedhttp://www.capitol.state.tx.us/ from . (2016). AnnualReport2015.Page 36. Retrieved from http://www.dars.state. . (n.d.)Family Cost Share – Paying Early for ChildhoodIntervention Services. . (n.d.).Paying Early for ChildhoodIntervention Services.Retrieved from . (n.d.).ECIServicesandEligibility. Retrieved from https://hhs.texas.gov/ . (n.d.).ECIServicesandEligibility. Retrieved from https://hhs.texas.gov/ . (n.d.).ECIParent Handbook.Retrieved fromhttps://stg.hhsc.texas.gov/ Part andtoddlers C–Infants withdisabilities.Retrieved fromhttp://idea. . (2016). DARS AnnualReport. 13). Self-evaluation report submitted totheSunsetCommission. . (2015). Access andintake servicescommunityoptionsbooklet. . (2015). Guardianship Program.Retrieved fromhttps://www. 16). HealthandHumanServicesSystem Transition Plan. 16, August 29). Personal communication: Children’s Autism 16, August 29). Personal communication:Children’s Autism 16). AutismProgram. Retrieved fromhttps://hhs.texas.gov/ 16, August 29). Personal communication:Children’s Autism 16). HealthandHumanServicesSystem Transition Plan. New DataonAutism:Five ImportantFacts toKnow. HHSC 211 16, July 18). Personal Communication: Money Follows the Follows Money Communication: 18). Personal July 16, and Medicaid communication: Texas 16). Personal . (FQHCs)? health centers qualified federally 16). What are ealth Resources and Service Administration. (2016). 2014 and Service Administration.ealth Resources (2016). ealth Resources and Service Administration. (2016). and Service Administration.ealth Resources (2016). Accreditation update. Accreditation Care. (2014). Health tration, Bureau of Primary . (2016). Personal communication. Personal . (2016). Retrieved from https://www. Retrieved Under Social Security. Disability Evaluation SSI Federal Payment Amounts for from https://www.ssa. 2016. Retrieved Payment 16). SSI Federal from https://www.ssa.gov/pubs/EN-05- Retrieved 15). The Appeals Process. 15). Annual Statistical Report on the Social Security Disability Insurance 15). Annual Statistical Report on the Social Security Disability Insurance 2016 Red Book – Example of Concurrent Benefits with Employment Benefits with Employment of Concurrent 16). 2016 Red Book – Example from https://www. 4. Retrieved 15). Social Security Disability Benefits. Page 15). Annual Statistical Report on the Social Security Disability Insurance – 2016 (SSI) Overview Supplemental Security Income 16). Understanding Texas Medicaid and CHIP Health Insurance Premium Payment Payment Premium Medicaid and CHIP Health Insurance Texas . (2016). from . Retrieved Medicaid and CHIP Claims/Enrollment Texas . (2016). https://hhs.texas.gov/ from . Retrieved Medicaid Buy-In Program . (2016). from https://hhs.texas.gov/ Medicaid Buy-in for. Retrieved . (2016). Children Payment Premium CHIP Health Insurance Medicaid and Texas . (2016). from http://gethipptexas.com/providers/ . Retrieved Providers . (2016). Page 20. Annual Report 2015. Page (2016). Services. e and Rehabilitative Page 20. Page Annual Report 2015. (2016). Services. e and Rehabilitative . Retrieved from fromhttp://texasable.org/ Act. Retrieved ABLE Texas Presentation to the Senate Committee on Veterans’ Affairs and Military Affairs on Veterans’ Committee to the Senate Presentation (2016). , S. A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 4. Ibid. Department of Assistiv Texas Social Security Administration. (20 Social Security Administration. (n.d.). gov/OACT/cola/SSI.html Ibid. Social Security Administration. (20 10041.pdf Social Security Administration. (20 from https://www.ssa.gov/policy/ Applications. Retrieved Outcome of Disabled-Worker 2014. Final Program, docs/statcomps/di_asr/2014/sect04.html#table60 Table 11.A. from https://www.ssa.gov/policy/ Status, Retrieved 2014. Beneficiaries in Current-Payment Program, docs/statcomps/di_asr/2014/sect01b.html#table11.a Ibid., Page 1 Ibid., Page Social Security Administration. (20 Social Security Administration. (20 Ibid. Social Security Administration. (20 Ibid. Social Security Administration. (20 from https://www.ssa.gov/redbook/eng/supportsexample.htm Supports. Retrieved Social Security Administration. (20 ssa.gov/pubs/EN-05-10029.pdf Ibid. Ibid. Table 11.A. from https://www.ssa.gov/policy/ Status, Retrieved 2014. Beneficiaries in Current-Payment Program, docs/statcomps/di_asr/2014/sect01b.html#table11.a from https://www.ssa.gov/ssi/text-over-ussi.htm Edition. Retrieved Texas Department of State Health Services Department of State Health Texas Ibid. Ibid. & Gaines S.G. Hupp, from https://hhs.texas.gov/ presentation]. Retrieved [PowerPoint services & initiatives Installations: veteran sites/hhs/files//031016-vami-senate.pdf Ibid. Department of Assistiv Texas Texas Health and Human Services Commission. (20 Health Texas and Human Services Health Texas Texas Health and Human Services Health Texas Ibid. and Human Services Health Texas and Human Services Health Texas and Human Services Health Texas from https://hhs.texas.gov/services/financial/insurance/health-insurance-premium- . Retrieved Program payment-hipp https://hhs.texas.gov/services/health/medicaid-and-chip/provider-information/texas-medicaid-and-chip- claimsenrollment Person Program. Person from http://bphc.hrsa.gov/uds/datacenter. Retrieved Data [online table]. Comparison Grantee Program aspx?year=2014&state=TX&compare=Nat (20 and Human Services. US Department of Health from http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Introduction/qualified.html Retrieved Resources and Services AdminisUS Health from http://bphc.hrsa.gov/policiesregulations/policies/transcriptstandardsandaccredidation.PDF Retrieved and Human Services Health Texas Partnership. Healthcare Ibid. ABLE. (2015). Texas H Services, and Human of Health US Department H Services, and Human of Health US Department services/health/medicaid-and-chip/programs/medicaid-buy-adults services/health/medicaid-and-chip/programs/medicaid-buy-children from http://www.hhsc.state.tx.us/medicaid/hipp/ . Retrieved Program Olmstead v. L.C., 527 U.S. 581 (1999). 581 527 U.S. L.C., v. Olmstead (20 Commission. Services and Human Health Texas from https:// and zip file]. Retrieved format Sites Data [text Look-Alike and Service Delivery Health Center datawarehouse.hrsa.gov/topics/hccsites.aspx

487 488 483 484 485 486 489 482 474 475 476 477 478 479 480 481 469 470 471 472 473 468 462 465 467 453 457 458 459 464 466 454 455 460 461 463 451 452 456 212

HHSC 492 491 490 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

transformation-plan.pdf Page 22.Retrieved fromhttps://hhs.texas.gov/sites/hhs/files/documents/about-hhs/transformation/final- Texas Health andHumanServicesCommission.(20 Edition. Retrieved fromhttps://www.ssa.gov/ssi/text-over-ussi.htm (20 Social SecurityAdministration. www.ssa.gov/pubs/EN-05-10029.pdf (20 Social SecurityAdministration. ssa.gov/disability/professionals/bluebook/12.00-MentalDisorders-Adult.htm 16). Understanding SupplementalSecurityIncome(SSI)Overview –2016 15). SocialSecurityDisabilityBenefits.Pages 5-11. Retrieved fromhttps:// 16). HealthandHumanServicesSystem Transition Plan. DSHS 213 219 219 220 213 216 216 217 217 217 215 217 , 2016 , st

rts

Cha l and Costs and a

State Hospitals: Utilization and Costs and Utilization Hospitals: State

alth Hospital Services Hospital alth Non-Maximum Security Placements Security Non-Maximum tion Inpatient Services and the Admissions Process Admissions the and Services Inpatient A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation a Care Measures Care Commitments niz Inpatient Settings Inpatient State Hospitals State Utilization Services: Crisis Civil Commitments Civil Forensic vs. Maximum ofQuality a Introduction to Introduction at Services Inpatient Organizational Charts Organizational rg Inpatient Mental He Inpatient of Types . Page 21. 21. Page Plan. Transition and Human Services System Health 2016). (July and Human Services Commission. Health Texas Source: http://www.hhsc.state.tx.us/hhs-transformation/docs/Transformation-Plan-Update.pdf from Retrieved Figure 80. Organizational Structure of DSHS as of Structure September 1 Organizational 80. Figure O At a Glance State Health Services Health State of Services Health Department State Texas Texas Department of Department Texas Figure 81. DSHS organizational structure After September 1, 2017 (Post-Transformation)

Source: Texas Health and Human Services Commission. (July 2016). Health and Human Services System Transition Plan. Page 21. Retrieved from http://www.hhsc.state.tx.us/hhs-transformation/docs/Transformation-Plan-Update.pdf

214 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas DSHS 215 2

1 competency to stand trial. to stand competency and review of past diagnoses and treatment history; of past and review e treatment during acute episodes during which a person’s mental which a person’s during acute episodes e treatment during A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation stabilize, discontinue, or begin new medications; begin new discontinue, or stabilize, services transferred to HHSC on September 1st, 2016. However, However, 2016. community services transferred to HHSC 1st, on September Adjust, intensiv Provide worsens; and/or, health mental a person’s Assess or restore Provide accurate diagnosis Provide

· · · Inpatient mental health services are provided by state, community, and private community, state, by Inpatient mental health services are provided crisis due psychiatric and adults experiencing a hospitals to children, adolescents, for a period of time so be necessary may Inpatient hospitalization to mental illness. that individuals can be closely monitored to: · Inpatient Mental Health Hospital Services Hospital Health Mental Inpatient Important Note: Inpatient Mental Health Hospital Services Hospital Health Inpatient Mental Important Note: SB 200 (84th, Nelson/Price), DSHS, directed by As a result of the HHS transformation has been undergoing reorganizations that massive along with the entire HHS System and substance health guide. Mental as of the writing of this are only partially complete use supported living hospitals and the state and operated psychiatric owned the state In order for this guide to provide 2017. 1st, transfer until September centers do not as clearly and concisely as use services substance information on mental health and are included in this section and in the hospital services possible, information on state section. Services tab under the HHS System Health Behavioral State Health Services Health State has been the Services (DSHS) Department of State Health the Texas Since 2003, the Mental Within DSHS, for Texas. use authority mental health and substance state the public has overseen Services Division (MHSA) Abuse and Substance Health health services behavioral DSHS provided system. delivery health service behavioral with a wide range use services) to individuals of and substance (i.e. mental health are adults in Texas that roughly 1 million It is estimated needs. mental health service children are living with Texas mental illness (SMI) and 519,368 living with serious (SED). disturbance serious emotional Texas Department of Department Texas DSHS 216 while heorshewait fortheir finalmentalhealthhearing. whether theindividual shouldstay atamentalhealth facilityorinthecommunity hours oftheinitialdetainment, aprobablecausehearing must beheldtodetermine actively seekinginpatienttreatment. Voluntary civil commitmentscanalsobeinitiatediftheperson needinghelpis Admissions custody (OPC) should be issued and the emergency detentioncustody extended. (OPC)shouldbeissuedandtheemergency (within 24 hours)andmake anassessmentaboutwhether anorderofprotective detention, inwhichtimeadoctormust48-hour emergency visitwiththeindividual transported toamentalhealthfacility, theinitialcivilcommitmentisonlyvalidfora Once amentalhealthwarrant has beengrantedandtheindividualhas services orderedby thetreatingphysician. nursing services, socialservices, therapeuticactivities, andany other psychological treatment asresidentialcareprovided inahospitalthatincludesmedicalservices, Chapter 411oftheTexas Administrative Codedefinesinpatientmentalhealth has lessacuteneedsandonlyrequirescoordinatedalternative services.3 Additionally, ahospitalphysician canmake areferraltothelocalLMHAifperson psychiatric conditionappropriateforadmissiontothestateemergency hospital. for inpatientservices, ahospitalphysician candetermine ifthepersonhasan provider oflast resort.WhentheLMHAhasnot screenedandreferredtheindividual setting available, withthevery restrictive setting ofastate hospitalconsideredthe for inpatientpsychiatric services, theLMHAdecidesonleast restrictive treatment services arerequired.Ifthescreeningandassessmentdetermine thatthereisaneed all individualsseekingmentalhealthservicestodetermine ifinpatientpsychiatric agreementwithapartneringLMHAthatrequiresthetoscreen management providing inpatientmentalhealthtreatment.Eachstate hospitalhasautilization this continuumofcare,thestate hospitals’primarypurposeistostabilize peopleby continuity ofcareinmeeting aperson’s needformentalhealthservices. Within As discussedearlier, DSHSdesignatesLMHAsasresponsibleforachieving I Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas present asubstantial andimminentriskofseriousharmtothemselves orothers. detained by apeaceofficer becauseheorshehas symptoms ofmentalillnessthat Civil commitmentstostate hospitalsoccurwhenanindividualisinvoluntarily CIVIL COMMITMENTS individual needsamaximumsecurityornon-maximumplacement. two typesofcommitments, anadministrative decisionismadeastowhether an comprehensive inpatientmentalhealthservices:civilandforensic.Withinthese There aretwotypesofinpatientcommitmentsinwhich individualsareprovided courts andlaw enforcement,suicidesafety planning. planninganddischarge interviews, structured therapeuticprogramming, collaborationwithappropriate of protective custody or90-day court-ordered mentalhealthservice stays (which detentions canextendfinal mentalhealthhearing, emergency to30-day orders individuals inthepatient’s life(e.g.family, friends, coworkers). health hearing,thecourt takes testimony frommedicalexperts, thepatient,and ntroduction to P rocess I np a 6 tient 4 Specificservicesincludediagnostic S ervices 9 Duringthefinalmental 10 a Following the nd t 7,8 h Within72 e 5

DSHS 217 In 11 13 Transitional programs for forensic commitments 16 felony offense involving an act, threat, or attempt of serious threat, or attempt an act, involving offense felony determined by professionals to be manifestly dangerous to to be manifestly professionals by determined In regards to the method of bed appropriation in inpatient In regards to the method 17 e been determined to be Not Guilty by Reason of Insanity (NGRI) Reason of Insanity by Guilty be Not to e been determined e been admitted to a hospital by judicial order because they have because they have order judicial by to a hospital e been admitted 14 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 12 MSUs are more expensive to operate than traditional state hospital units traditional state to operate than MSUs are more expensive 15 Civilly committed and committed Civilly or others, self and/or Chargedwith a violent Individuals hav Individuals the exceeding time not for a period of hospital a state to ordered and were committed. the crime they length of sentence maximum Individuals hav Individuals bodily injury. been determined Incompetent to Stand Trial (IST) and are in need of competency competency of Trial (IST) and are in need to Stand Incompetent determined been with legal counsel and consult can better so that they services restoration or them, the charges against understand

a small number of cases in which minimal improvement is seen in the first 60 days 60 days first is seen in the improvement which minimal of cases in a small number an extended request may treating physician individual’s treatment, an of inpatient subject but individuals up to 12 months, commitment for health commit civil mental before a jury rather their case heard have are entitled to commitments to extended than a judge. STATE HOSPITALS STATE mental of the nine state oversight Division provides Services The State Hospital treatment facility for youth (the residential health hospitals and one psychiatric Types of Settings Inpatient Types · imminent threat of harm or use of a deadly serious bodily injury, All cases involving evaluation unit (MSU) for an initial 30-day weapon are sent to a maximum security period. MAXIMUM VS. NON-MAXIMUM SECURITY PLACEMENTS NON-MAXIMUM SECURITY VS. MAXIMUM individuals who are: placed in maximum security commitments include Patients · FORENSIC COMMITMENTS go to either hospital in Texas to a state are forensically committed Individuals who this type Hospital; State Texas Campus of North or the Vernon Rusk State Hospital for two reasons: of commitment happens · · the court can then extend by three month increments if the treating physician has has physician the treating if increments month three by then extend can the court the community). to to return safe and stabilized not is the individual determined settings, only transitional forensic programs and forensic maximum security beds are settings, psychiatric for those populations; all other designated as forensic beds and reserved basis. serve come, first for either civil or forensic patients on a first beds are available are available for individuals who transfer out of maximum security units after theirare available that they are no longer dangeroustreatment team and a judge manifestly determines or others. to themselves and a statewide shortage of MSU beds has contributed to the increasing waitlists for shortage waitlists and a statewide of MSU beds has contributed to the increasing hospitals. forensic beds in state DSHS 218 inpatient carebutdonot have communityalternatives available. needstateand 116bedsweredesignatedforindividualswho nolonger hospital 2015, 204wereallotted toprovide acuteservicesforchildrenandadolescents adolescents, andadultsinTexas. Ofthe2,463 state-operated psychiatric bedsin total of2,995state psychiatric bedsacrossallbedtypesavailable forchildren, state-operated andstate-funded psychiatric beds. InFY2016, therewere a Figure 83below shows thetotal inpatientbedcapacityinTexas, includingboth inpatient treatment,thosenumberscanbefound inFigure56. include communityandprivatehospitalsthatcontractwithDSHStoprovide psychiatric hospitalfacilitiesin2016; note thatalthoughthischart doesnot Figure 83below shows thetotal numberofbedsateachthestate-operated individuals —25fewerthanin2014. In FY2015, theaverage dailycensusofallstate hospitalsinTexas was 2,238 436e-9eba-67b14f00ad22.PDF System [PowerPoint slides]. Retrieved from Source: Texas State Health Services. Department of (2016). Presentation to Select Committee on Mental Health: The Behavioral Health Figure 82. State MentalHealth Hospitals And Waco Center for Youth: 2016 more percapitathancomparablestates oninpatientpsychiatric services. for residentsoftheirspecific state hospitalservicearea.On average, Texas spends allocation ofstate hospitalresourcestocoordinateinpatientmentalhealthservices Waco CenterforYouth) displayed inFigure82below. EachLMHAreceives an Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4- 19 20

18 DSHS 219 ≥ 20.0% ≥ ≥ 9.8% ≥ ≤ 0.3% ≤ Performance Performance Target Contract 2015 FY Number of Beds 299 200 74 202 640 55 325 302 288 78 2,463 FY 2015 FY 2014 n/a 47.9% 43.6% n/a 17.7% 19.1% 0.43% 0.09% 0.11% n/a 60.7% 74.5% 54.1% FY 2013 Behavioral health data book, FY 2015, fourth quarter [PowerPoint [PowerPoint quarter fourth 2015, FY book, data health Behavioral Bed Type Adults and children Adults and Adults only Adults and children children Adults and Adults only Adults and children Adults and Adults only Adults only Adults and children Adults and Adults and children children Adults and Children only Children A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation http://www.dshs.texas.gov/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590002694 ;Texas ;Texas http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/3ea17faa-4c5b-4a15-9b2d-5af88e9cd4a9.PDF Percentage of - experi who services health mental community adults in Percentage domain one least at in improvement reliable enced Percentage of - experi who services health mental community adults in Percentage employment improved enced Percentage of admitted services health mental community adults in Percentage psychiatric community or state a to days 180 in times more or three hospital Percentage of at receiving services health mental community adults in Percentage ofhour one least month per services health mental Quality of Care Measure Quality ofCare State Mental Health Hospitals Mental Health State Austin State Hospital Austin State Big Spring State Hospital Hospital State Spring Big El Paso Psychiatric Center Center Psychiatric Paso El Kerrville State Hospital State Kerrville North Texas State Hospital State Texas North Rio Grande State Center Center State Grande Rio Rusk State Hospital State Rusk San Antonio State Hospital State Antonio San Terrell State Hospital State Terrell Waco Center for Youth Youth for Center Waco Total, all bed types bed all Total, CRISIS SERVICES: UTILIZATION AND COSTS UTILIZATION CRISIS SERVICES: for crisis mental health services are included in Figure 85The utilization and costs below. Note: Data for the first three items are from each year’s fourth quarter, data for the last item is from the third and fourth quarters fourth and third the from is item last the for data quarter, fourth year’s each from are items three first the for Data Note: (2016). of Department Services. Health State Texas Source: combined. from Retrieved slides]. Source: Texas Legislative Budget Board. (April, 2016). State Hospitals: Mental Health Facilities in Texas, Legislative Primer. Retrieved Retrieved Primer. Legislative Texas, in Facilities Health Mental Hospitals: State 2016). (April, Board. Budget Legislative Texas Source: from Hospitals. Health Mental State Communication: Personal 30). June (2016, ofDepartment Services. Health State MEASURES OF CARE QUALITY adult outcome measures for FY 2013-2015. selected data from on common Figure 84 shows Mental Health Community Receiving Adults for Selected Measures 84. Figure Services Figure 83. State-Operated Inpatient Psychiatric Beds In State Hospitals: 2016 Hospitals: In State Beds Psychiatric Inpatient State-Operated 83. Figure DSHS 220 renovation needshave actuallytaken state contractedbedsoutofoperation. contracted communityhospitalbeds—andunmet hospitalinfrastructure repairand any increaseinthenumberofstate-operated bedsinrecentyears—onlymore hospitals tofullyutilizethenumberofbedstheyhave. Therehasalsonot been also becausestaffing andhighturnover shortages have madeitdifficultfor many because hospitalsmust retain someopenbedcapacity incaseofemergencies, but censuses ofallhospitalsarebelow theirtotal fundedcapacities—thisispartly ofinpatientpsychiatricthat despitetherebeingashortage beds, theaveragedaily served ofallTexas state hospitalsin2015 ($34,749 perclientyear). both thehighest average lengthofstay (839days) andthehighest cost perindividual Kerrville StateHospital (whichonlyprovides transitionalforensicservices)had Figure 86. Utilization andCosts forState-Operated HospitalsinFY 2015 in theaverage cost perstate hospitalclient(an80percentincrease). almost doubled,from$11,912inFY2006to$21,437 inFY2015, anincreaseof$9,525 Over thepast decade,theyearlyaverage cost perpatientserved instate hospitalshas U I aspx?LinkIdentifier=id&ItemID=8590002694 health data book, FY 2015, fourth quarter [PowerPoint slides]. Retrieved from Note: Data are from each year’s fourth quarter. Source: Texas State Health Services. Department of (2016). Figure 85. Utilization/Cost forCrisisBehavioral Health Services Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas eril tt optlFrni ny196 patients (97% Forensic only Kerrville State Hospital lPs sciti etrMostly civil, some El Paso Psychiatric Center i pigSaeHsia ii n oesc180 patients (90% Civil and forensic Big Spring State Hospital utnSaeHsia Mostly civil, some Austin State Hospital State Hospital Average monthly number of persons receiving mental health crisis services Average monthly number of Average monthly cost per person receiving mental health crisis services np tiliz a tient a tion S ervices a nd forensic forensic ouainSre Average Daily Population Served C osts a t S t a of capacity) of capacity) 66 patients (89% of of capacity) of of capacity) of 258 patients (86% capacity) total Census (% of te Hospit http://www.dshs.texas.gov/WorkArea/linkit. Y21 Y21 FY 2015 FY 2014 FY 2013 ,3 ,0 6,767 5,209 5,039 49$6 $634 $669 $459 838.5 days 27.5 days 138.0 days 49.3 days charge Stay at Dis- of Average Length a ls: Behavioral 21 Asshows, 22 $34,749 $13,957 $27,292 $19,224 Client Served Average Cost per alsoshows 23 DSHS 221 Since 24 Average Cost per Cost Average Served Client $23,834 $10,831 $23,962 $19,479 $15,833 $21,437 $25,616 25 Average Length Length Average ofDis- at Stay charge 116.3 days 25.5 days 137.3 days 58.5 days 41.8 days 73.5 days 161.8 days Census (% of (% Census total capacity) 566 patients (88% (88% patients 566 ofcapacity) 52 patients (95% of(95% patients 52 capacity) ofcapacity) 268 patients (89% patients 268 ofcapacity) 246 patients (85% patients 246 capacity) 72 patients (92% of(92% patients 72 capacity) Population Served Population Daily Average Maximum security security Maximum and (Vernon) forensic forensic and Civil (Wichita) forensic Civil and forensicand Civil (96% patients 313 forensic forensic 2,236 patients 49.7% and (50.3% civil forensic) http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/3ea17faa-4c5b-4a15-9b2d- A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation State Hospital State North Texas State Hospital Hospital State Texas North Falls) Wichita & (Vernon Rio Grande State Center State Grande Rio some civil, Mostly Rusk State Hospital State Rusk San Antonio State Hospital State Antonio San some civil, Mostly Terrell State Hospital State Terrell some civil, Mostly Waco Center for Youthfor Center Waco only Civil TOTAL 5af88e9cd4a9.PDF lack of mental health needs or their especially severe due to an individual’s Whether trouble individuals have many treatments and services, access to community-based hospital. As shows, discharging from a state remaining in the community after hospitals account for a significant portion individuals who cycle in and out of state day. given hospitals on any of the roughly 2,236 patients who are in state Data obtained from: Texas Legislative Budget Board. (April, 2016). State Hospitals: Mental Health Facilities in Texas, Legislative Legislative Texas, in Facilities Health Mental Hospitals: State 2016). (April, Board. Budget Legislative Texas from: obtained Data from Retrieved Primer. inpatient hospitals serve as a safety net for many individuals who receive inadequate who receive individuals for many net a safety as inpatient hospitals serve and quality of community-based the availability treatments, or no community-based services has a direct impact on inpatient hospital capacity. DSHS 222 19 18 17 16 15 14 12 11 9 7 5 4 3 2 1 Endnotes Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 21 20 13 10 8 6

Texas Legislative Budg Q&sig2=hqkU6VLGKbpSDDtmWMC8sQ&bvm=bv.125221236,d.eWE state.tx.us%2Fmhsa%2Freports%2FSPH-Report-2014.pdf&usg=AFQjCNHRuxYGyypPJiNrLNkxYGu4JIiax- ja&uact=8&ved=0ahUKEwiS_9Oc3bzNAhVJNSYKHfDxBCkQFggeMAA&url=https%3A%2F%2Fwww.dshs. Page 8. Retrieved fromhttps://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=r- Served byStatePsychiatric Hospitals(SPHs):Consulting DSHS Rider 83RFPNo. Services for 529-14-0066. CannonDesign. (November 20 Texas Department of StateHealth Services(A legislative/2016Reports/JCAFSlegislativeReportForensicPlan2016.pdf Forensichensive Planfor Services.Page 1.Retrieved http://dshs.texas.gov/ConsumerandExternalAffairs/ from Joint Committee onA legislative/2016Reports/JCAFSlegislativeReportForensicPlan2016.pdf Forensichensive Planfor Services.Page 9. Retrieved fromhttp://dshs.texas.gov/ConsumerandExternalAffairs/ Joint Committee onA er=id&ItemID=8590005945 of StateHealth Services. Retrieved from https://www.dshs.texas.gov/WorkArea/linkit.aspx?LinkIdentifi- Smith, J. E.(n.d.).Ov tals-Mental_Health_Facilities_in_Texas_Diehl.pdf Primer. Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospi- Texas Legislative Budg Boyd, T. (December15 APS_pg_4800.asp Commitment &4810Emergency Detention.Retrieved from http://www.dfps.state.tx.us/handbooks/aps/files/ Texas DepartmentofFamily Pro Court-Ordered-Involuntary-Mental-Health-Services.asp (HCPC): Court-Ordered/Involuntary MentalHealthServices.Retrieved from http://www.mhmraharris.org/ Harris CenterforMental Health andIDD Texas Young La tals-Mental_Health_Facilities_in_Texas_Diehl.pdf Primer. Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospi- Texas Legislative Budg Texas Young La tals-Mental_Health_Facilities_in_Texas_Diehl.pdf Primer. Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospi- Texas Legislative Budg Texas Young La ing%20State%20Mental%20Hospitals%20in%20Texas%20-%20Legislative%20Primer.pdf Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Primer/Managing%20and%20Fund- Texas Legislative Budg Services%20SER%202013%2084%20Leg.pdf from https://www.sunset.texas.gov/public/uploads/files/reports/Department%20of%20State%20Health%20 Texas DepartmentofStateHealth Services ViewTAC?tac_view=5&ti=25&pt=1&ch=411&sch=J Texas Code,Title25 Admin hhsc.state.tx.us/reports/2016/050216-statewide-behavioral-health-strategic-plan.pdf Fiscal Years 2017-2021. Page 10. StatewideBehavioral Health CoordinatingCouncil.Retrieved fromhttp://www. Texas Health andHumanServicesCommission.(Ma Texas Legislative Budg 67b14f00ad22.PDF from: http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/5fc9614b-41a4-436e-9eba- The Behavioral HealthSystem [PowerPoint Slides].Texas DepartmentofStateHealth Services. Retrieved Hellerstedt, J a800bd306277.PDF from http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/3738c396-61ed-4aae-8d75- Statewide Behavioral HealthStrategic PlanandCoordinated Expenditures Overview andFunding. Retrieved ingFiles/StateHospitalsSectionPresentation-JointCommitteeonAccessandForensicServices.pdf Services [PowerPoint slides].Slide23. Retrieved fromhttps://www.dshs.texas.gov/mhsa/SB1507/2015-12Meet- cedures.pdf attachments/AEDE810D-5686-4150-8E55-753ED82B9C41/committedtohealinginvoluntarycommitmentpro- ment Procedures. Retrieved from http://texaslawhelp.org/files/685E99A9-A3EB-6584-CA74-137E0474AE2C/ cedures.pdf attachments/AEDE810D-5686-4150-8E55-753ED82B9C41/committedtohealinginvoluntarycommitmentpro- ment Procedures. Retrieved fromhttp://texaslawhelp.org/files/685E99A9-A3EB-6584-CA74-137E0474AE2C/ cedures.pdf attachments/AEDE810D-5686-4150-8E55-753ED82B9C41/committedtohealinginvoluntarycommitmentpro- ment Procedures. Retrieved fromhttp://texaslawhelp.org/files/685E99A9-A3EB-6584-CA74-137E0474AE2C/ . &LacefieldLewis, L.(February 18, 2016). Presentation totheSelectCommittee onMentalHealth: wyers AssociationandtheStateBarofTexas. (n.d.).Committed toHealing:Involuntary Commit- wyers AssociationandtheStateBarofTexas. (n.d.).Committed toHealing:Involuntary Commit- wyers AssociationandtheStateBarofTexas. (n.d.).Committed toHealing:Involuntary Commit- erview ofNorthTexas StateHospital-Vernon Campus[PowerPoint slides].Department ccess andForensic Services. (June theCreation 2016). ofaCompre- Recommendationsfor ccess andForensic Services. (June theCreation 2016). ofaCompre- Recommendationsfor , 2015). Overview oftheStateHospitalSystem: Joint Committee onAccess andForensic et Board.(2011). Managingandfundingstatementalhospitals in Texas: Legislative primer. et Board. (April2016). StateHospitals:Mental HealthFacilities inTexas, Legislative Prim- et Board.(April2016). StateHospitals: Mental Health Facilities inTexas, Legislative et Board.(April2016). StateHospitals: Mental Health Facilities inTexas, Legislative et Board.(April2016). StateHospitals: Mental Health Facilities inTexas, Legislative et Board.(February 18, 2016). Presentation totheSelectCommittee onMentalHealth: , Part 1,Chapter 411,Subchapter Jhttps://texreg.sos.state.tx.us/public/readtac$ext. 14). theTen-Year Analysis for theProvision Planfor ofServicestoPersons tective Services. (2009). DFPSProgram Handbooks: 4800MentalHealth . (2016). TheUniversity ofTexas HarrisCounty Psychiatric Center . (September 2013). DSHS SunsetSelf-Evaluation Report.Retrieved ugust 22,2014) Personal communication:StateHospitals y 2016). Texas StatewideBehavioral HealthStrategic Plan: DSHS 223 State Hospitals: Mental Health Facilities in Texas, Legislative Legislative in Texas, Mental Health Facilities State Hospitals: (April, 2016). Board. et Recommendations for Recommendations of a Compre- 2016). the Creation (June Services. ccess and Forensic Recommendations for of a Compre- 2016). Creation the (June Services. ccess and Forensic A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Retrieved from http://www.lbb.state.tx.us/Documents/Publications/Primer/3144_State_Hospitals-Men- Retrieved Joint Committee on A Committee Joint Ibid. on A Committee Joint Budg Legislative Texas http://www.legis.state.tx.us/tlodocs/84R/handouts/C3822016021810001/3ea17faa- from Retrieved Primer. 4c5b-4a15-9b2d-5af88e9cd4a9.PDF er. tal_Health_Facilities_in_Texas_Diehl.pdf http://dshs.texas.gov/ConsumerandExter- from Retrieved and 14. 10 Services. Pages Plan forhensive Forensic nalAffairs/legislative/2016Reports/JCAFSlegislativeReportForensicPlan2016.pdf from http://dshs.texas.gov/ConsumerandExternalAffairs/ 1. Retrieved Services. Page for Plan hensive Forensic legislative/2016Reports/JCAFSlegislativeReportForensicPlan2016.pdf

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the Independent Ombudsman for SSLCs for Ombudsman Independent the ransformation ransformation Recap DADS Organization Chart (September 1, 2016 – August 31, 2017) 31, August – 2016 1, (September Chart Organization DADS DS DADS T DADS State Supported State of Office Services Regulatory A ugust 31, 2017) 31, ugust A D At a Glance except 2016 programs and services transitioned to HHSC 1st, All DADS on September supported living centers the state Services and Regulatory Operations, for Program will that time, DADS At 2017. 1st, September by to transfer expected that are (SSLCs) agency. as a separate no longer exist and Disability Services Disability and of and Disability Services Aging Department Department Department of Aging 226 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas DADS 227 3,4

2 Those 1 Legislative Session. Legislative th , 2016. The remaining regulatory , 2016. st A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation functions and operation of the SSLCs will transfer by September 1, 2017, at which 1, 2017, September functions and operation of the SSLCs will transfer by point the agency will be discontinued. for in March 2016 released Transition Plan was and Human Services The Health The proposed plan Committee. Oversight the Transition Legislative review by recommendations, along with statutory recommendations on other programs recommendations on other along with statutory recommendations, bill, SB 204 (Hinojosa/Raymond). DADS Sunset were solidified in the within DADS, discussion on the but after lengthy few changes, The bill passed the Senate with a recommendation to close the the SB 204’s House members removed floor, House of the Members Commission. Restructuring the SSLC SSLC and establish Austin Bill’s Sunset reach an agreement on the DADS could not conference committee session. before the end of the legislative content, and SB 204 died days The HHSC Sunset bill (SB 200) transfers functions from DADS to HHSC. DADS’ DADS’ to HHSC. The HHSC bill (SB 200) transfers functions from DADS Sunset and the agency 1, 2017 functions will transfer entirely to HHSC September by and program client services will then be abolished. The majority of the agency’s functions transferred to HHSC 1 on September DADS Transformation Recap Transformation DADS Advisory under the review of the Sunset Commission, along with the was DADS before the 84 agencies, and Human Services Health Texas other and Disability Services Disability and Department Department of Aging The failure of SB 204 means that every SSLC will remain open until further legislative The failure of SB 204 means that every DADS-related other many recommendations from the However, direction is received. in the final HHSC Commission were adopted bill (SB 200), including Sunset Sunset changes for individuals with IDD. to nursing home requirements and services Sunset staff carefully reviewed DADS’ internal policies, procedures, and service and service procedures, internal policies, DADS’ carefully reviewed staff Sunset Commission ultimately recommended dissolving the agency The and delivery. and Human Services Commission (HHSC), its functions into the Health in moving intellectual, and Texans and individuals with physical, older serve an effort to better (IDD). disabilities developmental other issues surrounding the Commission also tackled the highly controversial The Sunset support living centers (SSLCs). The Commission continued operation of the state 2017 September SSLC by closing the Austin recommended closing six SSLCs, 2022. by September additional SSLCs to close and identifying five DADS 228 dilapidated infrastructure addseven more cost tothestate. costly, involving morethan13,900 employees andabudget of$661.9millionayear. Commission finalreport, maintainingthelarge system of state-run facilitiesis in thesefacilitiesdeclines, totheSunset theperpersoncosts increase.According Due tofixed costs andthedeterioration ofagingfacilities, asthenumber ofresidents Texas legislaturecandirectclosureof a state supportedlivingcenter. voted tokeep theAustin SSLCandallother SSLCsoperational.InTexas, onlythe Austin SSLCby September 2017. Asmentionedearlier, ultimatelythelegislature due totheDADS Sunset Recommendations toclosesixSSLCs, includingclosingthe Approximately 3,145 individualsresideinthesefacilities. eligibility requirements. Individuals seekingplacementinanSSLCmust meet both financialandfunctional serving personswithintellectualanddevelopmental disabilities andmentalillness. Antonio. RioGrandeStateCenterisalsoalicensedinpatientpsychiatric hospital, El Paso, Lubbock,Lufkin, Mexia, Richmond, Rio Grande,SanAngelo, andSan SSLCs operatein13locations:Abilene, Austin, Brenham,CorpusChristi, Denton, (ICFs) owned andoperatedby thestate (communityICFs areprivatelyowned). by thefacilities. TheSSLCsarelicensedandcertifiedIntermediateCare Facilities services. Behavioral healthtreatmentisarequired servicethatmust beprovided institutionsState supportedlivingcentersarelarge thatprovide 24-hour residential “Community Services” MedicalandSocialServices sectionunderHHSSystem. other disabilitiesinbothcommunity andresidentialinthe settingscanbefound Note: Additional onservices information individualswithintellectual and for transfer to HHSC by September 1 State Supported Living Centers (will of the84 Commission’sThe Sunset Advisory StaffReportof DADS, includingthefinalresults andDSHSSunset changes,HHSC seetheTexas Environment sectionofthe guide. of state-owned facilities:state hospitalsandSSLCs. For moreinformationonthe the newFacility OperationsDivisionunderHHSC, whichwilloperatetwotypes outlines thefutureofDADS’ programsandfunctions. TheSSLCswillbeplacedin Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas files/documents/about-hhs/transformation/final-transformation-plan.pdf. TransformationPlanis available athttps://hhs.texas.gov/sites/hhs/The finalHHSC Final%20Results.pdf texas.gov/public/uploads/files/reports/DADS%20Staff%20Report%20with%20 There was significantdebatearoundtheSSLCsduring84 closure orconsolidationoffacilitieshasbeenmet withstrong legislative opposition. population hasdeclinedsignificantly over thepast decade,any discussionrelatedto $856.70 perday, totaling over $360,000 peryear. reportrevealed thatdelivering servicestoapersonin anSSLCcostsAn HHSC th legislative sessionisavailable atthefollowing link:https://www.sunset. 7 Further, maintainingtheSSLCs’ 5 AlthoughtheSSLC 8 th legislative session st , 2017) 6

DADS 229 - FY 2019 2019 FY (Pro jected) services connections http://www. The 2015 - 10 alth services alth ograms and employ- and ograms FY 2018 2018 FY (Pro jected) Other 2015 Other 2015 11 - FY 2017 2017 FY (Pro jected) ment fami- their and residents between systems support lies/natural Physician and nursing and Physician he Behavioral training Skills therapies Occupational pr Vocational maintain to Services

Behavioral Health Services Provided Provided Services Health Behavioral plan state Medicaid to addition (in services) · 24-hour residential care and services and care residential 24-hour include: that · · · · · 12 - (Pro jected) . Retrieved from from Retrieved 2015. Guide Reference - require devel- State Supported Living Centers Long-Range Plan May 2016. May Plan Long-Range Centers Living Supported State and develop- and

or profound profound or be unable to provide provide to unable be a substantial risk ofrisk substantial a 13 mental disabilities and behavioral behavioral and disabilities mental or challenges, physi- personal most basic the for needs. cal opmental disabilities and be and disabilities opmental or fragile, medically intellectual Have Represent selfto physical injury others. or adult, an As Meet ICF/ID eligibility ICF/ID Meet ments. severe Have and intellectual Have intellectual and developmental and intellectual or disabilities,

Despite the 2009 agreement, the June 2015 monitoring 2015 Despite the 2009 agreement, the June · · · Eligibility · · · 9 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation https://www.dads.state.tx.us/services/SSLC/draft-sslc-planningreport-5-16.pdf Program Centers Living Supported State FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 4,207 3,993 3,756 3,547 3,362 3,186 3,075 2,931 2,787 2,643 monitoring report also identified instances of “individuals receiving psychiatric receiving psychiatric of “individuals instances monitoring report also identified stability.” making progress or maintaining services who were not Figure 88 presents information on the eligibility requirements and services supplied the eligibility information on presents Figure 88 SSLCs. by Services Health-Related and Behavioral Eligibility SSLC 88. Figure dads.state.tx.us/news_info/budget/docs/fy15referenceguide.pdf Data obtained from: Texas Department of Aging and Disability Services. (2015). (2015). ofDepartment Services. Disability and Aging Texas from: obtained Data the long-term services programs. vary greatly between per person costs Average Source: Texas Department of Aging and Disability Services (2016, May). May). ofDepartment (2016, Services Disability and Aging Texas Source: from Retrieved over Department of Justice agreement with the U.S. settlement As part of a 2009 and quality of care for health, safety, to improve agreed DADS conditions at SSLCs, care increased access to psychiatric in them. The agreement includes consumers living policy practices to reduce of the and as well as improved services, and psychological to visit and report Independent monitors were assigned in mid-2014 use of restraints. on conditions at all 13 SSLCs. Figure 87. State Supported Living Center Enrollment Trend and Projections, Projections, and Trend Enrollment Center Living Supported State 87. Figure 2010-2019 Years Fiscal report for the Austin SSLC continued to identify significant deficiencies. report for the Austin monitoring reports identified deficiencies related to psychiatric and psychological and psychiatric related to monitoring reports identified deficiencies progressing toward including individual residents not services at all of the SSLCs, stability. goals maintaining psychiatric and not psychiatric DADS 230 state.tx.us/Rad/long-term-svcs/downloads/2015-09-icf-rates.pdf participants with a BH diagnosis. Source: Texas Health and Human Services Commission. (2016, October 3). Personal Communication: Percentage enrolled of numbers are inthisdatasetfrom different thetotalnumberof residents inanearlier figure. *We reported thedatadirectly from DADS andHHSC. We are notaware ofwhythetotalSSLCresident Figure 91. Percentage SSLC of Residents withaBehavioral Health Diagnosis Figure 91describesSSLCresidentswithabehavioral healthdiagnosis. Source: Data captured from Health and Human Services Commission. (2015). *30 days for one month Figure 90. State MedicaidCosts Per Person, Per Month* Figure 90describesthestate Medicaid costs perperson,month*livinginanSSLC. Source: Data captured from HHSC Legislative Appropriations Request for FY 2018/19, September 12, 2016. Figure 89. SSLC Funding Trends andRequests Figure 89. describestheSSLCfundingtrendsandrequests forfuturefunding. program becost neutralintheaggregate. individual. TheCenterforMedicaid andMedicare Servicesrequiresthateachwaiver costs withineachprogramcanalsovarygreatlydepending onthelevel ofneedthe While thecosts shown above areaverage costs, itshouldbenoted thatperperson Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas SSLC rga Y02F21 Y04F21 FY2016 FY2015 FY2014 FY2013 FY2012 SSLC Program Program ecnae 70%5.9 71%5.3 69%41.87% 46.97% 56.13% 57.17% 57.49% 57.09% Percentage BH Diagnosis Number with a Residents* Total SSLC ,5 ,7 ,3 ,9 ,4 1,455 3,475 1,745 3,715 2,196 FY 2015 3,912 2,336 FY 2014 4,086 FY 2013 2,472 FY 2012 4,300 2,654 FY 2011 4,649 FY 2010 1,7 1,8 2,8 $313$25,701 $23,103 $21,180 $19,680 $17,477 641164$0,9,7 691723$6,0,6 $666,622,891 $668,105,568 $689,157,263 $702,396,976 $684,111,674 xedd21 siae 06Bdee 07Rqetd21 Requested 2019 Requested 2018 Budgeted 2017 Estimated 2016 Expended 2015 ICF Enhancement Rates. Retrieved from http://www.hhsc. DADS 231 tent with the goals of the highest level of level the goalstent with of the highest reviews for clients, their families, other other their families, reviews for clients, The Ombudsman office provides oversight office provides The Ombudsman 14 , respectfully, and with dignity , respectfully, s of complaints concerning agencys of complaints or policies 18 agencies, as appropriate agencies, 16 Each SSLC has an independent ombudsman working independent ombudsman working Each SSLC has an 15 , Nelson/Rose) passed in 2009 to create the Office of the in 2009 to create the Office , Nelson/Rose) passed st A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 17 , Rules, and Curriculum Development , Rules, standard of care of standard and DADS stakeholders, Ensuring people are treated fairly treated people are Ensuring other Making referrals to resolution informal dispute Performing Conducting independent review independent Conducting practices are consis practices policies and Ensuring Survey Operations Survey Enforcement Policy and Credentialing Licensing

and protection for individuals who reside in SSLCs. The office is independent of The office is independent SSLCs. for individuals who reside in and protection executive elected officials in the HHSC and DADS reports directly to the state’s and branches. and legislative · · onsite responsible for: onsite responsible · · · · · · The Regulatory Services division will house the following departments: The Regulatory Services division will house the following · Regulatory Services Regulatory HHS Transition Plan, the Regulatory Services Division 2016 According to the July in the Long federal certification for health care facilities participating will provide programs and state and Medicare Medicaid Services and Supports (LTSS) Term Regulatory Services licensed health care services. licensure for facilities providing services agencies licensure of home and community support that will also provide Regulatory Services and hospice services. home health, personal assistance, provide is intended to ensure that regulated facilities and agencies comply with federal and determinations as well as make rules appropriate to the services they provide, state and requirements for service, and identify deficient regarding minimum standards practice areas. Note: The State Long-term Care Ombudsman is not in the Office of the Independent of the Independent in the Office is not Care Ombudsman State Long-term The Note: for SSLCs. Ombudsman Senate Bill 643 (81 Office of Office Ombudsman Independent the SSLCs for Independent Ombudsman for SSLCs. Independent Ombudsman DADS 232 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Endnotes Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

Retrieved from http://www.hhsc.state.tx.us/hhs-transformation/docs/transition-plan.pdf Health andHumanServicesCommission.(2016). Retrieved from http://www.hhsc.state.tx.us/hhs-transformation/docs/transition-plan.pdf Health andHumanServicesCommission.(2016). Ibid. Ibid. Living Centers –AboutUs. Retrieved fromhttp://www.dads.state.tx.us/SSLCombudsman/about.html Department ofAgingandDisability Services(2015). SSLC.pdf Living Center (SSLC).Retrieved fromhttp://www.dads.state.tx.us/handbooks/lah/res/HCS_Diversion_from_ based Services(CBS)waiver individualsatimminentriskofadmission slotsprotocol toaStateSupported for Texas DepartmentofAgingandDisability Services state.tx.us/monitors/reports/ Department ofAgingandDisability Services. (20 Pg. 41.Retrieved from https://www.dads.state.tx.us/monitors/reports/austin-6-19-15.pdf Department ofAgingandDisability Services. (20 Pg. 41-46.Retrieved from https://www.dads.state.tx.us/monitors/reports/austin-6-19-15.pdf Department ofAgingandDisability Services. (20 Retrieved from https://www.dads.state.tx.us/monitors/reports/austin-6-19-15.pdf Department ofAgingandDisability Services. (20 Ibid. state.tx.us/Rad/long-term-svcs/downloads/2015-09-icf-rates.pdf Health andHumanServicesCommission.(2015). ICFEnhancementRates with%20Final%20Results.pdf Retrieved from https://www.sunset.texas.gov/public/uploads/files/reports/DADS%20Staff%20Report%20 Sunset Commission.(2015). DepartmentofA – April2016. Retrieved fromhttp://www.dads.state.tx.us/providers/pi/piac/4-21-16-reports.pdf Health andHumanServicesCommission.(2016). ReporttothePromo sunset.texas.gov/public/uploads/u64/Final%20Results%20of%20Sunset%20Reviews%202014_2015.pdf Commission.(20 Sunset Advisory Ibid. with%20Final%20Results.pdf Retrieved fromhttps://www.sunset.texas.gov/public/uploads/files/reports/DADS%20Staff%20Report%20 Sunset Commission.(2015). with%20Final%20Results.pdf Retrieved fromhttps://www.sunset.texas.gov/public/uploads/files/reports/DADS%20Staff%20Report%20 Sunset Commission.(2015). Department ofAgingandDisabilityServicesStaffReportwith Final Results.Pg 1. Department ofAgingandDisabilityServicesStaffReportwith 3. Final Results.Pg 15) Final ResultsofSunsetReviews 2014-2015.Retrieved fromhttps://www. ging andDisabilityServicesStaffReportwith Final Results. 15). ComplianceReports.Retrieved from http://www.dads. 15). Monitoring reportforAustinStateSupportedLivingCenter. 15). Monitoring reportforAustin StateSupportedLivingCenter. AustinStateSupportedLivingCenter.15). Monitoring reportfor Health andHumanServicesSystem Transition Plan.Pg. 17. Health andHumanServicesSystem Transition Plan.Pg. 16. . (2013). Diversion protocol: Targeted HomeandCommunity- Office of the Independent Ombudsman forStateSupported Office oftheIndependentOmbudsman ting Independence Advisory Committee ting IndependenceAdvisory . Retrieved fromhttp://www.hhsc. DFPS 233 245 250 251 252 252 253 254 255 255 257 260 261 233 234 234 237 239 240 241 243 245 248 249 263 264 266 236 237

Diversity of Children and Youth in CPS in Youth ofDiversity and Children

CPS Investigations CPS Services

Care

System

and prevention of prevention and system. CPS the within fatalities child System (STAR Health) (STAR System in the CPS System CPS the in accessible services during the reorganization of reorganization the during services system. services human and accessible health the

interventions and treatment plans for youth with dual diagnoses (i.e. mental health and health mental (i.e. diagnoses dual with youth for plans treatment and interventions Health Services Health Medications in Foster Care Foster in Medications ation ofation oflevels all into practices trauma-informed care. for youth transitioning from child to adult services (ages 17-24). (ages services adult to child from transitioning youth for Mandatory Screenings for Youth Entering Foster Care Foster Entering Youth for Screenings Mandatory

A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation oncerns of the barriers to implementation for the Foster Care Redesign Project. Redesign Care ofFoster the for implementation to barriers the sues oster Care Children Program (FFCC) and Medicaid for Transitioning Foster Care Youth (MTFCY) (MTFCY) Youth Care Foster Transitioning for Medicaid and (FFCC) Program Children Care oster C Focus on Normalization in Mental Health Treatments and Interventions and Treatments Health Mental in Normalization on Focus ransformation Highlights ransformation

Relinquishment of Relinquishment Services Health Mental Obtain to Custody disproportionality of minority and LGBTQIA youth in the CPS system. CPS the in youth of disproportionality LGBTQIA and minority and Early Intervention (PEI) Intervention Early and are Redesign are Intake (SWI) Intake focus on housing, employment and normalcy as crucial parts of parts crucial as normalcy and employment recovery. housing, on focus ransformation” Plan: Reduce Caseworker Turnover and Child Fatalities Child and Turnover Caseworker Reduce Plan: ransformation” e Licensing (CCL) Licensing e acts the usage and effectiveness of the Alternative Response System in the CPS investigative process. investigative CPS the in System of Response Alternative effectiveness and usage the the

otective Services (APS) Services otective otective Services (CPS) Services otective Superior Health Health Superior F Former Fatalities Child and Disproportionality Psychotropic Trauma-Informed Child Abuse/Neglect and Abuse/Neglect Child Parental Parental Response Alternative Mental Accessing Residential Institutional Is Continuing Policy Concerns Policy F Fast Charts Organizational 125: Bill Senate Lawsuit Against DFPS/CPS C Foster “TCPS Increased Services and Protective of Department Family Texas More individualized More disabilities). intellectual/developmental or use substance integr System-wide support Improving review Ongoing Maintaining quality, quality, Maintaining Tracking Increased monitoring Continued Addressing Funding Prevention Sunset and T and Sunset Statewide Pr Child Adult Pr Car Child Changing Environment Changing olicy

· · · P · · · · · · and Protective Services Protective and At a Glance Texas Department of Department Family Texas Fast Facts

In FY 2015: · The Statewide Intake (SWI) division of DSHS received an average of more than 2,000 contacts per day related to allegations of abuse, neglect or exploitation. 1 · There were a total of 274,448 cases of alleged child abuse and neglect statewide. 2 · 4,047 investigations of child abuse/neglect were transferred to the new Alternative Response (AR) system after being deemed low acuity and low safety risk reports.3 · 224,065 investigations of abuse/neglect were opened after CPS staff determined they met criteria for follow-up investigation.4 · Of the remaining 176,868 investigations completed, 40,506 were confirmed as child abuse and/or neglect and 17,151 children were removed from their homes.5 · 16,378 children were in the Texas foster care system as of August 31, 2015 (excluding the 11,517 children in non-foster substitute placements such as kinship care and DFPS adoptive homes).6 · DFPS confirmed 171 abuse/neglect related fatalities of children, five of whom died while they were enrolled in the state foster care system.7 · The prevalence of child abuse/neglect decreased slightly, from 9.2 confirmed cases per 1,000 children in 2014 to 9.1 confirmed casesper 1,000 children in 2015.8,9 · Adult Protective Services (APS) completed 78,180 in-home investigations, with 43,759 of those investigations being validated and 12,876 of those receiving follow-up services.10 · The majority of allegations of in-home elder abuse were reported by medical personnel (21.8 percent), relatives (16.4 percent), community agencies (13.7 percent), or the victim themselves (11.8 percent).11 · The Child Care Licensing (CCL) division of DFPS oversaw approximately 20,882 daycare operations (or homes) serving 1.09 million children (as of mid-year 2015).12 Organizational Charts

Organizational Structure of DFPS (Pre-Transformation, 2016)

Source: Texas Health and Human Services Commission. (July 2016). Health and Human Services System Transition Plan. Page 19. Retrieved from http://www.hhsc.state.tx.us/hhs-transformation/docs/Transformation-Plan-Update.pdf

Organizational Structure of DFPS (Post-Transformation, 2017)

234 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas DFPS 235 http://www. DFPS is divided into the same DFPS is divided into the same 13 Retrieved from from Retrieved Map. Courts Child Protection

A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 11 regions as the Health and Human Services System — see Figure 12 in the HHSC and Human Services System 11 regions as the Health is also divided Texas shows, below As Figure 92 section for a map of those regions. courts. of child protection regional networks into several Regions and Covered Courts Map of Child Protection 92. Figure Data obtained from: Texas Office of Court Administration. (2016, January 1). 1). January (2016, Administration. ofCourt Office Texas from: obtained Data txcourts.gov/media/1135666/child-protection-courts.pdf and Protective Services Protective and agency (DFPS) is the state Services and Protective of Family The Department and adults with older adults, of children, the safety responsible for ensuring vulnerable populations services and supports to these DFPS provides disabilities. headquartered and exploitation. DFPS is of abuse, neglect, to reduce the likelihood that work in 282 local offices in included 12,706 employees of 2015 and as in Austin 11 geographicregional headquarters. regions with Texas Department of Department Family Texas DFPS 236 agencies thatprovideagencies healthandhumanservicesinTexas, includingbehavioral health. SB 200(84 SB 200(84 84 In anefforttoimprove theefficientcoordinationandqualityof statehealthservices,the Sunset and Transformation Highlights Source: Texas Family Department of and Protective Services. (n.d.) Figure 93. Family Department of Protective Services(DFPS)Divisions reorganization ofhealthandhumanservicesbegan. As Figure93shows, DFPSwas comprisedoffive separate divisionsbeforethe Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas About_DFPS/default.asp · moved toDFPS’ Prevention andEarlyIntervention (PEI) Division: otherprevention andclientsupportprogramsfromagencies thanDFPSwillbe health andhumanservicessystem. Inphaseoneofthetransformation,some separate anddistinct departmentwithanewsunset dateofSeptember 1,2023. As aresultoftheSunset Commission’s evaluationprocess, DFPSwas continuedasa

Child Care Licensing (CCL) Adult Protective Services (APS) Child Protective Services (CPS) Prevention and Early Intervention (PEI) Statewide Intake (SWI) Division th on May 1, 2016. both by previouslymanaged HHSC, were transferred tothePEIDivision ofDFPS The Texas H Legislaturefollowed recommendationsfromtheSunset Commissionandpassed th th , Nelson/Price),directingthereorganizationandrestructuring ofthestate , Nelson/Price)takes aphasedapproachtoreorganizingtheTexas ome Visiting program and the NurseFamily Partnership program, 16 DFPS to HHSC in 2017. tion process, the Child Care Licensing unit will be transferred from and childcare facilities. the ongoing HHSC As a result of Transforma- regulations are met. Educates parents and communities on childcare Regulates the childcare system to ensure safety and other statewide ming that includes a public outreach campaign. also educates the public on adult abuse prevention with program- homes, state-contracted community settings, and state facilities. APS mental disabilities. abuse in client’s Services include investigations of adults (age 65 and over) and people over age 18 who have physical or abuse,Investigates allegations of neglect, older and exploitation of custody. unsafe home environments and placed into foster care homes or state manages the foster care system for children who are removed from to safely retain children in their own home. CPS also oversees and accordingly. CPS strives to strengthen and stabilize families in order child abuse and neglect and responds Investigates allegations of early prevention services.of programs in addition to funding and supporting community providers risky behaviors before they happen. PEI runs its own prevention services to help prevent child abuse, juvenile incarceration, and other Provides community outreach on mental health and other wellness harmful situations. youth and their families in an attempt to prevent dangerous and Youth Hotline, which offers counseling, resources, and referrals for and exploitation for both adults and children. SWI also runs the Texas Operates the Texas abuse,Abuse Hotline to process reports of neglect Description Learn about DFPS. Retrieved from http://www.dfps.state.tx.us/ 15 14

DFPS 237 , rd in a bt

O ody to to ody ust C

f that The Pregnant Post-Partum Post-Partum Pregnant The that ment o h The remaining four divisions within DFPS — State divisions within DFPS — State The remaining four ervices 19 S

22 h lt elinquis a R These children have serious mental health conditions and proper serious These children have Texas Legislature began the initial work needed to address Legislature began the initial Texas 21 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation rd l a l He 17 a For more detailed information on the transformation plan, see the Texas information on the transformation plan, see the Texas more detailed For 20 rent ent The Sunset Commission recommended recommended Commission Sunset The programs Risk Education Drug and Awareness the Parenting and Intervention but the 1, 2017, September by DFPS to moved DSHS be managed previously by HHSC to two programs move these that plan recommends HHSS transformation instead.

parental relinquishment of custody in Texas with the passage of Senate Bill 44 (83 in Texas parental relinquishment of custody Wide Intake (SWI), Child Protective Services (CPS), Adult Protective Services (CPS), Adult Services Protective (SWI), Child Protective Wide Intake in DFPS and not (PEI) — will remain and Early Intervention (APS), and Prevention to HHSC. be moved a separate agencyDFPS will continue to operate as during the transition and aims services health of all public health and behavioral to maintain seamless delivery SB 200 requires that HHSC further analyze the during the reorganization process. agency all DFPS activities to the consolidated feasibility of moving and requires of agencies for further reorganization that a report with recommendations to be 1, September by Committee Oversight to the Transition Legislative submitted 2018. In 2013, the 83 In 2013, Pa M their child to get options no other parents or guardians have In some instances relinquish their child to state needed mental health services and voluntarily mental health services conservatorship solely for the purpose of accessing those through DFPS. Changing Environment Changing Abuse and neglect investigations of community providers that are conducted by by that are conducted of community providers and neglect investigations Abuse Regulatory to HHSC’s are also slated to move Services (APS) Adult Protective all to keep expressed a desire have but stakeholders in 2017, Services Division within DFPS. investigations In phase two of the reorganization, all of the programs run by DFPS within the DFPS within by run programs all of the two of the reorganization, In phase residential childcare and daycare (CCL) division that regulate Child Care Licensing within HHSC. Regulatory Services Division to new facilities will be moved · Zaffirini/Burkett). In addition to ordering regular data collection and reporting Zaffirini/Burkett). Environment section of this guide. Environment treatment is often expensive due to the need for temporary residential treatment or treatment is often expensive coverage insufficient insurance Some parents have outpatient supports. extensive making it difficult to afford the mental health altogether, lack insurance while others in the household for themselves to guarantee safety treatments that are necessary critically needed to obtain relinquishment of custody children. Parental or other to Assume been considered as “Refusal mental health services has historically that results in the a form of neglect Responsibility”Parental DFPS, (RAPR) by Child Abuse/ Texas parents’ or guardians’ names being automatically added to the Neglect Central Registry. DFPS 238 the ChildAbuse/Neglect CentralRegistry. overturned andresultedinremoving thenamesofparent(s)/guardian(s) from 662 casesfoundanadditional37 casesthatmet criteriaforreview, 11ofwhich were the revisedoutcomesofthosecasesisstill forthcoming,butthe2013-2014 reviewof files thatwere reviewed—almost asmany cases aswere overturned inallof2015. In just thefirst halfofFY2016, 76 cases were overturned outofthe382total case entering DFPScaresolely toobtain mentalhealthservices hasincreasedsince2015. parental rightstoobtain needed mentalhealthservices, thenumber ofchildren parents andguardiansare not reportedtothechildabuseregistry forrelinquishing Then in2015, SB1889(84 Diversion BedProject. expanded toatotal of30beds—isknown astheResidentialTreatmentCenter(RTC) Central Registry whomet thecriteriaset forthinSB1889. names ofapproximately 172parentsandguardiansfromtheChildAbuse/Neglect Acceptfindings ofRefusal to Parental Responsibility(RAPR)andremoved the As aresultofSB1889(84 criterion. and guardiansfromtheChildAbuse/Neglect CentralRegistry thatmeet this 1889 alsodirectedDFPStoreviewpreviouscasefiles remove namesofparents mental healthservicesforachildwithseriousemotional disturbance (SED).SB custodial rightsonlybecausetheyattempted andwereunable toobtain needed or guardian’s nameinaChildAbuse/Neglect CentralRegistry iftheyrelinquish constituted childneglectby aparent.SB1889requiresDFPStonot includeaparent SB 1889). were previouslyruledaschildabuse/neglectbutarenow overturned asaresultof review andnotification letters weresenttothe73 overturned cases(i.e.73 review processfound888uniquecasesdatingfrom2001 to2010 thatrequired otherwise obtain. WhileSB1889(84 relinquishing custody toobtain neededmentalhealthservicesthattheycouldnot operating proceduressothatnonewparentsaredeemed RAPRsolelyfor SB 1889alsorequiredDFPStoadopt thenewdefinitionofneglectintotheir · · · overturned by SB1889: In FY2015, DFPSstaff reviewed954casesthatpotentially met thecriteriaforbeing for thisreason. number ofchildrenbeingplacedintostate custody (i.e.managingconservatorship) thatcouldreducethe 44 requiredDSHSandDFPStojointlystudy changes policy on parentalrelinquishmentsolelytoobtain mentalhealthservicesforachild,SB Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 83 state’s custody solelytoobtain neededmentalhealthservices. Treatment Centers(RTCs) forchildrenwhoareatriskofbeingrelinquishedintothe

rd removal was deemedappropriate). only one of those cases was laterruled to be “Reason To Believe” (i.e.theinitial happened). 77 ofthosecaseswere granted temporary managing 11 of those caseswere offered and 88 casesfrom FY 2015 were , Williams/Pitts) allocated$2.1milliontofundtenbedsinprivateResidential 26 Cases between 2011-2012 arestill beingreviewed anddatafromDFPSon 23 Also in2013, the2014-2015 (S.B. GeneralAppropriationsAct 1, 28 th th , Zaffirini/Burkett), DFPShas overturned previous , Zaffrini/Burkett) thedefinitionofwhat changed overturned “ReasontoBelieve” abuse (i.e. nolonger granted joint managing conservatorship(JMC). th , Zaffirini/Burkett) established thatcertain 27 conservatorship (TMC) and 25 The retrospective case 24 24 This program—later 29 DFPS 239 , th 30 or f SB 206 (84 The uniform 33 36 Legislature Legislature th creenings 35 S treatment center, and treatment center, re Ca tory tory a ed from their family home and taken into DFPS into taken family home and ed from their ter nd 34 from being relinquished to DFPS conservatorship, relinquished from being Ma 32 , West/Naishtat), which requires children who are , West/Naishtat), , West/Naishtat) established more consistent and more consistent established , West/Naishtat) th th 31 ill 125: A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation ntering Fos B E

h te Legislature passed a number of bills relating to trauma-informed Legislature passed a number of bills th a 150 children were diverted were diverted 150 children services at a residential received 66 children were ultimately remov 28 children conservatorship. en out

care including SB 125 (84 S Y The 84 There is still no available data on the number of families who have been offered or data on the number of families who have no available There is still state, joint or temporary managing conservatorships with the accepted who have reports that DFPS will SB 1889 implementation but that data will be included in the year. of each even-numbered release in November Finally, SB 1889 also requires DFPS to offer families joint managing conservatorship joint managing conservatorship also requires DFPS to offer families SB 1889 Finally, managing conservatorship of that requesting of a child before DFPS files a suit and is disturbance” emotional from a severe child, so long as the child “suffers need mental health services. entering into conservatorship to obtain · in the for the 30 beds list of 22 children were on the waiting a total 2016, As of July Bed Project. Diversion RTC Between September 2013 and May 2016, a total of 179 children have been referred to been referred 179 children have of a total 2016, and May 2013 September Between Bed Project: Diversion the RTC · As part of the effort to help reduce the number of children entering into DFPS into DFPS entering of children number the to help reduce effort of the As part 84 the services, health mental to obtain solely conservatorship · entering into DFPS conservatorship to receive a “developmentally appropriate a “developmentally entering into DFPS conservatorship to receive assessment” that includes a screening for trauma and mental comprehensive entrance into DFPS care. of the child’s health needs within 45 days thorough screening procedures for children entering into DFPS care, and these new thorough screening procedures for children entering into in placements that procedures are aimed at placing children with complex needs — hopefully resulting in fewer placement fit their individualized needs will better and success for children. changes and more long-term stability Schwertner/Burkett) also strengthened reporting requirements for voluntary reporting requirements for voluntary also strengthened Schwertner/Burkett) reporting of mental health services and required relinquishments solely to obtain conservatorships resulting temporary managing the number of subsequent joint and via SB 1889. from intervention allocated $4.8 million to add 20 beds to the Residential Treatment Center (RTC) (RTC) Center Treatment Residential 20 beds to the $4.8 million to add allocated of 30 beds. total making for a in 2013, started that was Bed Project Diversion assessment adopted statewide for this purpose is the Child and Adolescent for this purpose statewide Needs assessment adopted LMHAs tool routinely used by — the same and Strengths assessment, or CANS the In addition to completing to qualify children for mental health services. required to conduct interviews with several is also now assessment, DFPS CANS ongoing mental about the child’s knowledge life who have individuals in the child’s SB 125 (84 health needs. DFPS 240 on April1,2016. of ChildrenandFamilies forNewJersey, begantheirnewrolesworkingwithDFPS and specialist attorney Francis McGovern andKevin Ryan,formerCommissioner In the intervening time since the lawsuit against DFPS began, capacity issues and a lack In theintervening timesincethelawsuit against DFPSbegan, capacityissuesandalack court case againstinformation ontheongoing DFPS. the changes toDFPS’the changes foster caresystem. Judge Jack appointedtwospecialmasters inMarch2016 tohelpguideandoversee · instability arethenorm,” care system runby DFPSasone“whererape,abuse,psychotropic medicationand constitutional rightsofchildreninPMCfoster care.Judge Jack describedthefoster issued arulingonthecase,findingthat state had systematically violatedthe In December2015, U.S. Federal District Judge Janis GrahamJack ofCorpusChristi · In2011, whenthelawsuit was first broughtagainst CPS, therewereapproximately: other organizationshave advocacy sincejoinedasplaintiffsinthecase. by groups—Children’s twoadvocacy RightsandABetter Childhood.Over adozen children infoster careonalong-termbasis. Thecasewas originallybroughtforth after aclass-actionlawsuit was filedagainst DFPSin2011 onbehalfofall Texas The foster caresystem operatedby DFPScameunderincreasedpublicscrutiny La Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas best practices. that still farexceeds recommendedinnational the maximumnumberofcases(17) Texas have fallensomeinrecentyears—from31cases in 2014 to28in2015 —but risk ofexperiencinginstability intheirplacements. Average CPS caseloadsizesin thoroughly, whichleaves childreninthefoster caresystem andatgreater longer high caseloadsmake itdifficultforcasestobeprocessedquicklyandinsome with thePMCprogramidentifiedinlawsuit. CPScaseworker turnover and capacity issues, caseloadsizes, defining“manageable” andresolving other problems than whentheyentered.” · started beingimplementedinthebeginningof2016. include: Thesechanges been unsuccessful,andseveral oftheruling’s reformstoimprove thePMCprogram a permanentplacementwithinyearoftheirinitialremoval fromtheirhome. Conservatorship (PMC)program,specificallychildrenwhohave beenunabletofind specifically addressedhow CPStreatschildreninthe state’s Permanent Managing roughly $3to$4millionper year.

division. and addressingregulatory lapses inthe state’s residentiallicensing “broken” placement of children concerns of child safetyAddressing in foster careplacementsby disallowing 12,000 childreninPermanent Managing enough caseworkers to “ensure that caseloads are manageable” acrossthestate.enough caseworkers to “ensure that caseloads are manageable” casework Addressing · · ·

wsuit Ag More than 1 500 children in PMC for morethan 6,400 childreninPMC 43 46-47 45 /3 ofchildren in PMCexperiencing five ormoreplacements. The co-transitionmasters willcreateaplanforaddressing the Judge Jack estimated thattheco-transition masters willcost a inst er turnover andcaseload size issuesby directingDFPStohire in foster group homeswithout 24-hour awake supervision 40 41 The state’s appealsagainst Judge Jack’s rulinghave sofar where children “often age out of care more damaged outofcaremoredamaged where children“oftenage for three or moreyears, D F 48 PS See theTexas Environment sectionforfurther / CPS 44 10 years, and Thetwotransitionmasters, mediator Conservatorship (PMC), 37 37 The lawsuit 39 38 42 DFPS 241 55 53 52 50 However, However, 57 58

Legislative session in 2017. Legislative th The effects of trauma can last a lifetime. a lifetime. The effects of trauma can last 54 A high number of placements is traumatizing 59 edesign R Children in foster care have undergone abuse and neglect and as care have Children in foster 56 re A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Ca As a result of this shortage of available foster placements, Texas foster Texas placements, of this shortageAs a result foster available of 49 Increasing the number of available foster homes is part of the foster care is part of the foster homes foster of available Increasing the number 51 Keep children and youth closer to home and connected to their communities and to and connected closer to home children and youth Keep siblings.

Individuals who experience significant childhood abuse and family discord in their Individuals who experience significant health problems as adults. and behavioral a higher incidence of physical youth have children’s symptoms of trauma may sometimes be misinterpreted as deliberate be misinterpreted sometimes of trauma may symptoms children’s unrelated to trauma. of a condition or indicative problematic behavior · A disconnected and uncoordinated foster care system is likely to aggravate to aggravate is likely system care A disconnected and uncoordinated foster properly they are not mental health conditions if other childhood trauma and any addressed with timely and appropriate care. Lack of permanency and consistency mental health in childcare placements can also create trauma and exacerbate care. conditions for children in foster A youth who has experienced trauma is at higher risk of having issues with is at higher risk of having A youth who has experienced trauma and promiscuity, and suicide), use, mental health (such as depression substance criminal behavior. Foster Foster because nearly all of the overlap systems care and mental health delivery Foster Trauma suffered traumatic experiences. care have youth entering into foster abuse or chronic or sexual psychological, by experiencing physical, inflicted children. neglect has a profound effect on Texas Speaker of the House Joe Strauss has declared that fixing the foster care care the foster Strauss has declared that fixing Joe of the House Speaker Texas agenda is on the top of the legislative for the 85 system Capacity shortages are also not just an issue of numbers, but of matching each child but of matching an issue of numbers, just Capacity shortages are also not As former head of and identity. background, for their needs, setting to the appropriate Services Committee and Human Health Specia described it to the Senate DFPS John once you overlay child in care, but enough beds for every have “we may in April 2016, age does not our capacity and behavior), location, specific needs (including gender, align.” of availability of homes within the foster care system have continued to be a problem. continued have system care the foster within of homes of availability of policyA series for children more difficult made it changes of 2015 beginning at the members). In 2015, family extended (i.e. with in kinship placements to be placed safety-screening stricter as a result of these percent 37 by CPS grew by child removals the 56 percent during by placements fell informal kinship and short-term standards, time. same redesign pilot project in Region 3b (west of Dallas); from November 2014 to August 2015, 2015, to August 2014 from November of Dallas); (west project in Region 3b redesign pilot beds to 2,330 beds. 20 percent, from 1,950 capacity increased by placement foster total children waiting for placements have been forced to stay in less-than-ideal locations; in stay been forced to placements have for waiting children 2016 alone. February sleeping in CPS offices in two nights at least 16 children spent for children who are navigating the foster care system, further elevating the need to care system, the foster for children who are navigating embed trauma-informed care into CPS practices. outcomes for children (such as victimization and In an effort to reduce negative Care Redesign project on a Foster DFPS embarked care system, fatality) in the foster and well- permanency, outcomes for youth in the areas of safety, to improve in 2010 Care Redesign are to: goals of the Foster being. The overarching a result experience different degrees of traumatization. Mental health conditions are of traumatization. a result experience different degrees result from traumatic experiences. one of the consequences that typically DFPS 242 fostergeographic catchmentareas. careyouthinspecific with thehighest needs”. (CPA)Agencies inproviding servicestochildren behavioral health casemanagement currently exist between Texas ChildProtective Services(CPS)andChild Placing report inNovember 2015 thatassessedthe“status, policiesandpracticesthat The StephensGroup, abusinessandgovernment consultingagency, releaseda in. close toachild’s homeandcommunity, regardlessofwhatpartthestate theylive mental healthservicesaremoreconsistent acrossthestate andreadilyaccessible streamlining thedelivery ofcare istobetter coordinateservicesforfamiliessothat compilation ofDFPScontractswithover 300privateservice providers. of Thegoal ratherthana coordinated fromaSingleSourceContinuumContractor (SSCC) The Foster CareRedesignalsorestructures servicedelivery sothatcareis reductions intheaverage cost-per-child. encouraging children’s transitiontolower servicelevels andcorrespondingoverall positive outcomesinthe child’s careinstead oftheircurrentservicelevel, thereby a lower servicelevel. Throughtheredesigneffort,payments arenow tiedto reimbursement structure didnot createincentives forachildtobemoved to General ResidentialOperation,orTreatment Center).This intensive) andplacementtype(ChildPlacementAgency, Shelter, Emergency payment was linked toachild’s moderate, specialized,or servicelevel (basic, service-based fundingtoperformance-basedfunding.Under theprevioussystem, oftheFosterOne ofthebiggest changes CareRedesignhasbeentheswitch from · · · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · · addressed including: highlighted several areasoftheredesignedfoster caresystem thatstill needtobe · · and developmental disabilities) population”. “special medical,behavioral oremotional indicators, orareintheIDD(intellectual conservatorship have beenidentifiedashaving highneeds, meaningtheyhave

placements. Reduce the number of timesyouth Reduce the timeto permanenc Improve the quality of care andpositive outcomes for children and youth. caseworkers accountable for child outcomes while in DFPScare. Lack of key performance Escalation of needsand through under the Medicaid benefit, andin-homesupports. targeted case management provided throughlocal mental health authorities (LMHAs), localIDDauthorities, the right time.” difficult toprovide high-needschildren with“the rightcare,inthe setting, at Gaps in training forboth casework continuity of careas children move between service providers andsystems. understand each part of thesystem leads toa lack of provider accountabilityand Intricacies of themental health succeed. complex needs toreceive thespecialized and intensive servicestheyrequireto the child welfare system makes it hard forfamilies and children withparticularly Lack of a clearandconsistent definition 63 Underthenewsystem, isrequiredtoprovide ofservices for arange anSSCC 60, 61 67 65 Approximately 12.5percentofchildrenwhoareinDFPS measures make it difficult tohold CPAs orCPS y forchildren in foster care. system andcaseworkers’ inabilitytonavigate and ers and CPSfoster care contractorsmake it move between foster homesorother 62 -utilization of mental health services of what constitutes “high-need” within of what constitutes “high-need” 66 The reportfromtheStephensGroup 64 68 DFPS 243 70 lities Data on the a 72 t a 73 ild F educe R Ch Combined with the new CPD CPD new Combined with the 77 n: a nd l a P 75 tion” a urnover urnover T orm f As part of this transformation, CPS designed and implemented

Additionally, one of the exceptional items (#4) in DFPS’ proposed (#4) in DFPS’ items one of the exceptional Additionally, 76 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation ns 69 74 a ACH expects to spend approximately $5 million of its own money over money over $5 million of its own ACH expects to spend approximately r 71 T “ seworker Ca effectiveness of ACH’s program is forthcoming. Using data from the Region 3b program is forthcoming. of ACH’s effectiveness from the Perryman Dallas county), one study and Worth service area (including Fort care redesign will foster in the state’s dollar invested that every Group estimates and $1.66 in local revenue. revenue in state $3.44 return the course of the three-year contract, but representatives from the organization contract, but representatives the course of the three-year Redesign as a whole. Care about the future of Foster feel positive a self-improvement few years, DFPS has been prioritizing “transformation” the past place to work and a more effective process that is focused on making CPS a better overall. system CPS The most recent request for proposals (RFP) for Foster Care Redesign SSCC for Foster (RFP) for proposals recent request The most and that RFP opened in Texas, for DFPS Region 2 in Northwest contracts was Summer 2016. There is currently only one SSCC actively operating in Texas— All Church Home All Church Home There is currently only one SSCC in Texas— operating actively Our Kids Our Community area. ACH’s Worth in the Fort (ACH) Child Services, region that for a seven-county as the SSCCprogram serves care provider foster and Tarrant Somervell, Pinto, Parker, Palo, Johnson, includes Erath, Hood, counties. The initial results are mixed on the implementation of the Foster Care Redesign on the implementation of the Foster are mixed The initial results the program currently only 2016, pointed out in Spring Jack program. As Judge counties. percent of Texas about 800 children and is operating in only two covers The report from the Stephens Group raised concerns regarding the effectiveness of the effectiveness regarding raised concerns Group the Stephens report from The The or IDD. diagnoses health mental have who for children Care Redesign the Foster too standardized be may for care that recommendations concern report indicated and of families needs and abilities the individualized meet adequately and do not use issues. substance and/or IDD, of mental health, complex mixtures parents with with children that allows Care Redesign in the Foster also a provision There is in to be placed and IDD diagnoses) health disorders (i.e. mental dual diagnoses not causes trauma and may which likely community, far from their home institutions and trauma associated with repeatedly The instability outcomes. produce the best can have and familiar support networks children from their community removing this disproportionate well-being. As an example of effects on long-term detrimental is 2.7 while for children in DFPS care number of placements impact, the average average, more than 5.7 placements on high needs have as having youth identified twice as many. training program, the transformation process also aims to decrease child fatalities intraining program, the transformation process also aims to decrease child for caseworkers procedures and flowcharts using uniform, step-by-step DFPS care by 2018-19 budget is to “Strengthen and Expand High Quality Capacity and Systems in Quality Capacity and Systems and Expand High is to “Strengthen budget 2018-19 Care Redesign which includes the expansion of the Foster Care System”, the Foster in paid foster program to eight new catchment areas and roughly half of children million. of $101.3 care, at an initial cost a competency-based training program known as CPS Professional Development as CPS Professional Development training program known a competency-based classroom improved receive newly hired CPS caseworkers (CPD). As a result of CPD, mentor upon hiring, which and hands-on experience in addition to being assigned a and spend more worker direct feedback from another to get enables caseworkers time “learning and practicing skills in the field”. DFPS 244 by theChildWelfare LeagueofAmerica. significantly higher(almost double)thanthe17casespercaseworker recommended 31 or32active casesperworker inFY2015. However, average caseloadsremain The average caseloadforCPSworkers hasimproved inthelast twoyearstoabout while providing neededattention andsupporttoallvulnerablechildren. caseloads allows CPScaseworkers tobemoreeffective andthoroughintheirwork routine visits, identifysafety risks, andintervene appropriately. ofatonce.HighcaseloadsforCPSworkers canleadtofailuresconduct in charge for whatconstitutes asafe andappropriatenumberof casesforacaseworker tobe by Judge Jack inMarch2016 ofchoosingandsetting willbeincharge regulations wide approachdepictedabove, thenewDFPSco-transitionspecialists appointed ofasystem-In additiontothetransformationfocusingoninterdependent goals documents/2016/2016-05-05_CPS_Transformation_Progress_Report_Sunset.pdf Services Transformation.Protective Source: Texas Family Department of and Protective Services. (April 2016). Figure 94. Agency-Wide DFPS’Model of Transformation wide approachtotransformationthatDFPSisundertaking. 94 below shows theoverarching philosophy ofthesystem- andinterdependentgoals who areassessingtheimmediateandlong-termsafety risksthatchildrenface.Figure Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas for theupcoming legislative sessionistotry toreduceCPScaseworker turnover by The newDFPS CommissionerHankWilliams hasindicatedthat oneofhispriorities percent ayear(DallasCounty). of hidingthefactthatturnover ratesinsomecountieshave reachedashigh57 second quarterofFY2016, butstatewide averages canhave theunintendedeffect · · · · reasons caseworkers reportleaving: 9.5 percentin2015. the turnover rateforsupervisorsincreasedeven more–from 6.3 percentin2014 to for workers atCPSincreasedfrom25.2 percentin2014 to25.7 percentin2015, and staff, discontinuityoncases, andnegative outcomesforchildren.Theturnover rate

Poor supervisionand pay High caseloads Safety concerns (e.g. Job stress 82 CPS worker turnover statewide was still at23.0 percentinthe Page 2. Retrieved from working in unsafe neighborhoods late atnight) . 85 83,84 Exit surveys explainsomeofthemost common https://www.dfps.state.tx.us/About_DFPS/Reports_and_Presentations/CPS/ 81 High caseloadscanleadtohighturnover of Progress Report to the Sunset Advisory Commission: Child

78,79,80 Having lower DFPS 245 86 l a ent M tion in a DFPS encourages normalcy liz 88 91,92 a nterventions I orm nd N 89 a 90 , Schwertner/Dukes), encouraged age-appropriate , Schwertner/Dukes), th tments 87 a re A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation T

, Kolkhorst/Dutton) established an independent ombudsman office an independent ombudsman office established , Kolkhorst/Dutton) sed Focus on sed Focus th h a lt a ncre outside of DFPS (to be housed in HHSC)outside of DFPS (to be housed in and required the new ombudsman to complaints from children procedures to receive and implement statewide develop and follow assistance, necessary any provide and youth in DFPS conservatorship, through with investigation. As Figure 95 shows, the vast majority of the DFPS budget (80.1 percent) goes (80.1 majority of the DFPS budget the vast As Figure 95 shows, Funding state both Services is jointly funded by and Protective The Department of Family and billion in 2011 roughly $1.375 for DFPS was The budget and federal dollars. 57.4 period. In 2011, percent increase in that four-year — a 15.7 $1.591 billion in 2015 42.6 percent the other percent of DFPS funding came from federal sources while GR-dedicated funds and other general sources (e.g. funds, revenue came from state the federal share of 2015, By funding sources such as child support payments). percent. funding for DFPS had dropped to 53.4 Another bill, SB 1407 (84 bill, SB 1407 Another SB 830 (84 I He has defined normalcy & Alumni Council as “the Care Youth The National Foster participate in and to placement and youth in out-of-home opportunity for children life events responsibilities and experience age and culturally appropriate activities, and development.” normal growth that promote increasing pay and adding new caseworker positions to help reduce caseload sizes. caseload reduce to help positions caseworker new and adding pay increasing exceptional one of the 2018-19, for FY budget proposed in DFPS’ example, For of new CPS to add hundreds in new funding $202.2 million requests items (#2) SWI Intake Kinship Caseworkers, CPS Caseworkers, Investigation (e.g. CPS workers of DFPS to the ability improve and subsequently caseload sizes to reduce Specialists) from being subjected populations vulnerable – protecting main mission fulfill their and neglect. to abuse normalcy activities for children in foster care, defined a reasonable and prudent care, defined a reasonable normalcy in foster activities for children responsibilities decision-making shifted several for such decisions, parent standard in place for and put liability protections to the caregiver, from the caseworker and staff, also required training on normalcy for caregivers, SB 1407 caregivers. larger This training is part of CPS’ focus staff. Residential Child Care Licensing with CPS to activities and exposing children involved normalcy by on promoting the opportunity to experience in experiences that children outside of CPS care have the normal course of life. for children in care but foster families in particular receive mixed messages from mixed receive families in particular but foster for children in care families fear regulatory or foster Many allowed. on what is and is not caseworkers specifically to participate in an activity not legal repercussions if a child is allowed Advisory Independence The Promoting service plan. included in the child’s less restrictive push towards has been a crucial part of the system-wide Committee and more patient-centered services. DFPS 246 The total budgetforDFPSFY2016-17 was $3,588,695,161. Figure 96. Finance forFY DFPSBudgetbyMethodof 2016-17 FY18-19/documents/18-19_LAR.pdf 2018 and 2019. Pages 30-31. Retrieved from Source: Texas Family Department of and Protective Services. (September 6, 2016). Figure 95. DFPSBudget byStrategy forFY 2016-17 an integratedservicedelivery system. towards thedepartment’s missionofprotecting childrenby operating CPS-related Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 2018 and 2019. Pages 30-31. Retrieved from Source: Texas Family Department of and Protective Services. (September 6, 2016). FY18-19/documents/18-19_LAR.pdf https://www.dfps.state.tx.us/About_DFPS/Financial_and_Budget_Information/LAR/ https://www.dfps.state.tx.us/About_DFPS/Financial_and_Budget_Information/LAR/ Legislative Appropriations Request for Fiscal Years Legislative Appropriations Request for Fiscal Years

DFPS 247 Also as a result of 93 Legislative Appropriations Request for Fiscal Years Years Fiscal for Request Appropriations Legislative https://www.dfps.state.tx.us/About_DFPS/Financial_and_Budget_Information/LAR/ 94 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation As DFPS notes in their Legislative Appropriations Request for FY 2018-19, for FY 2018-19, Appropriations Request in their Legislative As DFPS notes 95 “The decline in federal Title IV-E financial participation is the result of financial participation is the Title IV-E “The decline in federal of children percentage – the rate penetration IV-E in the erosion continuing the HHS Transformation, the Texas Home Visiting and Nurse Family Partnership Partnership Visiting and Nurse Family Home the HHS Transformation, the Texas increasing the DFPS budget by HHSC from programs will be moving to DFPS, roughly $10 million. The 2018-19 legislative appropriations request for DFPS also has an increase in GR appropriations request legislative The 2018-19 Care Foster entitlement programs: in specific funds to account for caseload growth ($25.7 Payments Assistance Care million) and Adoption Subsidy/Permanency ($27.8 million). Source: Texas Department of Family and Protective Services. (September 6, 2016). 2016). 6, (September Services. Protective and ofDepartment Family Texas Source: biennium billion for the 2018-19 of $3.52 request a baseline budget DFPS submitted million of $64.09 decrease a net items) — that is including funds for exceptional (not million in general (GR) funds revenue $14.4 Roughly budget. from the 2016-17 to comply for 2018-19 appropriations request were cut from the DFPS legislative to reduce GR expenditures across all agencies requirement with the legislature’s legislative of this decrease in the 2018-19 the majority four percent. However, by which is is a result of the HHS Transformation process, appropriations request APS Provider and the Child Care Licensing & Regulation ($94.9 million) moving million) divisions from DFPS to HHSC. ($24.3 Investigations The total requested budget for DFPS FY 2018-19 is $3,524,605,414 not including not is $3,524,605,414 for DFPS FY 2018-19 budget requested The total those funds would add an If included in the budget, Item Funds. Exceptional of funding. additional $533,991,674 from Retrieved 30-31. Pages 2019. and 2018 FY18-19/documents/18-19_LAR.pdf Figure 97. Total DFPS Requested Budget by Method of Finance for FY 2018-19 of by Method Budget FY for DFPS Requested Finance Total 97. Figure much of the need for increased state spending on services related to the foster care on services related to the foster spending much of the need for increased state trend care child and the nationwide per foster higher costs is a result of both system program: of declining federal funding through the Title IV-E DFPS 248 · · · · · within DFPS: minutes in2015. increased by almost aminute inthelast fouryears—from7.3 minutesin2011 to8.2 The average holdtimeforaphonecalltotheStatewideIntake departmenthas mail/fax (3.2 percent). phone, asignificantnumberofreportscamethrough the Internet (18.5 percent)and While 77.6 percentofthereports abuse/neglectreceived by SWIin2015 camevia specialists. In 2015, SWIemployed approximately 418FTE staff, 309ofwhichworked asintake and state facilities. in alltypesofsettings, includingprivatehomes, childcarefacilities, nursinghomes, programs inDSHSandDADS). SWIhandlesreportsofabuseforadultsandchildren department (i.e.CPS, APS, orChildCareLicensing,inadditiontoclientservice SWI receives theinitialcallandthenroutesinformationtoappropriate and isthecentralhubforallincomingreportsofabuse, neglect,andexploitation. The StatewideIntake (SWI)divisionofDFPSoperatestheTexas Abuse Hotline Statewide Intake (SWI) Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas victims. of reportersabuseandneglectforchildren in-home investigations ofadult neglect perday. contacts during2015 —that’s anaverage ofmorethan2,000 reportsofabuseor

division. 4,516 cases forResidential Child Care and 3,700 cases for Da 12,952 cases for APSFacility abuse/neglect and 13 caserelated special requests), 110,290 cases for APS and 6,447 case related special requests), 280,895 casesforCPS in household thanin1996.” those samestandards todaymeansthatachildhastocomefrom apoorer not been increased inflation in more or indexed than 15 for years. Applying (AFDC) incomeandasset standards thatwere inplace1996[and]have of linking IV-E eligibility to the Aid to Families with Dependent Children care whoarein foster covered byIV-E. Thiserosion […]isthedirect result 100 102 Thoseintake specialists handled 781,935abuse-andneglect-related 101 98,99 Those781,935reportscorrespondedtothefollowing departments 97

y CareLicensing (DCL) Investigators withinthe CCL division, 103 In-Home Investigators (110,277 adult reports ofalleged Figure98below shows someofthemost commontypes vestigators (274,448 childabuse/neglect reports of alleged Investigators, 96 Licensing (RCCL) withintheCCL Licensing (RCCL) DFPS 249 109 107 https:// Page 6. Retrieved from from Retrieved 6. Page The Texas Youth Hotline Youth The Texas 104 108 Of those 274,448 allegations in 2015: Of those 274,448 2015 Annual Report and Data Book. Book. Data and Report Annual 2015 105,106 110 based on [a] preponderance of evidence, staff concluded of evidence, staff based on [a] preponderance screened out for not meeting criteria for abuse/neglect meeting out for not screened ), an easily accessible resource that provides “counseling, provides ), an easily accessible resource that A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation ystem (1.5 percent of all allegations) percent (1.5 ystem 224,065 investigations were opened and 176,868 investigations were completed. were investigations and 176,868 were opened investigations 224,065 neglect cases abuse or were confirmed investigations of completed 40,506 is defined as “ (confirmed occurred”). or neglect that abuse 4,047 low acuity and low-risk cases were transferred to the new Alternative the new Alternative transferred to cases were acuity and low-risk low 4,047 s Response 46,336 allegations were 46,336 www.TexasYouth.org

www.dfps.state.tx.us/About_DFPS/Data_Books_and_Annual_Reports/ · · · Child Protective Services (CPS) Services Protective Child to and investigating Services (CPS) is responsible for responding Child Protective services for families and at-home providing allegations of child abuse and neglect, care managing the foster environments, children from unsafe youth in need, removing and out of the CPS system youth to successfully transition as well as assisting system, CPS interacts with children at three stages: investigating Thus, environments. into safe placing youth in emergency or inpatient treatment, and abuse allegations, custody environment. transitioning youth back into normalcy and a healthy were alleged victims of abuse or children statewide of 290,471 a total In FY 2015, more than one child) of alleged child cases (some cases involve neglect in 274,448 the number of CPS abuse and neglect — a more than 23 percent increase from reports of child abuse/neglect in 2011. Source: Texas Department of Family Protective Services. (2016). (2016). Services. Protective ofDepartment Family Texas Source: (1-800-98-YOUTH Hotline Youth the Texas The SWI division of DFPS also operates or neglect, abuse, and referrals to youth and their parents in an effort to prevent resources, from home.” and running away delinquency, truancy, Figure 98. Source of Abuse/Neglect Reports Received by State-wide Intake in Intake State-wide by Received of Reports Abuse/Neglect Source 98. Figure Programs APS In-Home CPS and 2015: provides both crisis intervention and information regarding community resources. crisis intervention both provides · DFPS 250 · unavailable, CPSmay placeayouthinvariety of differentsettings, including: court fortemporarylegalconservatorship. Whenfamilyandkinshipplacementsare family orfriendswhocanprovide shelterandcareforthatchild,CPSwillpetition the When itisunsafe forachildtoremaininhisorherhomeandtherearenoappropriate · · · · 2015, and31,200ofthemlived insometypeofafoster careplacement. total ofmorethan47,000 children wereinDFPScustody atsomepointduringFY More than40percentofchildreninDFPSconservatorshiparekinshipplacements. foster substitute placements suchaskinshipcareandDFPSadoptive homes). children intheTexas foster caresystem (excluding the11,517childreninnon- treatment options have beenexhausted. AsofAugust 31, 2015, therewere16,378 A childisplacedinfoster careafterother servicesandoutpatient parentengagement home, and/or legalaction toterminateparentalrights. while thechildremainsinhome,acourtpetition toremove thechildfrom This couldincludefamily-based protective servicessuchasoutpatientengagement determines thatachildisnot safe, thenthecaseworker initiatesprotective services. behavioral healthservicesandassessmentsasnecessary. Ifthecaseworker health andpsychosocial functioningofeachchildandmake referralsforadditional in thechild’s life(e.g.teachersandsiblings),theCPSworker willassessthemental photographs ofinjuries(ifpresent)anddocumentedconversations withother adults living environment. victims, withalleged Baseduponin-personinterviews behavioral health,basic physical condition,andthesafety andlivabilityoftheir During childabuseandneglectinvestigations, aCPSworker screensthechild’s whether thereisathreattothesafety ofthechildrenintheirhomeenvironment. CPS investigates abuseandneglectallegationstomake adetermination asto Ch Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas most prevalentracialgroup. children infoster care,withAfrican-American children(22.4 percent)asthethird (39.2 percent)andCaucasianchildren(32.0 percent)make upthemajorityof chapter forfurtherinformation. Disproportionality andRacial/EthnicDiversity ofChildren andYouth sectioninthis Texas childpopulation)areoverrepresented inthefoster caresystem —seethe demographics ofTexas childrenasawhole,African-American children(11.4% of

Facilities ov Residential group care facilities Foster family Foster group children’ Emergency · · ·

ild Abuse/ died while they were enrolled in the state foster caresystem. DFPS confirmed171abuse/neglect relatedfatalities ofchildren,fiv from their homes inFY Following differentdegreesofCPS intervention, 17,151 childrenwereremoved victim). unduplicated confirmed In the 40,506 confirmed casesofchild abuseorneglect,therewere66,721 neglectful caregiver or environment. 111 erseen by another state agency. homes homes N s shelters eglect 117 2015 inorder to keep them safe fromanabusive and/or However, whenyoutake intoaccounttheracial child victims (i.e. some cases have morethanone 118 a nd 112 CPS 120

I nvestig 113 a tions 116 Hispanic e ofwhom 114,115 A 119

DFPS 251

https://www.

. Retrieved from from Retrieved 2015. Book Data and Report Annual ystem 121 S es collaboration with families and a focus on es collaboration t declare a formal finding of abuse or neglect. finding of declare a formal t 122 “assessments”, not investigations. not “assessments”, families with appropriate service providers. service with appropriate families esponse designate an alleged perpetrator (i.e. the name of the allegeddesignate an perpetrator R A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation tive a The CPS worker connects worker The CPS encourag as a whole The AR process The CPS worker conducts worker The CPS does no assessment A completed does not The report Central Registry). Child Abuse/Neglect to the added is not perpetrator and rehabilitation. treatment

dfps.state.tx.us/About_DFPS/Data_Books_and_Annual_Reports/2015/pdf/Databook2015.pdf National research has found that differential response systems lead to more systems National research has found that differential response · · · The AR used by Texas’ CPS is characterized by the following features: the following CPS is characterized by Texas’ The AR used by · The CPS Alternative Response (AR) system aims to ameliorate the stress of a CPS aims to ameliorate the stress Response (AR) system The CPS Alternative the typical adapting in need by services to more families provide and investigation CPS allegation. In doing so, identify a lower-risk when workers process investigation means of dealing with less serious cases of abuse and a non-adversarial provides In considering diverting manner. and less intrusive neglect in a more client-centered of history any of the allegation, the type and severity considers a case to AR, staff family to participate and be involved and the willingness of the previous reports, as “differential response,” at the national level AR, also known with support services. parental involvement, fostering places an emphasis on reinforcing family strengths, of support systems. and the development · Source: Texas Department of Family and Protective Services. (2016). (2016). Services. Protective and ofDepartment Family Texas Source: Altern Figure 99. How CPS Investigates Allegations ofAbuse Allegations Child CPS Investigates How 99. Figure Figure 99 illustrates the CPS investigation process upon receipt of an allegation: receipt upon process CPS investigation the 99 illustrates Figure DFPS 252 reduces theneedforlong-termservicesandmorecostly intensive interventions. initial investments, thisapproachismorecost-effective inthelongrunbecauseit · · · · include: · system called theHealth Passport totrackandmonitorthe medicalinformationof To helpsolve this continuityofcareissue,DFPSbeganusingacomputer-based the suddendiscontinuation ofmedicationswhenachild’s placementchanged. care createdseriousproblems suchastheover-prescription ofmedicationsor Historically, thelackofacentralmedical recordssystem forchildreninDFPS program andhasbeenoperatingthesinceitsinception. model. SuperiorHealth Plancontractedwiththestate toruntheSTAR Health caredeliverywith primarycareandbehavioral healthservicesusingamanaged In 2008, theSTAR Health programwas createdtoprovide childreninfoster care SUPERIOR HEALTH SYSTEM (STAR HEALTH) Accessing for theyear. System inFY2015, only1.5percentofthe274,448 total reportsofabuseorneglect A total of4,047 allegationsofchildabuseorneglectweretransferredtothenewAR community involvement, andimproved worker satisfaction. positive outcomesrelated tochildsafety, better increased familyengagement, Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas dentists, visionservices, andmore. has accesstoprimarycarephysicians, behavioral healthclinicians, specialists, transitional Medicaid services). in kinshipcare,foster 22,andformerfoster youthuptoage youthreceiving In FY2014, 30,732 childrenwereenrolledinSTAR Health (includingthose system. improving datasharingandaccesstohealthservicesforchildreninthefoster care program was designedtoimprove thecontinuityand coordinationofcareby 2015 werelatertransferredtofullabuse/neglectinvestigations. AR protocols andonly230ofthe4,047 casesthatwereinitiallyreferredto ARinFY AR tobeusedinallregionsstatewide by theendof2017. continues andtherearenounforeseenbarrierstoimplementation, DFPSexpects DFPS planstohave ARfullyfunctioningby May 2016. IfthecurrentsuccessofAR Dallas andLaredo. Afewcaseshave beentransferred toTyler andMidland,where Texas DFPSbeganARpilot programsinFY2015 inthreeregions—Amarillo, emotional, orphysical development. providers tohelpaddressbehaviors thatmay beharmingachild’s cognitive, social, parents,AR engages prompts themtoidentifytheirstrengths, andconnectsthemto

Depression Disease Management Program Depression Disease Management Detoxification Rehabilitation skills training Psychological Psychiatric 126 CPScaseworkers have received trainingonhow toimplementthe services testing (including screening, assessment, and diagnosis) services M ent a l He 129 STAR Health requiresthateachfoster carechild 130 Behavioral healthservicesoffered by Superior a lt h

131 S ervices 125 123 Despitehigher 127 128 Thestatewide 124

DFPS 253 Thus, Thus, Those who do 133 134 137 The Health Passport follows follows Passport Health The 132 With the implementation of the FFCC plan, more With the implementation of the FFCC 139 136 135 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation birthday. Effective January 2014, former foster care children receiving former foster January 2014, Effective birthday. th Young adults who do not qualify for FFCC may purchase health insurance purchase may qualify for FFCC adults who do not Young 138 retaining health insurance for former foster care children for a longer time period of health insurance for former foster retaining and reliable more consistent ensuring that they have outcomes by lead to better may and long- for recovery and supports needed access to the mental health care services term wellbeing. adults formerly in the foster care system will have health insurance coverage up until health insurance coverage will have care system adults formerly in the foster their 26 healthcare services through one of the insurance plans that existed at that time — existed the insurance plans that healthcare services through one of Care in Foster (MTFCY) or Former Youth Care for Transitioning Foster Medicaid — were transitioned to FFCC. Higher Education Program (FFCHE) not qualify for FFCC will still be covered under MTFCY as long as they meet MTFCY MTFCY as long as they meet under MTFCY be covered will still qualify for FFCC not income requirements. conservatorship that are There are two groups of young adults previously in CPS health services: individuals originally from Texas ineligible for access to post-care who and individuals state in another care system aged out of the foster who have to another since moved and have care system foster agedhave out of the Texas state. As a component of the Affordable Care Act (ACA), the Former Foster Care Children Care Foster Former the Care As a component of the Affordable Act (ACA), care to former foster insurance coverage health extended provides Program (FFCC) children under the age of 26. FORMER FOSTER CARE CHILDREN PROGRAM (FFCC) AND MEDICAID FOR AND MEDICAID PROGRAM (FFCC) CHILDREN CARE FORMER FOSTER (MTFCY) YOUTH CARE FOSTER TRANSITIONING lose health insurance care system children who age out of the foster foster Many mental health care experience trauma or other children in foster Many coverage. left the child welfare system. after they have conditions that impact them even than young adults in the general care alumni are more likely population Foster a stable keeping experience difficulties in finding and to rely on public assistance, and mental health concerns. a high risk for physical home, and have every child enrolled in the STAR Health program. Health in the STAR child enrolled every through the Health Insurance Exchange if they have sufficient resources and/or sufficient resources and/or if they have Exchange Insurance through the Health qualify for Medicaid. still or they may subsidies, federal marketplace income, or has no asset, FFCC care insurance plans, foster or other Medicaid Unlike insurance plans based There are two FFCC educational requirements for coverage. each by The services provided Health. and STAR on the age of the applicant: STAR and STAR of these plans vary — see HHSC section for more information on STAR services and eligibility. Health children wherever they go so that every caregiver, DFPS staff member and medical and medical member staff DFPS go they caregiver, wherever children every so that and or her past of his understanding a child has a full working with professional central, easy-to-find in one access that information and can current treatments through a password- online is available Passport Health Each child’s location. While consenters. and medical staff DFPS be accessed by website and can protected claims it provides medical record, a full and complete is not Passport the Health provided health services and behavioral dental, vision, physical, data on pharmacy, be directly uploaded drug allergies can also on a child’s to each child. Information and can alert medical professionals website and the system Passport to the Health or allergy. drug interaction unsafe if there is a potentially caregivers DFPS 254 for childrenwithcomplexemotional andpsychological needs. treatment centers(RTC). AnRTC provides careandtreatmentservicesexclusively children aretypicallyplacedforlessthan30days, andmorelong-termresidential sheltersinwhich term residentialfacilitiesthatprovide basicchildcare,emergency of18years.more childrenuptotheage arelicensedby GROs DFPSandincludelong- facility. isacongregatecarefacilitythatprovides AGRO residentialservicesfor13or parents, afoster residentialoperations(GRO) familygrouphome,orageneral not available orappropriate,thechildmay beplacedinafoster homewithfoster tx.us/Child_Care/Search_Texas_Child_Care/ppFacilitySearchResidential.asp child-care facilitiesinthe state —thatsearchtoolcanbefoundatwww.dfps.state. services forchildrenwithemotional disorders. areclassifiedas of thoseGROs RTCs andanother 124 ofthemprovide treatment As ofAugust 2015, therewereatotal regulatedby of235licensedGROs DFPS—74 to considertemporaryplacementwitharelative ifpossible. congregate carefacilities. Priortoplacingachildinfoster care,thecourtisrequired home-based environments, somechildreninthecustody ofthestate areplaced in While thestate recognizesthatitispreferredchildrengrow upinfamily, I Source: Texas Family Department of Protective Services. (n.d.) Figure 100. Health Insurance Programs forFormer Foster Care Children foster carechildren. See Figure100foranoverview ofexisting healthinsuranceprogramsforformer Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas a total of9,026 youth. services toatotal of3,483 childreninAugust 2015, had capacitytoserve whileGROs 137E0474AE2C/attachments/2AC8E4AE-0BE2-452E-90B0-6668C21C7A2D/foster-youth-health-insurance-finalsept2015.pdf Youth (MTFCY): September 2015 version. Medicaid for Aged Out Foster Youth Ages 18-25 Former Foster Care Children’s (FFCC) Program and Medicaid for Transitioning Foster Care Protection/Youth_and_Young_Adults/Transitional_Living/medical_benefits.asp; and Texas Law Help. (n.d.) Youth (MTFCY) tioning Foster Care for TransiMedicaid - (FFCC) Children Program Former Foster Care Plan Name nstitution · · · · · · · · · Eligibility

ship, alien status, and residence. age 18 or older. Refugee Minor Resettlement Program in the state of Texas at Inadequate health Aged out of U.S. Covers ages aid on their 18th birthday) Ineligible for FFC Meet all other care. Started receiving Ages 18 to Anyone who has aged a 144 l citizen or qualified non-citizen. DFPSprovides anonlinesearchtoolthatlists allofthese R Pages 4 and 5. Retrieved from http://texaslawhelp.org/files/685E99A9-A3EB-6584-CA74- esidenti 26. Texas conservatorship at age 18 or older. 18 to 21 Medicaid eligibility criteria such as U.S citizen- C (typically because they did not have Medic- Medicaid when he or she aged out of foster Medicaid when he or she aged out of coverage. out of foster care or the Unaccompanied out of Medical Benefits. a l S 142,143 ervices Retrieved from RTCs hadcapacitytoprovide https://www.dfps.state.tx.us/Child_ 140 Ifthisoption is 141 educational requirements. No asset, income, or person in a family) $1,384 for each additional per month (with an added $3,955 Income limit of ments Income or Other Require- Free Health Insurance .

DFPS 255 151 145 148 153 Confirmed deaths from Confirmed deaths 147 150 Overall abuse and neglect- Overall 146 154 deaths in FY 2015 continued to involve involve continued to 2015 deaths in FY 149 accounted for roughly 80 percent of all confirmed percent for roughly 80 accounted include a parent or guardian actively using substances and/ using substances actively or guardian include a parent who had a confirmed child abuse or neglect-related fatality child abuse who had a confirmed in child abuse or neglect-related deaths in FY 2015, but deaths in FY 2015, or neglect-related in child abuse 152 ISSUES

trators with an open and active CPS case at the time of death. case at the CPS active open and an trators with A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation child abuse and neglect-related deaths between 2011 and 2015. 2011 deaths between and neglect-related child abuse or actively under the influence of substances that impacted their ability to protect impacted their ability to protect that of substances influence under the or actively for the child. and care under the ageChildren of three represented the majority of (27 percent) and fathers percent) (36 Mothers primary perpetrators in 2015 had a history of prior involvement with CPS. involvement prior of a history had in 2015 families fatalities involved and neglect-related of abuse- 11 percent than More perpe and/or abuse and neglect- of (FY 2014) and 48 percent (FY 2015) 39 percent Between child fatalities related A history of child maltreatment and domestic abuse increases child fatality risks; increases abuse domestic and of child maltreatment A history of families 47 percent for accounted (7 percent) cares sitters/day and baby (18 percent) boyfriends in these cases. perpetrators a quarter of roughly While the majority of the 171 child of the majority While the Anglo (51) and Hispanic (67) children, African-American youth are more youth African-American (67) children, Hispanic and Anglo (51) death statistics, and neglect-related in child abuse represented disproportionately rate. fatality 4.2 per capita with a

related child fatalities in Texas have fallen in recent years. fallen in recent have in Texas related child fatalities physical abuse or intentional trauma dropped by 26 percent between 2011 and 2015, and 2015, 2011 26 percent between by abuse or intentional trauma dropped physical sleeping or death from unsafe from neglect (e.g. drowning and confirmed deaths time period. 22.5 percent during that same conditions) decreased by · · · · · It is important to look at trends in past child deaths in order to understand the risk child deaths in order to understand past It is important to look at trends in child abuse and neglect-related fatalities DFPS to prevent factors that can be used by risk factors for child abuse or neglect-related salient in the future. Some of the most pieces of information: out from the following fatalities can be drawn · The rate of child abuse and neglect-related deaths per 100,000 Texas children is Texas per 100,000 abuse and neglect-related deaths The rate of child in 2015. to 2.3 in 2011 from 3.5 also dropping, down CHILD FATALITIES IN THE CPS SYSTEM THE CPS IN CHILD FATALITIES but the rate of system, child welfare to occur in the Texas continue Child fatalities of 171 children that a total DFPS reports in recent years. has decreased these deaths percent decrease — a 36 in FY 2015 as a result of child abuse or neglect died in Texas deaths were The majority of these when there were 231 such deaths. from FY 2011, (41 percent). percent) as opposed to abuse-related neglect-related (59 CONTINUING DFPS 256 · foster carehomes;some ofthesenewrulesinclude: deaths ofchildreninfoster care,HB781(84 Following withinDFPS toaddressabuseandneglectrelated internalrulechanges · · · · · neglect-related deathsinTexas: There aremany possiblereasonsforthisdramaticdeclineinchildabuseand Safety/documents/Child_Fatality_Annual_Report_2014_2015.pdf and FY 2015 Analysis. Page 50. Retrieved from Source: Texas Family Department of and Protective Services. (2016, April). Figure 101. ChildFatalities in Texas: FY 2015 Figure 101 provides details onthechildfatalitiesinTexas inFY2015: Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · approved. minimum caregiver trainingrequirementsbefore contracts andplacementsare by requiringfoster careproviders toincludemorerigorous andchildplacingagencies

Additional interview Additional health services, suicide, and vehicle safety. handle child fatality cases involving co-sleeping, drowning, firearmaccidents, (CFR) Teams, such asthe Blue Ribbon Task Force and state andlocal Child Fatality Review that perpetuate these fatalities, analyzing child abuse and neglect fatalities and the riskfactorsandsystemic issues vehicles, and injuryresultingfrom domestic violence. causes of neglect-related child fatalities: unsafe sleeping arrangements, unsafe focus onpublic A bigger (MEDCARES), and community, including the Medical Child Abuse Resources andEducationSystem Improved More accessibilityandavailability of More consistent s Increased community-lev DFPS formed the Office ofChildSafe 156 Newregulationswereput intoplacethatenforcestricter monitoringof training andavailability of treatment resources forthemedical ystem-wide guidelines (beginning in 2012) forCPSworkers who ystem-wide guidelines (beginning s withneighbors, clergy, school employees, community health approaches to reducing three ofthe most prevalent el interventions andinitiatives to combat childdeaths, https://www.dfps.state.tx.us/Prevention_and_Early_Intervention/Office_of_Child_ ty in2014, tasked withindependently preventive, community-based behavioral

th , Burkett/Zaffirini) addressedtheissue Child Abuse and Neglect Fatalities Annual Report: FY 2014 155

DFPS 257 157 162,163 , Kolkhorst/Dutton), which , Kolkhorst/Dutton), 159 th and parenting of foster parents, and parents, of foster parenting and t law enforcement calls to the home. to the calls enforcement t law While not overrepresented at the statewide at the statewide overrepresented While not CPS investigators and caseworkers. and caseworkers. CPS investigators

160 Another bill passed in 2015 that should improve bill passed in 2015 Another , 161 158 ers and individuals who report abuse and neglect, who report abuse ers and individuals make it difficult for parents to obtain stable housing and obtain to for parents it difficult make erty and exposure to neighborhood risks and harms, erty and exposure A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Increased rates of pov Increased that disparities Societal employment, work among CPS Racial biases and/or among cultural competence Lack of Increased parent and family risks family parent and Increased Review of household finances and pas finances and of household Review members, and family members living outside the home, the outside living members family and members, relationships of personal Assessment

· · · · A number of theories have been offered as explanations for the disproportional been offered as explanations A number of theories have including: welfare system, groups in the child ethnic representation of certain racial and · created an independent ombudsman for youth in foster care to help streamline and care to help streamline ombudsman for youth in foster created an independent neglect. into reports of abuse and investigations standardize level, Hispanic children in Texas are another group disproportionately represented group are another Hispanic children in Texas level, of African This overrepresentation system. at certain points in the child welfare child welfare services has been present in all American and Hispanic youth receiving unique to Texas. and is not 50 states DISPROPORTIONALITY AND DIVERSITY OF CHILDREN AND YOUTH IN CPS YOUTH AND OF CHILDREN AND DIVERSITY DISPROPORTIONALITY in CPS Racial and Ethnic Diversity children and youth in of African American The disproportionate representation continues. CPS system the statewide In addition to these stricter screening requirements and the new child fatality trainings new child fatality and the screening requirements to these stricter In addition Changing process (see CPS transformation are part of the tools that and risk assessment to closely required now are also agencies child placing Section), (CPAs) Environment frequent divorces, marriages, homes (such as job losses, monitor changes in all foster additions). The goal and family oversight of this change more is to provide visitors, but also only child fatalities, not care children and prevent of foster and protection neglect. trauma and/or unnecessary · · safety for children in foster care going is SB 830 (84 in foster forward for children safety DFPS 258 2015, therewereatotal of6,888 childrenwaiting tobeadopted inTexas. feedback fromcaseworkers has beenvery positive. To date,morethan5,000 workers have taken thetraining andDFPSreportsthat training called,“Knowing Who You Are:RacialandEthnicIdentity Training.” CPSandAPS)arealsonow requiredtotake aracialdiversity caseworkers (both Committee toreducedisparities.the DisproportionalityAdvisory NewDFPS specialist positionsandworked toincreasestaff diversity andcollaborationwith kinship responsibility aren’t eligibletoreceive support serviceslike Temporary family, support network andculture.Unfortunately, individualswhotake onthis close tothefamilysothat childrenmaintainconnections totheircommunity, increasing supportforkinship care—placingthechildwith arelative or someone Another key componentto addressingracialandethnic disproportionality isCPS’ struggles thatfamiliesinpoverty face. the simulationsistoincreaseunderstanding andawareness abouttherealitiesand to provide somecaseworkers withPoverty Simulationtrainingsin2013. of Thegoal racial andethnic disparitiesinthechildwelfaresystem. For example,CPSstarted delivery forallchildren,CPShasmadesomeattempts inrecentyearstoreduce comprehensive andqualityservicesthroughitsregularprogrammingservice While DFPS’ istoaddressdisproportionalitythroughproviding maingoal Texas thanany typicallywait longer other grouptobeadopted (13months). removed fromahomebecauseofsafety concerns(.4 percent),Asianchildrenin proportion oftheconfirmedvictimsabuse(.6percent)andnumberchildren Anglo children(9.6 months).AndwhileAsianchildrenaccountforavery small adopted (medianof12.3months)comparedtoHispanicchildren(9.6 months)and to2015 data,African-AmericanAccording tobe childrenalsowait muchlonger state.tx.us/documents/about/Data_Books_and_Annual_Reports/2013/Combined13.pdf Source: Texas Family Department of and Protective Services. (2016). Figure 102. Disproportionality inCPS:Racial andEthnicDifferences inFY 2015 children invoved intheCPSsystem atvariouslevels: Figure 102shows theethnic andracialprofileofchildrenin Texas comparedwith Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 166 CPShasalsocreateddisproportionality

2015 DFPS Data Book. Page 42. Retrieved fromhttp://www.dfps. 167

165 164 InFY DFPS 259 171 That stigma can also That stigma 170 have a greater chance of having having a greater chance of have continue into adulthood, as studies into adulthood, as studies continue One study found that over 30 percent found that over One study 172

176 169 173 family that understands, accepts, and is responsive to and is responsive accepts, understands, family that Once kinship placements take place, programs like the Family Family the like place, programs take placements Once kinship 168 175 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 174 . of LGBTQIA youth reported suffering physical violence at the hands of a family the hands of violence at physical reported suffering youth of LGBTQIA out. coming after member Disparities for LGBTQIA foster care youth for LGBTQIA foster Disparities stable as adults less financially youth are care LGBTQIA former foster that show peers. heterosexual than their Difficulty finding a foster finding a Difficulty of 78 percent that up to found study One rangetheir full needs and identity. of from their foster or ran away either removed care were youth in foster LGBTQIA their sexual orientation or toward hostility of encountering as a result placements genderidentity. LGBTQIA youth who experience family rejection youth who experience LGBTQIA social treatment due to negative and unfair rates of harassment, exclusion Higher attitudes mental health issues in adulthood and are significantly more at risk for suicide risk for more at are significantly in adulthood and issues health mental use. and substance depression, attempts,

lead to an under-utilization of social supports (e.g. family or church clergy) and of social supports (e.g. family or lead to an under-utilization services (e.g., school-based counseling) or against if the child feels discriminated is self- Due to a lack of reporting and the fact that sexual orientation accepted. not number determine the actual identified and is fluid, it is difficult to gender identity the National Resource Center However, care system. of LGBTQIA youth in the foster in foster that LGBTQIA youth are overrepresented reports Development for Youth care. 5 and 15 percent of all youth in foster care, accounting for between Group Decision Making (FGCM) model are essential support services that can help support services are essential model Making (FGCM) Group Decision so the kinship placement transition to a successful bonds and support strengthen with associated trauma and instability to deal with the have child does not that the times. multiple to move having · specifically addressing the needs of There are currently no policies in Texas and there is no required data system care foster LGBTQIA youth in the state’s in comparison to adoption reporting on the number of LGBTQIA youth awaiting support services will Increasing family and caregiver peers. their hetero-normative their and reduce both the well-being of LGBTQIA children in Texas support likely care system. of entering into the foster risks and likelihood safety · · Research studies show that LGBTQIA youth have an increased risk of experiencing that LGBTQIA youth have show Research studies hetero- situations and outcomes compared to their different negative several peers: normative · Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Assistance Nutrition Supplemental or (TANF) Families Needy for Assistance encouragehelp to financial only limited provides CPS benefits. (SNAP) Program kinship placements. Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual Youth Youth and Asexual Intersex Queer, Transgender, Bisexual, Lesbian, Gay, (LGBTQIA) couples following same-sex national focus on the rights of With the increasing over Hodges, the conversation v. ruling in Obergefell the Supreme Court’s transgender, bisexual, gay, has expanded to include lesbian, disproportionality in also over-represented are and asexual (LGBTQIA) youth who intersex queer, this makes associated with LGBTQIA identity The stigma system. the child welfare conditions such as trauma and mental health vulnerable to both population more use, and heightened risk of suicide. depression, substance DFPS 260 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas children infoster carewereprescribedatleast onepsychotropic medication. for foster youthinTexas reachedapeakin2004,whencloseto42percentofall times higherthanchildrennot infoster care. Texas, childreninfoster carewereprescribedpsychotropic drugsatrates2.7to4.5 2011 reportby theU.S. Government Office(GAO)showed thatin Accountability children. powerful subset ofpsychotropic medicationsthatcancarrysignificantsideeffectsin that nationally, 10percentoffoster kidsreceived antipsychotic medications, a term effectssuchas stunted physical development. and requirementsfortheprescription ofpsychotropic medication. Psychotropic Medication UtilizationParameters in2005thatestablished standards subsequent increasedmediafocusontheissue,HHSC, DSHSandDFPSreleased children. Following thealarmingratesof prescriptions infoster carein2004and regulate andmonitortheprescription ofpsychotropic medicationsforfoster care Over thepast decade,Texas hasundertaken aseriesofdifferent steps tobetter individual’s mind,emotions, andbehavior. behavioral healthneeds withpsychotropic medications, drugsthataffectan Foster childrenhistorically have beendisproportionatelytreated fortheir PSYCHOTROPIC MEDICATIONS INFOSTER CARE As shown above inFigure103, psychotropic medicationprescriptions forfoster Medications-Use-in-TexasFosterChildrenACCESS.pdf Foster Care: Fiscal Years 2002-2015”. Retrieved from Source: Texas Health and Human Services Commission. (2016). Psychotropic “Update on the Use of Medications for Children in Texas Figure 103. Psychotropic Reduction of Medication Usein The Texas Foster Care psychotropic medications. the parameters clinicallyappropriateandinformedusageof was toencourage of suicidalthoughts. decreased/increased appetite, weightgain,headaches, nausea, andincreasedrisk also carrysignificantandpotentially long-lasting sideeffects, includingtrembling, Even wheneffective intreatingmentalhealthconditions, psychotropic medications 182,183 180 Usageofpsychotropic medicationsmay alsoresultinlong-

https://www.hhsc.state.tx.us/hhsc_projects/upmtfc/2015-Update-on-Psychotropic- 177 Psychotropic medicationprescriptions 179

181 Oneresearchstudy showed 184 The goal of Thegoal 178 A DFPS 261 187 Rates of 189 Many children in Many 188 Professionals who interact 190, 191 190, ed care organization (MCO) providing all (MCO) providing ed care organization , Kolkhorst/Nelson), which improved accountability accountability which improved , Kolkhorst/Nelson), rd 186 185 (83 ealth Passport discussed previously, which allows DFPS staff, DFPS staff, which allows discussed previously, ealth Passport , Kolkhorst/Nelson), which created provisions to strengthen informed to strengthen created provisions which , Kolkhorst/Nelson), A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation rd and regulation of psychotropic prescriptions, required additional training for additional required prescriptions, of psychotropic and regulation a doctor’s children, required to consent to medical care for foster adults authorized created a medication, psychotropic on for children days every 90 office visit plan for children youth transition brochure and informational medical consenter to biological parents of notification required and medications, prescription taking medications. being prescribed psychotropic their child (83 HB 915 The establishment of one manag The establishment The creation of the H of the The creation for care, allowing pharmacyin foster for children care utilization and acute decision making regarding past sharing and streamlined information improved treatments. and current medical professionals, foster parents and caregivers to track and easily access each and caregivers parents foster medical professionals, online location. one central in and medical information history medication child’s The passage of HB 915 The passage consent in prescribing psychotropic medications to children in state custody. custody. to children in state medications psychotropic in prescribing consent to discuss with youth required are now ad litem litem and attorneys Guardians ad for their are receiving and ask care they and mental health the medical clients inform youth agesto explicitly required 16 and older now also They are input. involving By medical consenter. own to be their the court petition may that they of the child, the child, and care on behalf can consent to medical who individuals of the abreast can be kept care in a child’s involved everyone system, the judiciary history. medical child’s

· foster care also experience trauma as a result of multiple removals and placements and placements removals care also experience trauma as a result of multiple foster welfare and nearly half of youth in the child and shelters, homes in different foster problems. or behavioral clinically significant emotional have system TRAUMA-INFORMED CARE TRAUMA-INFORMED risk are at greater nationally and in Texas who are in child welfare systems Youth use conditions than children in the for trauma-related mental health and substance majority of children who enter the foster general population, and the overwhelming experience trauma as a result of neglect or abuse. care system As a result of these and other changes, the percentage of children in Texas foster foster the percentage of children in Texas changes, As a result of these and other in 2005 from 37.9% medication has dropped psychotropic care being prescribed any Looking more closely at children taking (see Figure 103 above). to 22.6% in 2015 care of children in foster has reduced the number Texas multiple medications, 2004 and reduced by 71 percent since drugs by prescribed two or more psychotropic medications. or more psychiatric 73 percent the number of children taking five · · care youth have declined significantly in recent years, particularly in 2014 and 2015. 2015. and in 2014 particularly years, in recent significantly declined youth have care to and advocates by legislators of efforts a decade over result of is the reduction This in foster for children medications psychotropic issue of overprescribing address the include: recent successes care. A few · behavioral problems, developmental delays, and need for psychiatric intervention intervention for psychiatric and need delays, developmental problems, behavioral care youth range from 60 to 80 percent. for foster and work with these children must therefore be cognizant of their trauma-related therefore and work with these children must for mental health care. needs and increased potential the individual, and Trauma-informed care recognizes the effects of trauma on DFPS 262 · · · · · trauma-informed caretrainingprogramforanumber ofdifferent groups, including: to promote trauma-informedpracticesby operatingandmaintainingitsown screening fortraumawithin45days oftheirentryintoservices. entering intoDFPScarereceive acomprehensive assessment thatincludesa Then in2015, the84 informed carewithinDFPS. SB125(84 · · decreases relianceonpsychotropic medicationsandincreasesplacementstability. experiences. Itthereforeprovides anon-pharmacologicalapproachtohealingthat provides carethatisevidence-basedandtailoredtoan individual’s needsandunique Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · children receivingservicesthroughDFPS: these billsdidnot directlymodifyDFPSoperations, theyhadadefiniteimpacton that expandededucationandtrainingontraumatrauma-informed care.While The pushfortrauma-informedcareinTexas gainedtractionin2013 withthreebills and supportsneeded. understanding how toapproachtraumatizedchildrenandprovide themtheservices can provide communities, parents, schools, andcaseworkers abetter set ofskillsfor behavioral tendenciesand cognitive development. Asaresult,trauma-informedcare better insightintoachild’s traumareminders, stress signals, copingmechanisms, traditional servicesordailyliving.Understanding theeffectsoftraumacanprovide caregivers toavoid any re-traumatizationthatmay occurduringthedelivery of Awareness ofanindividual’s trauma-inducingexperiencescanhelpworkers and seeking behavioral healthservices. with anunderstanding oftherolethattraumaandviolenceplay inthelives ofpeople informed system, every componentoftheservicesystem isevaluatedandreframed framework thatstrengthens servicedelivery atalllevels ofcare.Inatrauma- Trauma-informed careisnot adiscrete intervention, butratherisatreatment

based personnel. probation officers, juvenile supervision officers, andcourt-supervisedcommunity- DFPS caseworkers andsupervisors. Adoptiv Foster parentsandkinship centers Child advocacy Court-appointed special adv training in trauma-informedcare. health intervention teams have training in trauma-informedpractices. SB 152(83 SB 7(83 SB 1356 (83 e parents, and rd , Nelson/Raymond) ensuredthatprofessionalsworkingonbehavioral rd rd , Nelson/Kolkhorst) requireddirectcare staff at state hospitalstohave , Van dePutte/McClendon) required trauma-informed trainingfor 193 th Legislaturesignificantlyexpandedandimproved trauma- (CACs), caregivers, ocates (CASA workers), 195 197

th , West/Naishtat) mandatedthatchildren 196 DFPScontinues 194 192

DFPS 263

Figure 198 199 Regional Availability Regional Funds distributed to many communi- to many distributed Funds ties Texas. across (78744), Austin (79107), Amarillo Christi Corpus (78520), Brownsville Dallas (75216), Dallas (78415), Worth Fort (79924), Paso El (78217), (77550), Galveston 76164), & (76106 (77506), Pasadena (77081), Houston (78501), McAllen (79415), Lubbock (76707) Waco (78207), Antonio San El County, Ector County, Cameron Hidalgo County, Gregg County, Paso County, Travis County, Potter County, County Webb All counties in Texas in counties All - Program Description and Service and Description Program Uses federal grant dollars to develop and support and develop to dollars grant federal Uses community increase to providers service existing strengthen of services, awareness prevention existing abuse child in involvement parental and community engage to families encourage and efforts, prevention con- CBCAP through provided Services services. in fatherhood education, parental respite, include: tracts and visitation, home leadership, parent services, campaigns. awareness public Contracts with community organizations in zip codes zip in organizations community with Contracts ofincidence high a have that imple- to crime juvenile programs. prevention delinquency juvenile ment may but communities across vary offered Services programs, youth-employment mentoring, include youth and activities, recreational preparation, career development. leadership for neglect and abuse child prevent to aims HOPES development the encouraging by 5 to 0 age children oflikelihood the reduce will that factors protective targeted are Services ofneglect. and abuse child home-visiting include a and counties specific to component. substitute (foster) in youth older prepare to Intended PAL CPS. and custody DFPS from exit their for care financial and social the with youth provide classes Services life. successful a lead to needed skills transpor housing, training, skills vocational include: classes, GED management, financial health, tation, providers also PAL mentoring. and counseling, and programs (SIL) Living Independent Supervised individuals. eligible for allowances living transitional A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Program Community-Based Community-Based - Abuse Child Preven (CBCAP) tion Community Youth Youth Community Development (CYD) Outcomes Health Prevention through Support Early and (HOPES) Adult for Preparation (PAL) Program Living The Prevention and Early Intervention (PEI) division of DFPS partners with of DFPS partners (PEI) division Intervention and Early The Prevention and runaway, truancy, abuse, neglect, to prevent and families providers community strategies intervention early Community-based enforcement. law with involvement access to timely providing by mental health conditions can address and programs populations who may and minority disparities for low-income services and reducing programs may these Additionally, or specialists. to private providers access have not health conditions behavioral mental health and risk of developing identify youth at outcomes such as homelessness, negative treatment to prevent and link them to incarceration, gaps in school from the home, removal poverty, family separation, from school altogether. dropout or complete enrollment and attendance, Prevention and Early Intervention (PEI) Intervention Early and Prevention 104 lists the various programs and services provided through the PEI division of DFPS. through the PEI the various programs and services provided 104 lists Texas and Services in (PEI) Programs and Early Intervention Prevention 104. Figure Programs and outreach efforts coordinated through this division address negative this division address negative efforts coordinated through Programs and outreach they are in crisis. services for youth before to provide outcomes and try 4.5 percent PEI programs — an almost by people were served 75,449 In FY 2015, in FY 2014. the number of individuals receiving PEI services increase over DFPS 264 sexual assault, andany other formsof abuse,neglectorexploitation. These exploitation (e.g.takingsocial securitychecksormisusing ajointbank account), by theiradultchildren, physical andemotional abuseby caregivers, financial investigations. Reportedallegationscaninclude self-neglect,abuseofparents Investigations by APSinvolve both in-homeinvestigations andfacility · · · · 18-64whoare: 65orolderandadultsage for individualsage abuse, neglect,andexploitationforspecificgroupsofpeople. APSprovides services ProtectiveThe Adult Services(APS)divisionofDFPSinvestigates allegationsof Adult Protective Services (APS) Texas Family Department of and Protective Services. (n.d.). Prevention and Early Intervention (PEI) Programs. Retrieved from https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/DFPS_FY15_Annual_Report.pdf; and Sources: Texas Family Department of and Protective Services. (2016). Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas https://www.dfps.state.tx.us/prevention_and_early_intervention/about_prevention_and_early_intervention/programs.asp

(TFTS) Together and Safe Texas Families: Services Network Statewide Youth Youth (STAR) Services to At Risk vention (Project HIP) Intervention and Pre- Project Help through Program providers) or related conditions (ICF/IDD), centers (SSLCs) and Intermediate Care Facilities for Intellectual Disabilities and disability, Receiving services contractedthrough an HHS Receiving community-based services Living in state hospitals Living at home with a mental,ph children and work towards family self-sufficiency. families to successfully nurture their the ability of focus on teaching parental techniques that increase viate stress and promote family cohesion. Programs Funds community-based programs designed to alle- aimed at preventing juvenile delinquency. programs that provide evidence-based services community-based Supports statewide networks of dential care, and individual and family counseling. intervention counseling, short-term emergency resi- Service available through STAR include: family crisis have been truant or delinquent, or have run away. services to youth who experience conflict at home, Contracts with community providers to offer short-term needs support. home visiting programs, parent education, and basic needs and include extensive family assessment, months. Services are individualized to each family’s who is pregnant or has given birth within the last four identified as childabuse or neglect, or a foster youth abuse and neglect, had a child who died with a cause parental rights previously terminated due to child child abuse in high-risk families who have had designed to increase protective factors and prevent Project HIP is a targeted intervention strategy Program Description and Service , contracted inpatient facilities, state-supported living ysical and/or intellectual/developmental from DSHSor DADS (e.g. LMHAs andIDD DFPS Annual Report 2015. Pages 20-23. Retrieved from agency orMCO.agency Nueces County Hidalgo County, Kerr Country, and Bexar County, Cameron County, All counties in Texas All counties in Texas All counties in Texas Regional Availability 200,201 DFPS 265 The 212 211 215 The rising costs The rising costs 206 205 The Austin region had more The Austin 216 This growth will likely lead to an lead likely will This growth 204 Adult common were the most children 210 Since 2000, individuals age 65 and older have age individuals and older have 65 Since 2000, The majority of facility abuse/neglect allegations 213 217 investigations There were 110,277 reports made of in-home abuse/ There were 110,277 of validated in-home allegations in-home of validated 202,203 207,208,209 validated in-home allegations received services (67.3 percent) services (67.3 received allegations in-home validated A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Roughly 10 percent (1,192) of all allegations of abuse or neglect in adult Roughly 10 percent (1,192) 214 78,180 completed in-home completed 78,180 separate instances 43,759 of the 29,442

of prescription drugs will also continue to increase the overall cost of the Medicare of the Medicare cost increase the overall drugs will also continue to of prescription coverage. for Medicare boomers become eligible program as baby been the fastest growing age Texas. group in growing fastest been the were for individuals enrolled in Home and Community-Based Service Programs (32.3 and Community-Based were for individuals enrolled in Home percent), State-Supported (21.3 Hospitals Living Centers (31.1 percent), and State percent). neglect of adults in FY 2015, with the majority of reports initiated by medical the majority of reports initiated by with neglect of adults in FY 2015, percent) community agencies percent), (13.7 (16.4 personnel (21.8 percent), relatives (11.8 percent). and the victim themselves One possible reason for the higher percentage of validated in-home allegations self-neglect in-home cases involve than validated facilities allegations is that most When a perpetrator. and are thus more readily validated than allegations involving In contrast to in-home investigations, the majority of reports of abuse and neglect to in-home investigations, In contrast personnel (27.1 of people: institutional two groups in adult facilities come from just percent). (23.4 percent) and the victims themselves As mentioned earlier, APS conducts abuse and neglect investigations in facilities in in facilities abuse and neglect investigations APS conducts As mentioned earlier, of abuse or neglect In regards to investigations homes. private additions to client’s contracted and certain ICF/IDDs SSLCs, hospitals, in residential facilities (i.e. state into reports of abuse investigations 11,935 facility inpatient facilities), APS completed or neglect of adults in FY 2015. The incidence of adult abuse, neglect and exploitation per 1,000 Texans aged 65 or Texans 1,000 and exploitation per The incidence of adult abuse, neglect percent in 2013 and 10.4 percent in 2011 from 12.4 older has fallen in recent years, percent in 2015. to 8.9 investigative and support services help to protect the mental health and wellness of wellness and health the mental to protect help services and support investigative Texans. and aging disabilities with persons about 11.6 in 2015, aged reached 3,225,614 65 and older of Texans The population to 18 to increase that number is expected population, and total Texas’ percent of 20 years. the next percent in allegations of abuse than any other region due to the high concentration of inpatient other allegations of abuse than any also had a higher percentage of allegations region, but Austin facilities in the Austin state’s to the rate in the confirmed as abuse or neglect (12 percent) when compared percent). 10 regions (9.5 other perpetrators of APS investigations into in-home maltreatment (38 percent). into in-home maltreatment of APS investigations perpetrators increased demand for mental health services in the future as more individuals as more future for mental health services in the increased demand in the “baby boomer” social other and generation become eligible for Medicare have not does Medicare Because tailored to older Americans. services that are ageover 65 Medicaid and all individuals for eligibility like financial requirements services as health publicly-funded receive who do not individuals are eligible, many them at ageadults begin receiving 65 when they enter Medicare. facilities in 2015 (11,935) were confirmed after an investigation by APS. (11,935) were confirmed after an investigation facilities in 2015 following breakdown shows the outcomes of the 110,277 reports of in-home abuse or reports of of the 110,277 the outcomes shows breakdown following neglect made to APS in 2015: · · · DFPS 266 Figure 105. Childcare Operations OverseenandRegulated by CCL regulated, monitoredand/or overseen by theCCLdivisionofDFPS: monitors forcompliance.Figure105describesthefive typesofchildcareoperations helps toinvestigate instances ofabuseandneglectatchildcarefacilitiesthatCCL the publiconminimumstandards requiredforchildcarefacilitiestooperateand compliance withstate licensingstandards, rulesandlaws. CCLalsoworkstoeducate approves permitsfornewresidentialchildcarefacilities, andmonitorsongoing The Texas ChildCareLicensing(CCL)divisionregulateschildcareoperations, Child Care Licensing (CCL) after anaffirmative findingofabuse/neglect. does not have thecapabilityorresourcestoprovide supportsorservices ongoing serviceinterventions but allegations areconfirmed,APSprovides emergency Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Source: Texas Family Department of and Protective Services. (2015). child_care/other_child_care_information/childcare_types.asp Elder Abuse isEveryone’s Businessisonesuchpublicawareness campaign. publicaboutelderabuseviaoutreachcampaigns; also educatesthegeneral In additiontotheinvestigations ofabuseandneglectconductedby APS, thisdivision abuse may constitute criminalconduct. APS investigators andstaff willalertlaw enforcementimmediatelyifthesuspected toreceive guardianshipservices.consenting toservicesarereferredtheHHSC related toexcessive summerheat. also distributes literatureabouthealthrisksfortheelderly, includingdangers or unconfirmedallegationsofabuse/neglect. not statutorily authorizedtoprovide servicestoadultswhohave unsubstantiated regardless ofwhether therehave beenaffirmative findingsofabuseor not,APSis Listed Family Homes Similar to Licensed Childcare Homes but inspected less frequently (every 1-2 Registered Child Care Homes or At-home Day Cares) known as Group Day Care Homes Licensed Childcare Homes (also Day Cares Licensed Child Care Centers or dential TreatmentCenters) Child Placing Agencies and Resi- Residential Childcare (including Facility Type reported allegation of abuse,reported allegation of neglect, or misconduct. for 1-3 unrelated children. These homes are not inspected unless there is a Includes individuals who receive compensation for providing in-home childcare 14 are allowed to be present in the home at any given time. age of years), held to slightly less stringent standards, and only six children under the annually for compliance. day care, children must not exceed 12 at any time.the total number of Inspected through 13 years. Including the children related to the caregiver running the Individuals provide childcare in the caregiver’s residence for children from birth the 24-hour day.care center for only part of Inspected annually for compliance. Centers that serve seven or more children from ages 0 to 13 who attend the child- mental health services. Inspected annually for compliance. in a location other than the child’s own home. Facilities often provide medical and Facilities that provide childcare services to 13 or more children for 24 hours a day Description Types Childcare. of 218 219 WhereasCPScanprovide services Individualswhoareincapableof Retrieved from https://www.dfps.state.tx.us/ 220 APS DFPS 267 The remaining 8.3 The remaining 8.3 222 These 20,882 childcare These 20,882 221

223 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation percent of children (90,761) who received childcare through CCL-monitored child childcare through CCL-monitored who received (90,761) percent of children or license child care those services in registered received 2015 care facilities in FY child and small employer-based temporary shelters, family homes, listed homes, care providers. The CCL division’s regulation of childcare services and facilities in Texas ultimately ultimately Texas in and facilities services of childcare regulation CCL division’s The outcomes, and emotional social negative neglect, abuse, of injury, the risk reduces and facilities Licensing childcare diseases. of communicable and the transmission that in ensuring line of defense the first regulations is compliance with monitoring that will help them and treatment health services the behavioral are getting Texans process. the recovery through 1,000 almost centers and homes in Texas, daycare there were 20,882 In FY 2015, in 2013. were operating in Texas fewer centers than centers served a total of 1,099,918 children in FY 2015, with the vast majority of those majority with the vast children in FY 2015, of 1,099,918 a total centers served centers, programs in licensed childcare childcare by served children (91.7 percent) and school age programs. programs, before- and after-school DFPS 268 26 25 23 22 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Endnotes Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 24 21 20 19 18 17 16 15

DFPS conservatorship becauseofmentalhealthneeds/JMC andRTC Bed Data. Retrieved fromhttps://drive. google.com/file/d/0B-CM0KurzX_rbTVjX0p4c0psRTA/view?usp=sharing DFPS conservatorship becauseof mentalhealthneeds/JMCandRTC BedData.Retrieved fromhttps://drive. DFPS-DSHS-Joint-Report.pdf (December 2014). Joint ReportonSenateBill44.Page 26. Retrieved fromfile:///Users/Matti/Downloads/SB44- Texas Department ofFamily and Pro Texas LegislatureOnline. (2013). SWP_pg_4280.asp Responsibility inCPSReports.Retrieved fromhttp://www.dfps.state.tx.us/handbooks/swi_procedures/files/ Texas Department ofFamily and Pro aspx?fileticket=fi6PipPGmEg%3D&tabid=328 mental healthservices,says newgovernment report. Retrieved fromhttp://www.bazelon.org/LinkClick. Judge Da Texas Health andHumanServicesCommission.( Texas Health andHumanServicesCommission.( Texas Health andHumanServicesCommission.( Texas Health andHumanServicesCommission.( Texas Health andHumanServicesCommission.( Texas Sunset A Texas LegislatureOnline.(2015). Report.pdf https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/DFPS_FY15_Annual_ Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2014/pdf/Databook14All.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro pdf from https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015. Texas DepartmentofFamily andPro pdf from https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015. Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro pdf from https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015. Texas DepartmentofFamily andPro dfps.state.tx.us/About_DFPS/Statewide_Intake/ Texas DepartmentofFamily andPro Texas DepartmentofFamily andPro Texas DepartmentofFamily andPro History.aspx?LegSess=83R&Bill=SB44 Update.pdf Plan. Page 19. Retrieved fromhttp://www.hhsc.state.tx.us/hhs-transformation/docs/Transformation-Plan- Update.pdf Plan. Page 18. Retrieved fromhttp://www.hhsc.state.tx.us/hhs-transformation/docs/Transformation-Plan- Update.pdf Plan. Page 18. Retrieved fromhttp://www.hhsc.state.tx.us/hhs-transformation/docs/Transformation-Plan- Update.pdf Plan. Page 18. Retrieved fromhttp://www.hhsc.state.tx.us/hhs-transformation/docs/Transformation-Plan- Update.pdf Plan. Page 18. Retrieved fromhttp://www.hhsc.state.tx.us/hhs-transformation/docs/Transformation-Plan- Final%20Results.pdf Final Results.Page 15. Retrieved fromhttps://www.sunset.texas.gov/public/uploads/files/reports/DFPS%20 History.aspx?LegSess=84R&Bill=SB200 vid L.BazelonCenterforMental Health Law. (2003).Parents give upcustodyofchildren for dvisory Committee. (July 2015). DepartmentofFamily andProtective Services:StaffReportwith Senate Bill200. Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ Senate Bill44.Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ tective Services. (2016). SenateBill1889 Case ReadandChildren whoenter tective Services. (2016). SenateBill1889 Case ReadandChildren whoenter tective ServicesandTexas DepartmentofStateHealth Services. tective Services. (n.d.)DeterminingRefusaltoAssume Parental tective Services. (2016). AnnualReport2015.Page 2.Retrieved from: tective Services. (2016). DFPSDataBook2015.Page 73. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 11.Retrieved from tective Services. (2016). DFPSDataBook2015.Page 7. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 40. Retrieved from tective Services. (2015). DFPSDataBook2014.Page 40. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 180. Retrieved from tective Services. (2016). DFPSDataBook2015.Pages 49and50. Retrieved tective Services. (2016). DFPSDataBook2015.Pages 27and39. Retrieved tective Services. (2016). DFPSDataBook2015.Page 37. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 37. Retrieved from tective Services. (2016). DFPSDataBook2015.Pages 3and37. Retrieved tective Services. (2016). StatewideIntake. Retrieved fromhttps://www. July 2016). HealthandHumanServicesSystem Transition July 2016). HealthandHumanServicesSystem Transition July 2016). HealthandHumanServicesSystem Transition July 2016). HealthandHumanServicesSystem Transition July 2016). HealthandHumanServicesSystem Transition DFPS 269 Promoting Independence Advisory Committee: Independence Advisory Committee: Promoting 2016). July tective Services. (July 20, 2016). Personal Communication: Senate Bill Senate Communication: Personal 2016). 20, (July Services. tective enter who Children Case Read and Senate Bill 1889 (2016). Services. tective enter who Children Case Read and Senate Bill 1889 (2016). Services. tective who enter Case Read and Children Senate Bill 1889 (2016). Services. tective who enter Case Read and Children Senate Bill 1889 (2016). Services. tective http://www.capitol.state.tx.us/BillLookup/ from Senate Bill 206. Retrieved from http://www.capitol.state.tx.us/tlodocs/84R/ Retrieved Senate Bill 1889. Page 4. Retrieved from http://www.capitol.state.tx.us/ 4. Retrieved Page Senate Bill 1889. . The Texas Tribune. . The Texas Facilities Crunch Strands Children in Psych Home 16). Foster Texas 84th Legislative Session Summary for Session Legislative Mental 84th Texas 22, 2015). (June ental Health. w, E. (December 17, 2015). Judge: Foster Care System Violates Children’s Rights. The Rights. Violates Children’s Care System Foster Judge: 2015). E. (December 17, w, The Rights. Violates Children’s Care System Foster Judge: 2015). E. (December 17, w, The Texas Tribune. Shortage. The Texas Foster Kids Sleeping in State Offices Amid More , 2016). Retrieved Tribune. Retrieved The Texas Care Reforms. Foster For Call Caseworkers Texas , 2016). A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation . (March 21, 2016). Federal judge picks ‘best of the best’ to help her overhaul Texas foster care. foster judge Texas picks ‘best to help her overhaul of the best’ Federal . (March 21, 2016). care. foster judge Texas picks ‘best to help her overhaul of the best’ Federal . (March 21, 2016). crisis: Children sleeping in CPS offices again as more foster-care Texas 2016). . (March 17, . (December 17, 2015). Federal judge finds Texas has “broken” foster care system, says she’ll order says system, Texas has care foster “broken” judge finds Federal 2015). . (December 17, protect to better Straus vows Joe house speaker As more CPS bigwigs quit, Texas . (April 12, 2016). . (March 21, 2016). Federal judge picks ‘best of the best’ to help her overhaul Texas foster care. foster judge Texas picks ‘best to help her overhaul of the best’ Federal . (March 21, 2016). Retrieved from http:// Retrieved KHOU. their jobs. them to leave share what drove CPS workers 2016). 7, June Chronicle of Social Chronicle Rights. to Children’s Lawsuit Loses Child Welfare Texas 2015). . (December 18, Chronicle of Social Chronicle Rights. to Children’s Lawsuit Loses Child Welfare Texas 2015). . (December 18, Walters, E. (March 17 Walters, from https://www.texastribune.org/2016/03/17/more-kids-sleeping-cps-offices-amid-placement- Retrieved shor/ R. T Garrett, Retrieved from http://trailblazersblog.dallasnews.com/2016/03/federal-judge-picks- Retrieved Dallas Morning News. best-of-the-best-to-help-her-overhaul-texas-foster-care.html/ E. (March 9 Walters, ( T. Eiserer, R. T Garrett, from http://trailblazersblog.dallasnews.com/2016/03/federal-judge-picks- Retrieved Dallas Morning News. best-of-the-best-to-help-her-overhaul-texas-foster-care.html/ from http:// Retrieved out of places to care for them. Dallas Morning News. from homes but state removed trailblazersblog.dallasnews.com/2016/03/texas-foster-care-crisis-children-sleeping-in-cps-offices-again-as- Langford, T. (April 8, 20 (April 8, Langford, T. from https://www.texastribune.org/2016/04/08/foster-care-home-crunch-means-length-psych- Retrieved stays-g/ R. T Garrett, from https://www.texastribune.org/2016/03/09/texas-caseworkers-call-foster-care-reforms/ www.khou.com/news/local/texas/cps-workers-share-what-drove-them-to-leave-their-jobs/235365971 Retrieved from http://trailblazersblog.dallasnews.com/2015/12/federal-judge- Retrieved Dallas Morning News. changes. finds-texas-has-broken-foster-care-system-says-shell-order-changes.html/ E. & Ramsha Walters, E. & Ramsha Walters, R. T Garrett, from http://trailblazersblog.dallasnews.com/2016/04/as-more- Retrieved abused kids. Dallas Morning News. cps-bigwigs-quit-texas-house-speaker-joe-straus-vows-to-better-protect-abused-kids.html/ Kelly, J Kelly, from https://chronicleofsocialchange.org/featured/texas-loses-child-welfare-lawsuit-to- Change. Retrieved childrens-rights/14892 R. T Garrett, from https://www.texastribune.org/2015/12/17/judge-foster-care-system-violates- Tribune. Retrieved Texas childrens-rights/ from https://www.texastribune.org/2015/12/17/judge-foster-care-system-violates- Tribune. Retrieved Texas childrens-rights/ Hogg Foundation for M Foundation Hogg R. T Garrett, from http://trailblazersblog.dallasnews.com/2016/03/federal-judge-picks- Retrieved Dallas Morning News. best-of-the-best-to-help-her-overhaul-texas-foster-care.html/ J Kelly, from https://chronicleofsocialchange.org/featured/texas-loses-child-welfare-lawsuit-to- Change. Retrieved childrens-rights/14892 Texas Legislature Online. (2015). Legislature Online. (2015). Texas Legislature Online. (2015). Texas History.aspx?LegSess=84R&Bill=SB206 Legislature Online. (2015). Texas billtext/pdf/SB01889F.pdf#navpanes=0 Texas Department of Family and Pro Department of Family Texas and Pro Department of Family Texas Services Commission. ( and Human Health Texas from http://www.dads.state.tx.us/providers/pi/piac/7-21-16- Retrieved 43. Page Department Activity Report. reports.pdf from http://hogg.utexas.edu/wp-content/uploads/2015/11/Legislative- Health-Related Legislation. Retrieved Summary_Final_2015.docx 1889 and Refusal to Accept Parental Responsibility Case Reads. Responsibility to Accept Parental Refusal 1889 and and Pro of Family Department Texas https://drive. from Bed Data. Retrieved and RTC mental health needs/JMC because of DFPS conservatorship google.com/file/d/0B-CM0KurzX_rbTVjX0p4c0psRTA/view?usp=sharing and Pro of Family Department Texas https://drive. from Bed Data. Retrieved and RTC mental health needs/JMC because of DFPS conservatorship google.com/file/d/0B-CM0KurzX_rbTVjX0p4c0psRTA/view?usp=sharing from https://drive. Retrieved Bed Data. because of mental health needs/JMC and RTC DFPS conservatorship google.com/file/d/0B-CM0KurzX_rbTVjX0p4c0psRTA/view?usp=sharing from https://drive. Retrieved Bed Data. because of mental health needs/JMC and RTC DFPS conservatorship google.com/file/d/0B-CM0KurzX_rbTVjX0p4c0psRTA/view?usp=sharing tlodocs/84R/billtext/pdf/SB01889F.pdf#navpanes=0 google.com/file/d/0B-CM0KurzX_rbTVjX0p4c0psRTA/view?usp=sharing and Pro of Family Department Texas

50 46 49 45 47 48 41 44 40 42 43 38 39 35 36 33 37 28 29 30 31 32 34 27 DFPS 270 56 55 54 53 52 51 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 75 74 70 69 68 67 66 65 64 63 62 61 60 59 58 57 73 72 71

www.ncbi.nlm.nih.gov/pubmed/9635069 ChildhoodExperiences(ACE)Study.The Adverse Am.J. Preventive Med14 (4), 245-258. Retrieved fromhttp:// Relationship ofchildhoodabuseandhouseholddysfunctiontomany oftheleadingcausesdeathinadults: Felitti, V 4884.pdf aTrauma-Informed Approach.for Retrieved fromhttp://store.samhsa.gov/shin/content/SMA14-4884/SMA14- Substance Abuse &M fixing-a-woefully-underfunded-cps/ The Texas Standard. Retrieved fromhttp://www.texasstandard.org/stories/texas-is-all-talk-and-no-action-in- Fanning, R. (April15, 20 Redesign_Advocacy-Update_6page-Pages.pdf Page 3. Retrieved fromhttp://www.northtexascf.org/wp-content/uploads/2016/05/032116_ACH_Foster-Care- ACHChildandFamily Services:OurCommunity, OurKids shortfall.html from http://www.governing.com/topics/health-human-services/tt-texas-foster-care-system-faces-40-million- Walters, E.(April21,20 more-removed-from-homes-but-state-out-of-places-to-care-for-them.html/ and_Budget_Information/LAR/FY18-19/documents/18-19_LAR.pdf Fiscalfor Years 2018and2019. Page 18. Retrieved fromhttps://www.dfps.state.tx.us/About_DFPS/Financial_ Texas DepartmentofFamily andPro dfps.state.tx.us/Adoption_and_Foster_Care/About_Foster_Care/Foster_Care_Redesign/ Texas DepartmentofFamily andPro content/uploads/2016/05/Perryman-Report-Foster-Care-Redesign-Impact.pdf System inSelectedCounties andtheStateofTexas. Page 13. Retrieved fromhttp://www.northtexascf.org/wp- ThePerryman Group. (April20 EditorialBoard.(January 15 EditorialBoard.(January 15 Malisow, C documents/2015/2015-12-03_Stephen_Group_High_Needs_Assessment.pdf System. Page 18. Retrieved from https://www.dfps.state.tx.us/About_DFPS/Reports_and_Presentations/CPS/ StephenGroup. (Nov documents/2015/2015-12-03_Stephen_Group_High_Needs_Assessment.pdf Pages 7and8. Retrieved fromhttps://www.dfps.state.tx.us/About_DFPS/Reports_and_Presentations/CPS/ StephenGroup. (Nov documents/2015/2015-12-03_Stephen_Group_High_Needs_Assessment.pdf System. Page 7. Retrieved fromhttps://www.dfps.state.tx.us/About_DFPS/Reports_and_Presentations/CPS/ StephenGroup. (Nov uploads/2016/05/Rees-Jones-Foster-Care-Policy-Paper.pdf ofChildren inFosterHealth andSafety Care. Page 2.Retrieved fromhttp://www.northtexascf.org/wp-content/ TheRees-Jones CenterforF documents/2015/2015-12-03_Stephen_Group_High_Needs_Assessment.pdf (November, 2015). Available: https://www.dfps.state.tx.us/About_DFPS/Reports_and_Presentations/CPS/ StephenGroup. “Mee dfps.state.tx.us/Adoption_and_Foster_Care/About_Foster_Care/Foster_Care_Redesign/ Texas DepartmentofFamily andPro Resources/Documents/2011-2_Foster%20Care%20Redesign.pdf Texas AllianceofChildandFamily Services Resources/Documents/2011-2_Foster%20Care%20Redesign.pdf Texas AllianceofChildandFamily Services content/uploads/2016/05/Perryman-Report-Foster-Care-Redesign-Impact.pdf System inSelectedCounties andtheStateofTexas. Page 1.Retrieved fromhttp://www.northtexascf.org/wp- ThePerryman Group. (April 20 dfps.state.tx.us/Adoption_and_Foster_Care/About_Foster_Care/Foster_Care_Redesign/ Texas DepartmentofFamily andPro pdf Recommendations. Retrieved from https://www.princeton.edu/futureofchildren/publications/docs/14_01_01. Bass, S., Shields http://www.dfps.state.tx.us/training/trauma_informed_care/ Texas DepartmentofFamily andPro Care andAlternative toSeclusionandRestraint (NCTIC). Retrieved fromhttp://beta.samhsa.gov/nctic Substance Abuse andM http://www.dfps.state.tx.us/training/trauma_informed_care/ Star-Telegram. Retrieved fromhttp://www.startelegram.com/opinion/editorials/article54981715.html Star-Telegram. Retrieved fromhttp://www.startelegram.com/opinion/editorials/article54981715.html kids-suffering-in-the-texas-foster-care-system-8161341 System. HoustonPress. Retrieved fromhttp://www.houstonpress.com/news/there-s-little-outrage-for-12-000- Texas DepartmentofFamily andProtective Services. (n.d.)Trauma Care Training Informed . Retrieved from . J, Anda,R.F., Nordenberg,D., Williamson,D. F., Spitz,A.M.,Edwards, V., &Marks. J. S. (1998). . (February 16, 2016). There’s Little for12,000 Outrage KidsSufferinginthe Texas Foster Care , M.K.&Behrman,R.E.(2004).Children, Families, andFoster Care: Analysis and ember 2015). MeetingtheNeedsofHighChildren intheTexas ChildWelfare ember 2015). MeetingtheNeedsofHighChildren intheTexas ChildWelfare System. ember 2015). MeetingtheNeedsofHighChildren intheTexas ChildWelfare ting theNeedsofHighChildreninTexas ChildWelfare System.” ental Health (2014). ServicesAdministration. SAMSHA’s Concept ofTrauma andGuidance 16). Texas’ Foster CareSystem Faces $40MShortfall.TheTexas Tribune.Retrieved ental Health (2014). ServicesAdministration. NationalCenter Trauma-Informed for 16). KidsAreDyingonCPS’ Watch: we’re ‘Ifwewant change, tohave going topay forit’. , 2016). Fort Worth nonprofitdetermined tohelpfix Texasfoster care.Fort Worth , 2016). Fort Worth nonprofitdetermined tohelpfix Texasfoster care.Fort Worth oster CareExcellence atChildren’s Medical Center. (April2016). Addressing the 16). AnAssessment oftheEconomicImplicationsRedesigning theFoster Care 16). AnAssessment oftheEconomicImplicationsRedesigningFoster Care tective Services. (September 6, 2016). Legislative Appropriations Request tective Services. (n.d.).Foster Care Redesign.Retrieved fromhttps://www. tective Services. (n.d.).Foster Care Redesign.Retrieved fromhttps://www. tective Services. (n.d.).Foster Care Redesign.Retrieved fromhttps://www. tective Services. (n.d.).Trauma Care Training Informed . Retrieved from . (2011). Foster Care Redesign.Retrieved fromhttp://www.tacfs.org/ . (2011). Foster Care Redesign.Retrieved fromhttp://www.tacfs.org/ . (March21,2016). Foster Care RedesignIs Working. DFPS 271 Promoting Independence Advisory Committee Advisory Committee Independence Promoting . (2016). Legislative Appropriations Request Appropriations Legislative 2016). 6, (September Services. tective Request Appropriations Legislative 2016). 6, (September Services. tective from 4. Retrieved Annual Report 2015. Page (2016). Services. tective Request for Appropriations Legislative 2012). 16, (August Services. tective from Retrieved 78. Annual Report 2015. Page (2016). Services. tective Legislative Appropriations Request for Appropriations Legislative 2012). 16, (August Services. tective Request Appropriations Legislative 2016). 6, (September Services. tective Request Appropriations Legislative 2016). 6, (September Services. tective Request Appropriations Legislative 2016). 6, (September Services. tective Legislative Appropriations Request Appropriations Legislative 2016). 6, (September Services. tective Progress Report to the Sunset Advisory Sunset Advisory Report to the Progress 2015). (October Services. tective Retrieved from Data Book. 2015 Annual Report and Retrieved (2016). Services. tective . Retrieved from fromhttps://www. . Retrieved management workload Caseload and (2010). y. Retrieved Retrieved 4). 3 follow-up Fatalities. points to Senate Hearing on CPS and Child Texas 84th Legislative Session Summary for Session Legislative Mental 84th Texas 22, 2015). (June ental Health. Summary for Session Legislative Mental 84th Texas 22, 2015). (June ental Health. tection/Transformation/ High caseloads: How do they impact delivery of health and human services? of health and impact delivery do they How High caseloads: (2010). y Institute. A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Presentation to the House Committee on County Affairs: Local Resources, Community Local Resources, Affairs: on County Committee to the House Presentation 2016). uly 7, . (April 1, 2016). So many Dallas CPS investigators have quit, state has to bring in backups from has to bring in backups from quit, state have Dallas CPS investigators So many . (April 1, 2016). has to bring in backups from quit, state have Dallas CPS investigators So many . (April 1, 2016). Retrieved Tribune. Retrieved The Texas New Chief Says. 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Page 2018 and 2019. for Years Fiscal and_Budget_Information/LAR/FY18-19/documents/18-19_LAR.pdf https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/DFPS_FY15_Annual_ Report.pdf from https://www.dfps.state.tx.us/About_DFPS/Financial_and_ 71. Retrieved 2014 and 2015. Page Years Fiscal Budget_Information/LAR/FY14-15/documents/14-15_LAR_Vol1.pdf Retrieved from http://hogg.utexas.edu/wp-content/uploads/2015/11/Legislative- Health-Related Legislation. Retrieved Summary_Final_2015.docx from http://www.dads.state.tx.us/providers/pi/piac/ Retrieved (PIAC). for M Foundation Hogg from http://hogg.utexas.edu/wp-content/uploads/2015/11/Legislative- Health-Related Legislation. Retrieved Summary_Final_2015.docx and Pro Department of Family Texas Pro and Department of Family Texas Texas Department of Family and Pro Department of Family Texas for M Foundation Hogg Services Department of Aging and Disability Texas https://www.dfps.state.tx.us/About_DFPS/Financial_ from Retrieved 27-28. 2014 and 2015. Pages Years Fiscal and_Budget_Information/LAR/FY14-15/documents/14-15_LAR_Vol1.pdf https://www.dfps.state.tx.us/About_DFPS/ from Retrieved 37-38. Pages 2018 and 2019. for Years Fiscal Financial_and_Budget_Information/LAR/FY18-19/documents/18-19_LAR.pdf https://www.dfps.state.tx.us/About_DFPS/ from 15 and 31. Retrieved Pages 2018 and 2019. for Years Fiscal Financial_and_Budget_Information/LAR/FY18-19/documents/18-19_LAR.pdf from https://www.dfps.state.tx.us/About_DFPS/ Retrieved 15 and 175. Pages 2018 and 2019. for Years Fiscal Financial_and_Budget_Information/LAR/FY18-19/documents/18-19_LAR.pdf Retrieved from http://trailblazersblog.dallasnews.com/2016/04/so-many- Retrieved Dallas Morning News. areas. other dallas-cps-investigators-have-quit-the-state-has-to-move-in-backups-from-other-areas.html/ R. T Garrett, from http://trailblazersblog.dallasnews.com/2016/04/so-many- Retrieved Dallas Morning News. areas. other dallas-cps-investigators-have-quit-the-state-has-to-move-in-backups-from-other-areas.html/ E. ( Walters, from https://www.texastribune.org/2016/07/06/child-welfare-chief-wants-higher-pay-caseworkers/ from http://txchildren.org/state-of-the-children/3-follow-up-points-to-senate-hearing-on-cps-and-childfatalities R. T Garrett, (J Gilliam, C. Slides]. Retrieved [PowerPoint Stabilization Redesign and Workforce Care Foster Care, Foster Partnerships, from http://www.legis.state.tx.us/tlodocs/84R/handouts/C2102016070710001/924f2b70-9770-48c4-8f78- 116456eebf27.PDF from https://www.dfps.state.tx.us/About_DFPS/Financial_ Retrieved 17. Page 2018 and 2019. for Years Fiscal and_Budget_Information/LAR/FY18-19/documents/18-19_LAR.pdf Keel, J. (20 J. Keel, website: Officehttp:// from State Auditor’s 13-036). Retrieved (SAO Report No. Services and Protective of Family www.sao.state.tx.us/reports/main/13-036.pdf Care for Children. (201 Texans and Pro Department of Family Texas Texas Department of Family and Pro of Family Department Texas Gatewa Information Child Welfare Polic Social Work https://www.dfps.state.tx.us/About_DFPS/Data_Books_and_Annual_Reports/2015/pdf/FY2015_AnnualRpt_ Databook.pdf Retrieved from https://www.dfps. Retrieved (n.d.) Transformation. Services. Protective and of Family Department Texas state.tx.us/Child_Pro childwelfare.gov/pubs/case_work_management/case_work_management.pdf from http://www.socialworkpolicy.org/wp-content/uploads/2010/02/r2p-cw-caseload-swpi-1-10.pdf Retrieved Retrieved from http://www.dfps.state.tx.us/About_ from Retrieved Services Transformation. Child Protective Commission: DFPS/Reports_and_Presentations/CPS/documents/2015/2015-10-21_CPS_Transformation_Progress_Report_ Sunset.pdf

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Page 2.Retrieved fromhttp://www.northtexascf.org/wp-content/ TheRees-Jones CenterforF content/uploads/2016/05/Perryman-Report-Foster-Care-Redesign-Impact.pdf System inSelectedCounties andtheStateofTexas. Page 4.Retrieved fromhttp://www.northtexascf.org/wp- ThePerryman Group. (April 20 https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andProtective Services. (2016). DFPSDataBook2015.Page 27. Retrieved from uly 7, 2016). Presentation totheHouseCommittee onCounty Affairs: Local Resources, Community uly 7, 2016). Presentation totheHouseCommittee onCounty Affairs: LocalResources, Community oster CareExcellence atChildren’s Medical Center. (April2016). Addressing the 16). AnAssessment oftheEconomicImplicationsRedesigningFoster Care y. (2008).Differential response to reports ofchildabuseandneglect.Retrieved y. (2008).Differential response to reports ofchildabuseandneglect.Retrieved tective Services. (2016). DFPSDataBook2015.Pages 39and41.Retrieved tective Services. (2016). DFPSDataBook2015.Page 39. Retrieved from tective Services. (2016). DFPSDataBook2015.Pages 37 and39. Retrieved tective Services. (2016). DFPSDataBook2015.Page 37. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 37. Retrieved from tective Services. (August 16, 2012). Legislative Appropriations Requestfor tective Services. (2016). DFPSDataBook2015.Page 27. Retrieved from tective Services. (2016). AnnualReport2015.Page 4.Retrieved from tective Services. (2016). DFPSDataBook2015.Page 3. Retrieved from 3. tective Services. (2016). DFPSDataBook2015.Page 3. tective Services. (2016). DFPSDataBook2015.Page tective Services. (2016). DFPSDataBook2015.Page 1.Retrieved from tective Services. (2016). 2015AnnualReport. Page 15. Retrieved from tective Services. (2014). 2013AnnualReport. Page. Retrieved 15 from tective Services. (2016). DFPSDataBook2015.Page 42.Retrieved from tective Services. (2016). DFPSDataBook2015.Page 50. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 50. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 180. Retrieved from Differential ResponseinChildProtective, October26).Differential Services: Retrieved from Retrieved from DFPS 273 About Medicaid, Chapter 7: Medicaid Managed Care. Managed Care. Medicaid 7: About Medicaid, Chapter Edition. , Tenth Perspective Medicaid and CHIP In 15). Texas Child Abuse and Neglect Fatalities Annual Child Abuse and Neglect Fatalities (April 2016). Services. tective Child Abuse and Neglect Fatalities Annual Child Abuse and Neglect Fatalities (April 2016). Services. tective Annual Child Abuse and Neglect Fatalities (April 2016). 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STAR Services. tective Child Abuse and Neglect Fatalities Annual Child Abuse and Neglect Fatalities (April 2016). Services. tective Annual Child Abuse and Neglect Fatalities (April 2016). Services. tective Annual Child Abuse and Neglect Fatalities (April 2016). Services. tective . Retrieved from https://www.dfps. foster. Retrieved for youth Healthcare former Texas . Retrieved from https://www.dfps. foster. Retrieved for youth Healthcare former Texas . Retrieved from fromhttp://www.superiorhealthplan.com/ . Retrieved Health to STAR 4). Welcome http://www.superiorhealthplan.com/ from Health. Retrieved to STAR 4). Welcome The transition to adulthood: How states can support older youth in foster states can support older youth National to adulthood: How care. The transition in foster states can support older youth National to adulthood: How care. The transition A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation The Affordable Care Act and Youth Aging Out of Foster Youth Aging Out of Act and Care The Affordable (April 2014). dvocacy and Reform Center. Retrieved Retrieved in Texas. Care Out’ of Foster Those ‘Aging A Guide For Project. (2014). Justice ter Youth /www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf . Page 50. Retrieved from http://www.dfps.state.tx.us/Prevention_and_ Retrieved 50. . Page Report: FY 2014 and FY 2015 Analysis Early_Intervention/Office_of_Child_Safety/documents/Child_Fatality_Annual_Report_2014_2015.pdf Pro and Department of Family Texas from http://www.dfps.state.tx.us/Prevention_and_ Retrieved 50. . 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Retrieved Report: FY 2014 and FY 2015 Analysis Intervention/Office_of_Child_Safety/documents/Child_Fatality_Annual_Report_2014_2015.pdf https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf from http://www.dfps.state.tx.us/Prevention_ Retrieved 4 and 15. . Pages Report: FY 2014 and FY 2015 Analysis and_Early_Intervention/Office_of_Child_Safety/documents/Child_Fatality_Annual_Report_2014_2015.pdf Care: New Opportunities and Strategies for from http://www.clasp.org/resources-and- Action. Retrieved and Strategies New Opportunities Care: publications/publication-1/The-Affordable-Care-Act-and-Youth-Aging-Out-of-Foster-Care.pdf Connection. (n.d.). Youth Texas Fos Texas from http://texasfosteryouth.org Connection. (n.d.). Youth Texas Golonka, S. (2010). (2010). Golonka, S. A State Policy state.tx.us/txyouth/health/healthcare.asp from https://www.dfps.state.tx.us/Child_Protection/State_Care/parent_guide_foster_care. Retrieved parents. asp from https://www.dfps.state.tx.us/Child_Care/documents/Standards_and_ (GROs). Retrieved Operations Regulations/748_GRO.pdf Superior Health Plan. (201 Superior Health and Pro Department of Family Texas Services Commission. (n.d.) and Human Health Texas from https://www.hhsc.state.tx.us/medicaid/about/PB/Chapter7.pdf Retrieved (2010). Golonka, S. from http://www.nga.org/files/live/sites/NGA/ Retrieved Practices. Association Center for Best Governor’s files/pdf/1012FOSTERCARE.PDF from http://www.nga.org/files/live/sites/NGA/ Retrieved Practices. Association Center for Best Governor’s files/pdf/1012FOSTERCARE.PDF Texas Department of Family and Pro of Family Department Texas and Pro of Family Department Texas (20 Human Services Commission. and Health Texas Plan. (201 Superior Health for-members/programs/star-health/ for-members/programs/star-health/ from https://www.dfps.state.tx.us/Child_Protection/Medical_Services/guide-passport.asp Retrieved Page 37. Retrieved from Retrieved 37. 2015. Page Data Book DFPS (2016). Services. Protective and of Family Department Texas https:/ http://www.hhsc.state.tx.us/medicaid/about/PB/PinkBook.pdf from Retrieved https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf https://www.dfps.state.tx.us/Child_Protection/Medical_Services/guide-star.asp#glance from Retrieved

151 152 153 149 150 140 143 144 145 146 147 148 137 139 138 141 142 134 135 136 131 132 133 126 127 130 128 129 DFPS 274 179 173 172 171 167 166 165 164 163 162 161 160 159 158 157 156 155 154 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 178 177 176 175 174 170 169 168

projects/upmtfc/2015-Update-on-Psychotropic-Medications-Use-in-TexasFosterChildrenACCESS.pdf Children inTexas Foster Care: Fiscal Years 2002-2015.Retrieved fromhttps://www.hhsc.state.tx.us/hhsc_ Dworsky, A.(2013). Feinstein, R.,Greenblat Feinstein, R.,Greenblat LambdaLegalDefenseandEducationFund. (2001). from https://www.childwelfare.gov/pubs/LGBTQyouth.pdf ChildWelfare InformationGatewa s3-website-us-east-1.amazonaws.com//files/assets/resources/HRC_Youth_Foster_Care-issue_brief_FINAL.pdf HumanRightsCampaign.(2015). LGB from https://www.childwelfare.gov/pubs/LGBTQyouth.pdf ChildWelfare InformationGatewa Texas DepartmentofFamily andPro Texas DepartmentofFamily andPro Texas DepartmentofFamily andPro Retrieved from https://www.dfps.state.tx.us/Child_Protection/Initiatives/Disproportionality/whats_texas.asp Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro americanbar.org/groups/domestic_violence/resources/statistics/Race_Ethnicity_Statisitcs.html AmericanBarAssociation.(n.d.)DomesticViolence byRace&Ethnicity Disparities-and-Disproportionality-in-Child-Welfare_An-Analysis-of-the-Research-December-2011.pdf research. [PowerPoint Slides].Retrieved fromhttp://www.cssp.org/publications/child-welfare/alliance/ Racial EquityinChildWelfare. (2011). DisparitiesandDisproportionality inChild Welfare: Analysis ofthe TheCenterfortheStudyofSocialPolicy andTheAnnieE.Casey F Disproportionality/cps_initiatives.asp Reduce Disproportionality. Retrieved fromhttps://www.dfps.state.tx.us/Child_Protection/Initiatives/ Texas DepartmentofFamily andPro System. Retrieved fromhttps://www.dfps.state.tx.us/Child_Protection/Initiatives/Disproportionality/ Texas DepartmentofFamily andPro sb-830-report.pdf Children andYouthOmbundsman for inFoster Care. Retrieved fromhttp://www.hhsc.state.tx.us/reports/2016/ Texas Health andHumanServicesCommissionOfficeoftheOmbundsman.( rules.asp [Press Release].Retrieved fromhttp://www.dfps.state.tx.us/About_DFPS/News/2014/2014-04-04_foster_care_ Texas DepartmentofFamily andPro History.aspx?LegSess=84R&Bill=HB781 Texas LegislatureOnline.(2015). History.aspx?LegSess=84R&Bill=HB781 Texas LegislatureOnline.(2015). Early_Intervention/Office_of_Child_Safety/documents/Child_Fatality_Annual_Report_2014_2015.pdf Report: FY2014and2015Analysis. Page 10. Retrieved fromhttp://www.dfps.state.tx.us/Prevention_and_ Texas DepartmentofFamily andPro Early_Intervention/Office_of_Child_Safety/documents/Child_Fatality_Annual_Report_2014_2015.pdf Report: FY2014and2015Analysis. Page 34.Retrieved from http://www.dfps.state.tx.us/Prevention_and_ Texas DepartmentofFamily andPro Early_Intervention/Office_of_Child_Safety/documents/Child_Fatality_Annual_Report_2014_2015.pdf Report: FY2014and2015Analysis. Page 17. Retrieved fromhttp://www.dfps.state.tx.us/Prevention_and_ of psychotropic prescriptions. Retrieved fromhttp://www.gao.gov/products/GAO-12-270T U.S. Go Texas Health andHumanServicesCommission. (20 Retrieved fromhttp://www.texastribune.org/2013/05/15/house-oks-foster-advocates-informed-consent-bill/ Aaronson,B. (May 15 brief_01_04_2013.pdf Care: DocumentNo. PP13-04. Retrievedhttp://www.acf.hhs.gov/sites/default/files/opre/opre_lgbt_ from org/uploads/digital-library/resource_239.pdf lesbian, gay, bisexual, andtransgender youth intheNewYork Juvenile JusticeSystem. Retrieved fromhttp://njjn. org/uploads/digital-library/resource_239.pdf lesbian, gay, bisexual, andtransgender youth intheNewYork Juvenile JusticeSystem. Retrieved fromhttp://njjn. org/publications/youth-in-the-margins Lesbian, Gay, Bisexual, andTransgender AdolescentsinFoster Care. Retrieved fromhttp://www.lambdalegal. Disproportionality/cps_initiatives.asp Reduce Disproportionality. Retrieved fromhttps://www.dfps.state.tx.us/Child_Protection/Initiatives/ Disproportionality/cps_initiatives.asp Reduce Disproportionality. Retrieved fromhttps://www.dfps.state.tx.us/Child_Protection/Initiatives/ Retrieved from https://www.dfps.state.tx.us/Child_Protection/Initiatives/Disproportionality/whats_texas.asp vernment Accountability Office.(2011)vernment Foster Accountability children: HHSguidancecouldhelpstates improve oversight The EconomicWell-being ofLesbian,Gay, andBisexual Youth Transitioning OutofFoster , 2013). Senatebacksbillon psychotropic drugsforfoster kids. TheTexas Tribune. t, A.,Hass, L.,Koh, S., all?:Areport &Rana,K.(2001). ontheunmetneedsof Justicefor t, A.,Hass, L.,Koh, S., all?:Areport &Rana,K.(2001). ontheunmetneedsof Justicefor House Bill781.Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ House Bill781.Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ y. parents (2013).. Retrieved Supportingyour foster LGBTQ youth: Aguidefor y. parents (2013).. Retrieved Supportingyour foster LGBTQ youth: Aguidefor tective Services. (n.d.)What’s DFPSDoingAboutDisproportionality? tective Services. (2016). DFPSDataBook2015.Page 207. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 207. Retrieved from tective Services. (n.d.)CPSInitiatives andPrograms Targeted to tective Services. (n.d.).Disproportionality inChildProtective Services tective Services. (April4,2014). rulesapproved. care safety Newfoster tective Services. (April2016). ChildAbuseandNeglectFatalities Annual tective Services. (April2016). ChildAbuseandNeglectFatalities Annual tective Services. (n.d.)CPSInitiatives andPrograms Targeted to tective Services. (n.d.)CPSInitiatives andPrograms Targeted to tective Services. (n.d.)What’s DFPSDoingAboutDisproportionality? TQ YouthTQ intheFoster Care System. Retrieved from http://hrc-assets. 16). UpdateontheUse ofPsychotropic Medicationsfor Youth intheMargins: AReportontheUnmetNeedsof oundation onbehalfofTheAlliancefor . Retrieved fromhttp://www. January 2016). Reportonthe DFPS 275 Retrieved from Retrieved 2015 (Projections). Population, Texas . (2014). Psychotropic Psychotropic 2012). 6, (July Round Table. Medication ychotropic Retrieved from Retrieved in Texas. The Aging Population 2015). tee. (December 15, Understanding Trauma-Informed Care in the Texas Child Welfare Child Welfare in the Texas Care Trauma-Informed 15). Understanding Prevention & Early & Early Prevention ersight & Accountability Commission. (2014). Retrieved from Retrieved and Services. (n.d.). In-home Investigations Services. tective from Retrieved 9. DFPS Data Book 2015. Page (2016). Services. tective Page 20. Retrieved Retrieved 20. DFPS Annual Report 2015. Page (2016). Services. tective Use of Psychotropic Medications in Texas Foster Foster Medications in Texas of Psychotropic (n.d.) Use Services. tective . Retrieved for caregivers (n.d.). Medical consent training Services. tective – A Guide to Medical Medications (n.d.). Psychotropic Services. tective Retrieved from https:// Retrieved Investigations. (n.d.). APS Provider Services. tective Retrieved from http://www.capitol.state.tx.us/BillLookup/ Senate Bill 1356. Retrieved from http://www.capitol.state.tx.us/BillLookup/History. Senate Bill 7. from http://www.capitol.state.tx.us/BillLookup/ Senate Bill 152. Retrieved Retrieved from http://www.capitol.state.tx.us/BillLookup/ Senate Bill 125. Retrieved Retrieved from http://www.nimh.nih. Retrieved health medications. Mental (2012). ealth. Addressing the Addressing (April 2016). Center. Medical at Children’s Care Excellence oster The Kaiser Family Family The Kaiser Spending and Financing. on Medicare The Facts 2016). 20, July Mental health problems of Mental health problems A. (1998). & Litrownik, Chadwick, D., W., Ganger, erk, J., Promising practices practices Promising (2011). & Wilson, C. S., ., Tullberg, E., Richardson, L., Langan, H., Ko, A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Metabolic side effects of atypical antipsychotics in children: A effects E. (2005). Metabolic side in children: of atypical antipsychotics & Fombonne, .J., ., Zima, B. T., Scott, L.D., Auslander, W. F., Munson, M. R., Ollie, M. T., & Spitznagel, E. L. (2005). Munson, M. R., Ollie, M. T., F., W. Auslander, L.D., Scott, T., ., Zima, B. Antipsychotic treatment among treatment Antipsychotic A. (2011). A., Noll, E., & Rothbard, M., Riddle, M. D. Rubin, oon, Y., & Trib Talk. Tribune big drug problem. The Texas its kicked Texas How 2014). 26, (August . S. ., Phillips, S. D., Wagner, H. R., Barth, R. P., Kolko, D. J., Campbell, Y., Landsverk, J. (2004). Mental J. Landsverk, Campbell, Y., J., D. Kolko, H. R., Barth, R. P., Wagner, D., S. ., Phillips, Texas House Human Services Commit House Texas ( & Neuman, T. Cubanski, J. from http://kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and- Retrieved Foundation. financing/ Texas Department of Family and Pro and Department of Family Texas Pro and Department of Family Texas Pro and Department of Family Texas Services Department of State Health Texas https://www.dshs.texas.gov/chs/popdat/ST2015.shtm http://osd.texas.gov/Resources/Presentations/OSD/2015/2015_12_15_HouseHumanServicesAging.pdf History.aspx?LegSess=84R&Bill=SB125 Services Ov Health California Mental Pro and Department of Family Texas www.dfps.state.tx.us/Adult_Protection/About_Adult_Protective_Services/provider_investigations.asp https://www.dfps.state.tx.us/Adult_Protection/About_Adult_Protective_Services/in_home.asp https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf History.aspx?LegSess=83R&Bill=SB1356 Legislature Online. (2013). Texas aspx?LegSess=83R&Bill=SB7 Legislature Online. (2013). Texas History.aspx?LegSess=83R&Bill=SB152 Legislature Online. (2015). Texas for Children. (October 20 CASA Texas http://texascasa.org/wp- from Retrieved 2 and 10. Pages the Field. Data and Recommendations from System content/uploads/2015/10/FINAL-Trauma-Survey-Report-10.5.15.pdf from http://www.mhsoac.ca.gov/Counties/PEI/Prevention-and-Early- (PEI). Retrieved Intervention Intervention.aspx Clausen, J. M., Landsv Clausen, J. Conradi, L., Agosti, J foster placement stability: A care to improve for practice child welfare using trauma-informed and strategies from http://www.ncbi.nlm.nih.gov/ Retrieved 207-225. 90(6), Child Welfare, series collaborative. breakthrough pubmed/22533050 Legislature Online. (2013). Texas from https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/DFPS_FY15_ Annual_Report.pdf . Journal . Journal A national survey with child welfare: involved to mental health services by youths health need and access from http://www.ncbi. Retrieved 960-970. (43)8, of Child and Adolescentof the American Academy Psychiatry, nlm.nih.gov/pubmed/15266190 J.C McMillen, McCown, F McCown, from https://www.tribtalk.org/2014/08/26/how-texas-kicked-its-big-drug-problem/ Retrieved Center for F The Rees-Jones from http://www.northtexascf.org/wp-content/ 2. Retrieved Page Care. Health and Safety in Foster of Children uploads/2016/05/Rees-Jones-Foster-Care-Policy-Paper.pdf J B. Burns, of the American Journal in the foster among older youths system. care disorders of psychiatric Prevalence from http://www.ncbi.nlm.nih.gov/ Retrieved 44(1), 88-95. of Child and AdolescentAcademy Psychiatry, pubmed/15608548 from http://goo.gl/B0TlI8 Retrieved 283-296. 7(3), Studies, of Child and Family in foster Journal children care. http://www.ncbi.nlm.nih.gov/ from Retrieved 19(5), 533-550. of Psychopharmacology Journal review. literature pubmed/16166191 and Pro Department of Family Texas and Pro Department of Family Texas and Pro Department of Family Texas Supreme Court Children’s Commission, Ps Commission, Court Children’s Supreme Y S., DosReis, V Fedorowicz, from http://www.hhsc.state.tx.us/hhsc_projects/upmtfc/ Retrieved Children. from http://www.dfps.state.tx.us/child_protection/medical_services/medical-consent-training.asp from https://www.dfps.state.tx.us/Child_Protection/Medical_Services/guide- Retrieved Services at CPS. psychotropic.asp National Institute of Mental H of Mental Institute National fromhttp://texaschildrenscommission.gov/media/35318/ foster Retrieved youth. care and Texas medication Final-Psych-Meds-Report-PRINT_01-10-13.pdf fromhttp://pediatrics.aappublications.org/content/ Retrieved 1459–1466. 128, in fosteryouth . Pediatrics, care pediatrics/early/2011/11/16/peds.2010-2970.full.pdf gov/health/publications/mental-health-medications/nimh-mental-health-medications.pdf

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https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro Retrieved from http://www.dfps.state.tx.us/everyonesbusiness/ Texas DepartmentofFamily andPro Agencywide/Sunset_Report/ Commission. Retrieved fromhttps://www.dfps.state.tx.us/About_DFPS/Reports_and_Presentations/ Texas DepartmentofFamily andPro Services Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro pdf from https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015. Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro https://www.dfps.state.tx.us/About_DFPS/Annual_Reports_and_Data_Books/2015/pdf/Databook2015.pdf Texas DepartmentofFamily andPro and_Budget_Information/LAR/FY18-19/documents/18-19_LAR.pdf Fiscalfor Years 2018and2019. Page 75. Retrieved from https://www.dfps.state.tx.us/About_DFPS/Financial_ Texas DepartmentofFamily andPro Budget_Information/LAR/FY16-17/documents/16-17_LAR_Vol1.pdf Fiscal Years 2016and2017. Page 73. Retrieved fromhttps://www.dfps.state.tx.us/About_DFPS/Financial_and_ Texas DepartmentofFamily andPro Budget_Information/LAR/FY14-15/documents/14-15_LAR_Vol1.pdf Fiscal Years 2014and2015.Page 73. Retrievedhttps://www.dfps.state.tx.us/About_DFPS/Financial_and_ from Texas DepartmentofFamily andPro financing/ Foundation. Retrieved fromhttp://kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and- Cubanski,J. &Neuman,T. ( July 20, 2016). TheFacts onMedicare SpendingandFinancing.The Kaiser Family tective Services. (2016). DFPSDataBook2015.Page 76. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 76. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 73. Retrieved from tective Services. (n.d.).AdultAbuse&Exploitation: It’s Everyone’s Business! tective Services. (2013). Self-evaluation report: Submittedto theSunset tective Services. (July 9, 2014). Personal Protective communication:Adult tective Services. (2016). DFPSDataBook2015.Page 25. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 23. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 21.Retrieved from tective Services. (2016). DFPSDataBook2015.Page 25. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 25. Retrieved from tective Services. (2016). DFPSDataBook2015.Pages 12and20. Retrieved tective Services. (2016). DFPSDataBook2015.Page 18. Retrieved from tective Services. (2016). DFPSDataBook2015.Page 11.Retrieved from tective Services. (September 6, 2016). Legislative Appropriations Request tective Services. (August 11,2014). Legislative Appropriations Requestfor tective Services. (August 16, 2012). Legislative Appropriations Requestfor TWC 277 286 286 287 287 288 288 289 277 277 278 284 285 288 280 282 283 284 7 The labor force participation rate is the is rate participation force labor The 6

Program for Older Individuals Who Are Blind Are Who Individuals Older for Program outcome-based vocational rehabilitation services for individuals living with serious with living individuals for services vocational rehabilitation outcome-based The same year, the unemployment rate for individuals receiving services through the through services individuals receiving for rate the unemployment year, same The 4

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A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation oncerns onment illness or intellectual and developmental disabilities (IDD). The National Alliance on Mental Illness Illness Mental on Alliance National The (IDD). disabilities developmental and intellectual or illness rograms ehabilitation for Persons with Disabilities (VR) Disabilities with Persons for ehabilitation Impairments Visual with Individuals for Program ehabilitation with IDD, the national labor force participation rate is 30.5%. is rate participation force labor national the IDD, with s Enterprises of Texas program Texas ofEnterprises s cts C Texas Workforce Commission (TWC) Programs (TWC) Commission Workforce Texas

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The unemployment rate is the ratio of ratio the is rate unemployment the to employment seeking and The unemployed is that population the 2 represented 3% of the nation’s total workforce. total of3% represented nation’s the ams Transferred from DARS per Sunset Legislation Sunset per DARS from Transferred ams au ofau Statistics. Labor Skills Development Skills Vocational R Vocational Cris The Busines The Services Living Independent Veterans TWC Other P Policy Concerns Policy F Fast Chart Organization R Vocational Integr st F st month. public mental health system in Texas was 85.6%. was Texas in system health mental public For individuals For current labor force. labor current In March 2016, there were 4.3 million people with disabilities (ages 16 to 64) employed in the United States. This This States. United the in employed 64) to (ages 16 disabilities with people million 4.3 were there 2016, March In group The national and state unemployment rates do not always reflect the prevalence ofprevalence the reflect always not do rates with unemployment people state for and unemployment national The mental serious was services health mental public receiving individuals for rate unemployment national the that reported (NAMI) 2012. in 80% approximately The national unemployment rate was 4.7% in May 2016, down 0.3% from the previous month, according to the to according month, previous the from 0.3% down 2016, May in 4.7% was rate unemployment national The Bure Ensuring sustainable employment outcomes for people with serious and persistent mental illness mental persistent and serious with people for outcomes employment sustainable Ensuring of continuity Maintaining for accountability Establishing illness mental persistent and of percentage work. seeking actively or employed either is that population the Overview ofOverview Funding Changing Envir Changing Highlights Sunset Progr olicy a

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At a Glance Commission Commission Workforce Texas Texas Workforce Workforce Texas Organization Chart

Source: Legislative Budget Board. (2016). Legislative Appropriations Request for Fiscal Years 2018 and 2019 – Texas Workforce Commission. Pg. 15. Retrieved from http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=320&fy=2018

278 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas TWC 279

10 11 Figure 106 describes three major types of 12 , including child care, for targeted populations populations targeted care, for child , including Workforce Development Boards allow for regional Boards allow Development Workforce 9 the unemployment benefits and tax programs. benefits the unemployment A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation participating in workforce training; and training; workforce in participating Developing the workforce; Developing services support Providing Administering

beneficiaries who utilize TWC services. services. beneficiaries who utilize TWC Texas Workforce Solutions provides workforce development services that are workforce development provides Solutions Workforce Texas and 2) help and maintain employment, intended to: 1) help consumers find partners Workforce needed to conduct business. hire the skilled workers employers local independent adult basic education providers, include community colleges, and other businesses, private groups, economic development school districts, across these various stakeholders Collaboration and coordination agencies. state and support a workforce mission to “promote overall TWC’s to meet is necessary and communities the individuals, that creates value and offers employers, system economic prosperity.” sustain and opportunity to achieve In FY2015, TWC served nearly 770,000 Texans through programs every year, in year, through programs every Texans nearly 770,000 served TWC In FY2015, employers. 86,000 addition to over · · comprised network a local and statewide Solutions, Workforce is part of Texas TWC and their contracted service providers Boards, Development 28 Workforce of TWC, and community partners. Commission agency is the state charged Commission (TWC) with Workforce The Texas and employers both services to development workforce and providing overseeing end goals the of the Governor’s works toward TWC across the state. job seekers development the needed workforce providing by strategy economic development component. major functions include: TWC’s · Texas Workforce Workforce Texas planning and service delivery. Through this network, TWC reaches consumers at the reaches consumers TWC Through this network, planning and service delivery. Tele-Centers. five and state Solutions offices across the in Workforce local level TWC 280 2012. rate forindividualsreceivingpublicmentalhealthserviceswas approximately 80%in National AllianceonMental Illness(NAMI)reportedthatthenationalunemployment with seriousmentalillnessorintellectualanddevelopmental disabilities (IDD).The unemployment ratesdonot always reflecttheprevalenceofunemployment forpeople individualswithdisabilitieschallenges faceinthejobmarket, nationalandstate-level (IDD) acrossthecountrywas 30.5%. force participationrateforindividualswithintellectualanddevelopmental disabilities the publicmentalhealthsystem inTexas was 85.6%. rate inTexas was 4.6%inJuly 2016, up0.1% fromthepreviousmonth. unemployment taxes andreimbursements pay forstate unemployment benefits. The (SNAP E&T), childcare,andother workforceandsupport services. Employer-paid state Services, Supplemental NutritionAssistance ProgramEmployment andTraining Temporary (WIA), Act Assistance forNeedyFamilies (TANF) Choices, Employment to Workforce Development Boardsthat planandadminister theWorkforce Investment funding comingfromfederal sources. TWC provides grants, through allocationformulas, TWC’s fundingiscomprisedofboth federalandstate dollars, withthemajorityof Funding of Texas when provided withtheappropriateopportunities andsupports. the laborforce.Integrationoftheseindividualscan contributetotheeconomicgrowth diversity andofferemployers uniqueskillsets andperspectives whenintegratedinto Individuals withdisabilities, includingserious mentalillness, canenhanceworkforce second largest numberperstate inthenation. data, therewereover 3.4 millionindividualswithdisabilities livinginTexas, the A 2016 reportby theTexas Workforce Investment Councilstated thatbasedon2014 barriers associatedwithjoiningandparticipatingfullyinthelaborforce. Individuals withdisabilities, includingseriousmentalillness, oftenexperience previous month,accordingtotheBureauofLaborStatistics. The nationalunemployment ratewas 4.7%inMay 2016, down 0.3% fromthe Figure 106. TWCBeneficiary and Coordinated Action Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas mental illness, employment canplay aprimary roleinrecovery andwell-being. without disabilities atevery level ofeducationalattainment. disabilities aremorelikely toworkparttimeand,onaverage,earnlessthanindividuals Job Seekers Provides temporary income to workers who have lost their jobs Employers Texans Seeking Unemployment Benefits Beneficiary 17

The same year, theunemployment rateforindividualsreceivingservicesthrough 21 ing programs, and, as appropriate, unemployment benefits. Offers career development information, job search resources, train- and statistics. valuable information on employment law and labor market trends Offers recruiting, training and retaining, outplacement services, and their own. through no fault of TWC Action 20 In 2015, theaveragemonthlylabor 18 Yet forpersonslivingwithserious 16 Because of the unique Because oftheunique 13 Theunemployment 15 14 People with 22 19 TWC 281 23 24 Legislative Appropriations Request for Fiscal Years 2018 and 2019 – Texas Workforce Workforce Texas – 2019 and 2018 Years Fiscal for Request Appropriations Legislative Legislative Appropriations Request for Fiscal Years 2018 and 2019 – Texas Workforce Workforce Texas – 2019 and 2018 Years Fiscal for Request Appropriations Legislative http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=320&fy=2018 http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=320&fy=2018 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Retrieved from from Retrieved Commission. The total requested TWC budget for FY 2018-19 is $3,068,520,433. If the Exceptional If the Exceptional is $3,068,520,433. for FY 2018-19 budget TWC requested The total additional funds would add $16 million to the budget. were included, the Item Funds (2016). Board. Budget Legislative Source: Retrieved from from Retrieved Commission. 2018-19 by Method of FY Finance Funding TWC Requested 108. Figure The total TWC budget for FY 2016-17 was $2,835,257,230. was 2016-17 for FY budget TWC The total (2016). Board. Budget Legislative Source:

Note that the DARS to TWC transfer of programs moves approximately $309 million in $309 approximately of programs moves transfer to TWC the DARS that Note funds). which are federal (82% of to TWC FY 2017 2016-17 by Method of TWC Budget FY Finance 107. Figure U.S. Department of Labor allocates funds from the Federal Unemployment Tax (FUTA) (FUTA) Tax Unemployment the Federal from funds allocates of Labor Department U.S. costs. and operational administrative for to pay states to the TWC 282 developmental, ormentaldisabilities. impairment, substance use disorders, traumaticbraininjury, andother physical, directly withindividualsdisabilities, includingseriousmentalillness, hearing Transformation process. Asaresult,starting September 1,2016, TWC begantowork of Assistive andRehabilitative Services(DARS) toTWC aspartoftheHHSC 2016, thestate transitionedemployment-related programsfromtheDepartment treatments orsupportstoTexans withamentalhealthcondition.However, in Prior toSeptember 2016, TWC didnot provide any directbehavioral health Changing Environment Commission. Retrieved from Source: Legislative Budget Board. (2016). Figure 109. TWCFunding byStrategy FY 2016-17 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas ol3 Indirect administration Program accountability and enforcement Goal 3 Support a workforce system to achieve and sustain economic prosperity Description Goal 2 Goal 1 Goal http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=320&fy=2018 Legislative Appropriations Request for Fiscal Years 2018 and 2019 – Texas Workforce 25 TWC 283 27 with disabilities with disabilities with visual impairments with visual Older Individuals Who Are Blind Older Individuals exas Program , Nelson/Price) as ex-officio members. Additionally, SB 208 Additionally, , Nelson/Price) as ex-officio members. th A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation The transfer of the programs from DARS to TWC involved 1,860.9 1,860.9 involved to TWC The transfer of the programs from DARS 26 , Campbell/Burkett), the TWC “Sunset Bill,” placed all of the state’s placed all of the state’s Bill,” “Sunset the TWC , Campbell/Burkett), th The Criss Cole Rehabilitation Center The Criss Cole for individuals Rehabilitation Program The Vocational of T Enterprises The Business for Program Services Living The Independent The Vocational Rehabilitation program for individuals Rehabilitation program The Vocational

full-time equivalent employees; a budget of $309 million (82% of which are federal a budget full-time equivalent employees; consumers. federal funds; and more than 96,000 and funds), including state programs that are funded through the federal Workforce Innovation and Innovation funded through the federal Workforce programs that are Programs within DARS TWC. Opportunity Act (WIOA) under one agency, together programs DARS while all other TWC, be housed in that criterion will now that met will be transferred to HHSC. director to executive commissioner and TWC SB 208 also required the DARS Committee Oversight and Human Services Transition Legislative join the Health 84 SB 200, (created by · · · · SB 208 (84 Sunset Highlights Sunset agency as a state of its programs dissolved and several DARS 1, 2016, On September include: Those programs to TWC. were transferred · required the executive commissioner of HHSC, the commissioner of DARS, and the commissioner of DARS, commissioner of HHSC, required the executive the Oversight to both a plan to be submitted director to develop executive TWC’s the transfer of all services and programs to detailing and the governor Committee plan focused on ensuring The transition ensure a careful and deliberate transition. to transferred from DARS of the programs being the continuity and accountability leaders to include and TWC DARS, SB 208 also required HHSC, and HHSC. TWC transition plan within the larger submitted was HHS transition plan that their DARS with and the LBB on March 1, 2016, the governor, Committee, to the Oversight the larger HHS SB 200, Required by 2016. in August delivered a revised version will implement the health and human services the state transition plan outlines how information on SB 200 can be found in the More consolidation in coming years. HHSC of this Guide. section Vocational Rehabilitation SB 208 identified nine requirements for the transfer of (VR) to ensure that unnecessary including that measures be taken services, occur and that there be of transferred services and programs did not disruptions agencies that refer consumers for state data with other for exchanging a strategy VR services. TWC 284 also intendedtohelpindividualswithdisabilities transitionfromschooltowork. serious mentalhealthconditions)preparefor, find,and keep jobs. TheVRprogramis individuals withdisabilities (physical anddevelopmental disabilities aswell programisastate-federal partnershipdesignedtohelp Rehabilitation (VR) to helpindividualswithworkreadinessandemployment success. TheVocational are themainreasonswhy individualswithIDDmaintainemployment. reported datashow thatearnings, productivity, andthequalityofsocialrelationships work schedules, part-timework,orsupportedemployment. mental illnesstoget andkeep ajob, thereareoptions forsupport suchasflexible effects, and stigma canmake itharderforanindividualwithadisability orserious suchasdifficultywithparticularschedules,While challenges medicationside wellbeing. For peoplewithmentalillness, workcanplay aprimaryroletoward theirrecovery and D V Sunset Legislation Programs Transferred from DARS per Programs. Source: Texas Workforce Commission. (2015). Figure 110. Key TransitionDates Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas of purpose. a dailyroutine,financialsecurity, healthbenefits, socialinteraction,andasense If a person already receives Supplemental Security Income (SSI) or Social Security If apersonalready receives Supplemental SecurityIncome(SSI) orSocialSecurity · · · · In ordertoreceive VRservices, anindividualmust:

uut3,21 TWC must integrate its into the Local VR staff Workforce Development Boards and Workforce August 31, 2018 TWC is required to integrate the two separate VR programs for individuals with visual impair October 1, 2017 Vocational Rehabilitation Program and other programs transferred from DARS to TWC. September 1, 2016 Texas was required to submit the WIOA the U.S. State Plan to the Secretary of Department of March 3, 2016 HHSC’s executive commissioner was required to submit a transition plan (including the plan March 1, 2016 Date oc is Be able to ge Need vocational rehabilitationservices in orderto Have Be present in the s keep ajob;and a a Retrieved from http://www.twc.state.tx.us/files/news/dars-transition-plan-twc.pdf bilities ( a physical and/or mental condition that affects theindividual’s ability towork; tion 28 29 Benefits of a job for an individual living with mental illness can include Benefitsofajobforanindividuallivingwithmentalillnesscaninclude IndividualswithIDDalsobenefitfromemployment. Studiesofself- t andkeep ajob after receiving services. a ments and individuals with other disabilities into a single program. Solutions Offices. Labor. Committee, the governor, and the Legislative Budget Board (LBB). vocational rehabilitation (VR) and other programsfor the transfer to of TWC) to the Oversight Action l tate ofTexas; R VR e ha ) bilit Plan for the Transfer Vocational of Rehabilitation Services and Other Services and a tion f or help theindividualget and/or P ersons wit 31,32 Thereareprograms 30 h

33 -

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36 VR 38 or f m a irments rogr . The transition plan states that The transition plan states P a 39

37 mp I l tion a a tates that after September 1, 2016, TWC and TWC 1, 2016, tates that after September tance services isu V bilit

yment services, as needed yment services, h ha e Eligibility for VR services does not depend on an individual’s individual’s on an depend not does VR services for Eligibility 34 R l ls wit a A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation a tion 35 Assessments Rehabilitation teaching Counseling, guidance, and referral Specialized services for deafblind individuals Develop an Individualized Plan for Employment (IPE) with VR counselors (IPE) with an Individualized Plan for Employment Develop as needed training and related services, Receive assis employment Receive post-emplo Receive Apply for services service eligibility Undergo to determine an assessment a

· · · · 1. 6. 4. 5. 2. 3. oc ndividu More information on the VR program can be found online at http://www.twc.state. online information on the VR program can be found More tx.us/jobseekers/vocational-rehabilitation-adults there will be specific ongoing consumers efforts to coordinate services for these V I Rehabilitation Program for Individuals with Visual Impairments The Vocational a visual impairment that is a barrier services to eligible individuals who: 1) have provides outcomes, their employment 2) can benefit from VR services to better to employment, gainful employment. get, and retain and 3) require VR services to prepare for, People who are eligible to receive VR services work with a VR counselor to work with a VR VR services to receive who are eligible People each case. VR services and needed for are appropriate what services determine an in a voice services have those who receive meaning that are consumer-focused, create with their (IPE), which consumers for Employment Individualized Plan goals an individual has outline what employment An IPE helps VR counselors. based VR Services are those goals. in achieving VR services can assist and how needs, depending on the disability, needs and vary greatly on an individual’s include counseling, training, may services Work-related goals. and employment services. and other job placement assistance, devices, assistive medical treatment, Disability Insurance (SSDI), the individual is presumed eligible for vocationaleligible for is presumed individual the (SSDI), Insurance Disability services. rehabilitation services available to eligible individuals with visual impairments include:services available Consumers who obtain these vocational rehabilitation services follow six steps in six steps rehabilitation services follow these vocational obtain Consumers who process: the service delivery income. The DARS to TWC transition plan s to TWC The DARS HHSC of services to children with blindness the delivery will continue to coordinate Program, While HHSC the Blind Children’s operates now or visual impairments. will closely coordinate with HHSCTWC to ensure that the needs of consumers with blindness or visual impairments are addressed. VR service providers partner with businesses to develop new employment new employment partner with businesses to develop VR service providers to target work with public school districts also Program staff opportunities. who need services to help them transition from secondary with disabilities students school or work. education to post-secondary TWC 286 Th million. requested VRprogramsbudget fortheFY2018-19 bienniumwas over $590 On September 1,2016, allVRservicestransitioned fromDARS toTWC. The P I services inTWC. during thetransitionofagingoutBlindChildren’s toVR PrograminHHSC Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas a memberof theTexas House of Representatives andtheTexas Senate,Judge Cole who lost hissightwhileservingasaMarineduringWorld War II. Duringhistimeas an adultresidentialtraining facilityinAustin namedinhonor ofJudge CrissCole, that was formerlyoperatedby theDARS is DivisionforBlind Services(DBS).CCRC isacomprehensiveThe CrissColeRehabilitation Center(CCRC) VRtrainingfacility Legislature. All accepted changes will go intoeffectonOctober1,2017.Legislature. Allacceptedwillgo changes andstandards byneeded policy changes October1,2017, adatemandatedby theTexas of thetwoprograms. ThisreviewinFY2016 was intendedtopositionTWC tomake timelines. must alsodetermine Theagency how torealigntheregionalboundaries policies andprovider standards toidentifynecessary revisionsandassociated Impairments intoasingleVRprogramnolaterthanOctober 1,2017. Physical andMental Disabilities withtheVRProgramforIndividualsVisual TWC was furtherrequiredtointegratetheVRProgramforPersons with and tosupportspecializationofVRcounselorsservingdifferent clientpopulations. to develop planstoorganizeservicesbasedoneachconsumer’s individualizedneeds transition. Aspartoftheintegrationprocess, TWC usedthe expertiseoftheVRstaff provide services. policies forproviding consumerservices, and different standards for vendors who different regionalboundaries, differentregionalmanagementstructures, different populationandthevisually impairedpopulationhad programs servingthegeneral no laterthanSeptember 1,2016. BeforetheVRprogramstransferredtoTWC, theVR TWC was requiredtodevelop atransitionplanfortheintegrationofVRprograms TWC must facilitatethisintegrationthroughthefollowing minimumactions: work witheachofthe28Boardstoensureintegration is successful. Development BoardsandWorkforce SolutionsOffices by August 31, 2018. TWC will SB 208requiredTWC tointegrate VRstaff intothenetwork ofLocal Workforce ntegr rogr e C 41 riss TheVRstaff atthattimecontinuedproviding the same servicesduringthe a 5) 4) 3) 2) 1) a ms

ting t Recommend adoption ofany necess Consolidate policies;and Redesign performancemeasures; different clientpopulations; Develop aplantosupportspecializationofVRcounselors serving mee Reorganize servicedelivery toachieve anintegratedVRprogramthat 43 40 C Duringthetransitionprocess, DARS andTWC willreviewprogram ole ts eachconsumer’s individualneeds; h R e e V ha oc bilit a tion a tion a l R ary rules. e C ha enter bilit a 45 42 44 tion

TWC 287 46 m a or f m a s progr 49 a rogr ex lind P T

B f 54 Residents at CCRC receive training in training at CCRC Residents receive 47 People who are selected to join the BET who are selected to join the BET People 51 o Are ervices S Wh 55 ls a CCRC’s ultimate goal is to empower consumers to fully consumers ultimate goal is to empower CCRC’s iving nterprises o nterprises 48 L E 53 BET collaborates with the Vocational Rehabilitation Program with the Vocational collaborates BET A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation The same year, BET employed over 1,400 Texans in its food service and in its Texans 1,400 over employed BET year, The same 50 ndividu 52 I usiness usiness B e lder ndependent program become licensed BET managersfrom profits and earn their personal income program become licensed BET In properties. and federal state their businesses which are located on produced by managers $65 million in produced more than BET managed businesses by 2015, annual sales. vending facilities. vending core skills such as orientation and mobility, Braille, daily living, career development, development, daily living, career Braille, and mobility, such as orientation core skills technology. and assistive I O Who Are Blind Program for Older Individuals The Independent Living Services and live institutionalization services to help eligible individuals avoid provides will continue Although TWC homes and communities. independently in their own the agency grant funding and be responsible for program oversight, to receive will enter into an interagency contract with the HHSC these who will administer will work closely with HHSC of additional TWC its administration and services. independent living programs. On September 1, 2016, the BET program transitioned from DARS to TWC. The to TWC. from DARS program transitioned the BET 1, 2016, On September is before the transition. TWC structured was program continues to operate as it in rules and program structure program currently undergoing BET a review of the operational opportunities for improved to identify any biennium the FY2016-17 to managers benefits in the program, which provides Fund, BET Trust The efficiency. does. will continue to operate as it currently Th state- program is a federally-sponsored, (BET) of Texas The Business Enterprises food management to Texans opportunities program that provides administered who are blind. Today, CCRC works with consumers who are blind to help them achieve CCRC achieve blind to help them who are works with consumers Today, goals. independent living and employment was a strong advocate for providing access to services for people with disabilities. people for to services access for providing advocate a strong was participate in their employment, community, and society. community, in their employment, participate for Individuals with Visual Impairments to identify individuals who may be ideal individuals who may Visual Impairments to identify for Individuals with and vending in food service program and who are interested participants in this management and employment. training TWC 288 and other transitionassistance. provided over 112,000 veterans withservices suchasjobsearchassistance, training, with employment-related needs. InFY2015, TWC andWorkforce Solutionsoffices across thestate have veterans representatives, who specialize inassisting veterans at allWorkforce Solutionsoffices. same asthoseprovided tonon-militarycivilians, veterans receive priorityservice within theTWC servicedelivery system, meaningthatwhilemany servicesarethe through specificrules, policies, guidance,andinitiatives. Veterans aregiven priority TWC provides servicestoveterans livinginTexas, aswellmoreindirectsupport V · · · Examples ofpast grantprojectsinclude: skills oftheirexisting workforce. training programsforbusinesseswhowant totrainnewworkers orupgradethe Funds, inordertoprovide tocommunityandtechnicalcolleges customized job TWC’s SkillsDevelopment programprovides grants, alsocalledSkillsDevelopment S Commission (TWC) Programs Texasof Workforce Overview Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Creditfor Heroes.Program andtheCollege Examples ofTWC’s veteran-specific services includethe Texas Veterans Leadership Program isa resourceandreferralnetwork connecting veterans ofIraq and · partners. InFY2014, TWC: technical colleges, workforcedevelopment boards, andeconomicdevelopment through collaborationsbetween TWC, localbusinesses, publiccommunityand · · · Texas Legislature. The SkillsDevelopment programisfundedentirelyby appropriationsfromthe

kills eter certified workers. that trained 400 welders, mechanists, andengineers to increasethenumberof health care regulations. $60,757 grantthattrained 18 small business employees tobecomecompliantwith grant that trained 143 employees within the electrical industry. Texas HydraulicspartneredwithTWC and Osteogenics Biomedical CoServ Inc. partnered with TW Upgraded the skillsof 10 Supported the creation of 5 Served 103 T Awarded 63 Skills Dev a D ns evelopment exas businesses; S 59 peci

elopment Fund Grants totaling $36 million; f ,003 workers in existing jobs. partnered with TWC fora andSouthPlainsCollege ic ,779 new jobs;and 61 S 56 60 C and NorthCentral Texas fora$161,845 College ervices Successfuloutcomesoftheprogramareachieved Many oftheTWC Workforce Solutionsoffices 62 TheTexas Veterans Leadership Temple fora $399,254 College grant 57 TWC 289 63 Program Overview Program to instruction writing and reading, math, language, English Provides workplace. the succeed in students help the with employers and claimants insurance unemployment Provides the concerning determination adverse an challenge to opportunity of chargeback the or benefits to entitlement employer’s an to benefits account. the to support institutions educational public local to funds Grants apprenticeship ofcost registered in instruction classroom job-related programs. training provides colleges; and schools career private regulates and Licenses the and students, schools, to assistance technical and information public. which families, low-income eligible for services care child Subsidizes work, to parents enabling by self-sufficiency long-term promotes training. job in participate or school, attend public from transition to customers for foundation the Provides employment-related through self-sufficiency and work to assistance services. ofcomplaints Investigates discrimination; housing and employment discrimination; housing and employment prevent to training provides compliance. for policies agency state applicable reviews services related and search, job recruiting, comprehensive Provides seeking employers connect to order in seekers job and businesses to employment. seeking individuals and workers of recruitment the in market labor the testing with employers Assists non-immi- bring to approval granted are they before workers domestic U.S. the to workers foreign grant ofclaims Resolves employed not is child a that ensures wages; unpaid safety, child’s the to detrimental is that manner or occupation an in well-being. or health, salary, conditions, working patterns, hiring or staffing occupational trends. and history, employment local to barriers substantial overcoming in parents noncustodial Assists economically becoming while advancement career and employment payments. support child consistent making and self-sufficient exhaust to likely are who claimants benefits unemployment Identifies reemployment with them connects and benefits, unemployment all work. to return quickly them help services to and colleges, technical colleges, community to grants Provides job customized implement to order in organizations community-based for Assistance Temporary for eligible customers for programs training employers. with cooperation in (TANF) Needy Families ms a rogr P

A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation TWC er h t Programs & Services & Programs Literacy and Education Adult Appeals Apprenticeship Colleges & Schools Career Services Child Care Choices Rights Civil Service Employment Certification Labor Foreign Law Labor Information Career & Market Labor Choices Parent Noncustodial regarding information customized and statistics employment Provides Services Reemployment Rapid Self Sufficiency Figure 111. TWC Programs & Services with Program Overview with Program & Services TWC Programs 111. Figure O Afghanistan to a veterans resource and referral specialist in each of the 28 workforce 28 workforce of the in each specialist referral and resource a veterans to Afghanistan to veterans that allows a program is College for Heroes Credit areas. development colleges. certain through military experience credit for their classroom receive TWC 290 Source: Texas Workforce Commission. (n.d.) Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Work Opportunity Tax Credit WorkInTexas.com WorkforceInvestment Act Unemployment Tax Unemployment Benefits Trade(TAA) Adjustment Assistance & TrainingEmployment Supplemental Nutrition Assistance Program for VeteransSkills Skills for Small Business Program Senior Community Service Employment Programs & Services Programs and Services. disadvantaged in their efforts to find employment. qualified employees from a target population who may be somewhat Provides a federal tax credit for private, for-profit businesses that hire assistance to anyone seeking work in Texas. Provides recruitment assistance to Texas employers and job search vocational programs for adults, dislocated workers, and youth. Provides market-driven employment, training, adult education, and subject to the Texas Unemployment Compensation Act. Collects wage information and unemployment taxes from employers their own. who have lost jobs through no fault of Provides temporary, partial income replacement to eligible individuals job shifts. goods and services or of foreign import of tance, and other services to individuals who have lost their jobs due to Provides training, re-employment services, temporary financial assis- employment through work-related education and training activities. Supplemental Nutrition Assistance Program (SNAP) recipients for Promotes long-term self-sufficiency and independence by preparing programs for businesses that want to hire and train veterans. and technical colleges in order to provide customized job training and entering the Texas workforce by providing grants to community post-9/11 veteransAddresses returning home the training needs of 100 employees). small businesses (lessfor current than and newly hired employees of Finances tuition and fees for community and technical college courses in securing unsubsidized employment. job skills through temporary subsidized employment and training, and Assists eligible individuals ages 55 and older in gaining competitive Program Overview Retrieved from http://www.twc.state.tx.us/programs TWC 291 . Retrieved from http:// Monthly Update. Retrieved National Employment . Retrieved from http:// . Retrieved Monthly Update Employment ). National Retrieved from http://www2. Retrieved and Recovery. Employment . Retrieved from http://www2. . Retrieved and Recovery Employment Retrieved from http:// Retrieved SHEET. FACT and Recovery Employment . Retrieved from . Retrieved and Mental Illness Employment Road to Recovery: 14). Retrieved from Retrieved Mental Illness. and Employment Road to Recovery: 14). http://www.twc.state.tx.us/about- from Retrieved Workforce. About Texas . Retrieved from http://www.twc. . Retrieved – Funding Commission Workforce 15). Texas Rehabilitation Services and Other 15). Plan for of Vocational the Transfer Retrieved from http://www. Retrieved and Recovery. Meaningful Work . Retrieved from http://www.bls.gov/eag/eag. . Retrieved 16). Economy at a Glance, Texas Retrieved from http://www.bls. Retrieved Participation. at a Glance - Labor Force Topics 14). Retrieved from fromhttp://www.bls.gov/eag/eag. Retrieved a Glance, Texas. 16). Economy at http://www.bls. from Retrieved Unemployment. Measures to Government 15). How Services for Persons with Physical and Mental with Physical (n.d.). Services for Persons Services. e and Rehabilitative A Guide Rehabilitation Program: Vocational (2013). Services. e and Rehabilitative Vocational Rehabilitation for Persons with Rehabilitation for Persons Vocational (2016). Services. e and Rehabilitative TIDE Jobs Report: Steady Job Numbers May Signal Start of Turnaround for May Signal Start of Turnaround People Numbers Report: Steady Job 16). nTIDE Jobs nTIDE Jobs Report: Steady Job Numbers May Signal Start of Turnaround for May Signal Start of Turnaround People Numbers Report: Steady Job 16). nTIDE Jobs . Retrieved from http:// . Retrieved Profile – A Texas with Disabilities People Council. (2016). vestment from Retrieved 8. . Page Profile with Disabilities: A Texas Persons Council. (2016). vestment from 1. Retrieved . Page Profile with Disabilities: A Texas Persons Council. (2016). vestment Legislative Appropriations Request for Fiscal Years 2018 and Years Request for Appropriations Legislative Fiscal t Board. (2016). Legislative Appropriations Request for Fiscal Years 2018 and Years for Request Appropriations Legislative Fiscal t Board. (2016). A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Partnerships in Employment: Supporting Adults with Intellectual and Developmental Supporting Adults with Intellectual and Developmental in Employment: Partnerships 14). Texas Department of Assistiv Texas from http://www.dars.state.tx.us/drs/index.shtml Disabilities. Retrieved Department of Assistiv Texas for from http://www.dars.state.tx.us/publications/pdf/01856.pdf Applicants. Retrieved Ibid. Ibid. (20 J. Winsor, from https://www.aucd.org/docs/resources/pie_adults_Nov2014_ . Retrieved Disabilities in Their Communities families.pdf (n.d.) Illness. National Alliance on Mental www2.nami.org/factsheets/supportedemploymentoverview_factsheet.pdf America. (n.d.) Health Mental Texas Department of Assistiv Texas Commission. (20 Workforce Texas Ibid. (n.d.). Illness. National Alliance on Mental mentalhealthamerica.net/meaningful-work-and-recovery from https://kesslerfoundation.org/node/851 with Disabilities. Retrieved In Workforce Texas Commission. (20 Workforce Texas state.tx.us/about-texas-workforce#funding BudgeLegislative from http://www.twc.state.tx.us/files/news/dars-transition-plan-twc.pdf Retrieved Services and Programs. nami.org/Template.cfm?Section=Employment1&Template=/ContentManagement/ContentDisplay. cfm&ContentID=160740&MicrositeID=0%22 gov.texas.gov/files/twic/Disabilities_Profile.pdf gov.texas.gov/files/twic/Disabilities_Profile.pdf Ibid. (n.d.). Illness. National Alliance on Mental In Workforce Texas http://gov.texas.gov/files/twic/Disabilities_Profile.pdf (20 Foundation. Kessler http://gov.texas.gov/files/twic/Disabilities_Profile.pdf from http://www.dars.state.tx.us/drs/vr.shtml and Mental Disabilities. Retrieved Physical Bureau of Labor Statistics. (20 Bureau of Labor Statistics. tx.htm In Workforce Texas Ibid. (20 Illness. National Alliance on Mental https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/RoadtoRecovery.pdf nami.org/Template.cfm?Section=Employment1&Template=/ContentManagement/ContentDisplay. cfm&ContentID=160740&MicrositeID=0%22 from http://docs.lbb.state.tx.us/display. Retrieved 10. . Pg. Commission Workforce 2019 – Texas aspx?DocType=LAR&agy=320&fy=2018 Ibid. Ibid. BudgeLegislative (2016). National Conference of State Legislators. Ibid. (20 Foundation. Kessler https://kesslerfoundation.org/node/851 from with Disabilities. Retrieved (20 Bureau of Labor Statistics. gov/bls/cps_fact_sheets/lfp_mock.htm Ibid. Commission. (n.d.). Workforce Texas texas-workforce from http://docs.lbb.state.tx.us/display. Retrieved 55. Page Commission. Workforce 2019 – Texas aspx?DocType=LAR&agy=320&fy=2018 www.ncsl.org/research/labor-and-employment/national-employment-monthly-update.aspx Bureau of Labor Statistics. (20 Statistics. Bureau of Labor (20 Statistics. Bureau of Labor (20 Illness. on Mental National Alliance National Conference of State Legislators. (2016 Legislators. of State Conference National www.ncsl.org/research/labor-and-employment/national-employment-monthly-update.aspx tx.htm gov/cps/cps_htgm.htm https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/RoadtoRecovery.pdf

34 35 30 31 32 28 33 22 24 27 29 16 19 21 23 26 15 17 18 20 25 11 12 6 7 8 9 10 13 14 Endnotes 1 2 3 4 5 TWC 292 63 61 60 58 57 56 55 54 53 50 49 47 46 45 44 43 42 41 40 39 38 37 36 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 62 59 52 51 48

jobseekers/college-credit-heroes Texas Workforce Commission.(20 Ibid. Legislative Budge just-veterans Texas Workforce Commission.(20 Ibid. Texas Workforce Commission.(n.d.) year-2014-twc.pdf Retrieved from http://www.twc.state.tx.us/files/businesses/skills-development-fund-annual-report-fiscal- Texas Workforce Commission.(20 state.tx.us/programs/skills-development-program-overview Texas Workforce Commission.(20 Ibid. Services andPrograms. Retrieved fromhttp://www.twc.state.tx.us/files/news/dars-transition-plan-twc.pdf Texas Workforce Commission.(20 Ibid. Ibid. Texas DepartmentofAssistiv Texas DepartmentofAssistiv Ibid. Ibid. Texas DepartmentofAssistiv Ibid. Ibid. Ibid. Ibid. twc.pdf Services andPrograms. Page 45. Retrieved fromhttp://www.twc.state.tx.us/files/news/dars-transition-plan- Texas Workforce Commission.(20 aspx?DocType=LAR&agy=320&fy=2018 2019 –Texas Workforce Commission. Page 59. Retrieved from http://docs.lbb.state.tx.us/display. Legislative Budge Ibid. twc.pdf Services andPrograms. Page 45. Retrieved fromhttp://www.twc.state.tx.us/files/news/dars-transition-plan- Texas Workforce Commission.(20 are BlindorVisually Impaired. Pg. 45. Retrieved fromhttp://www.dars.state.tx.us/dbs/vr.shtml Texas DepartmentofAssistiv Ibid. Disabilities. Re Texas DepartmentofAssistive andRehabilitative Services. Persons (n.d.).Servicesfor withPhysical andMental aspx?DocType=LAR&agy=320&fy=2018 2019 –Texas Workforce Commission. Page 9. Retrieved fromhttp://docs.lbb.state.tx.us/display. businesses/skills-development-fund-overview-twc.pdf www.dars.state.tx.us/reports/annual2015/annualreport2015.pdf Program. Retrievedhttp://www.dars.state.tx.us/dbs/bet/index.shtml from www.dars.state.tx.us/reports/annual2015/annualreport2015.pdf trieved fromhttp://www.dars.state.tx.us/drs/index.shtml t Board.(2016). Fiscal Legislative Appropriations Requestfor Years 2018and t Board.(2016). Fiscal Legislative Appropriations Requestfor Years 2018and e andRehabilitative Services. (2016). Vocational Persons Rehabilitationfor Who e andRehabilitative Services. (2016). 2015AnnualReport.Retrieved fromhttp:// e andRehabilitative Services. (2016). AbouttheBusiness EnterprisesofTexas e andRehabilitative Services. (2016). 2015AnnualReport.Retrieved fromhttp:// 16). College Heroes. Credit Retrieved for fromhttp://www.twc.state.tx.us/ Veterans.16). Justfor Retrieved fromhttp://www.twc.state.tx.us/jobseekers/ 14). SkillsDevelopment Fund AnnualReportFiscal Year 2014.Page 2-12. 16). SkillsDevelopment –Program Overview. Retrieved fromhttp://www.twc. theTransfer ofVocational15). Planfor RehabilitationServicesandOther theTransfer ofVocational15). Planfor RehabilitationServicesandOther theTransfer ofVocational15). Planfor RehabilitationServicesandOther Skills Development Fund. Retrieved fromhttp://www.twc.state.tx.us/files/ TDCJ 293

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for Incarcerated Females Incarcerated for for jailers and correctional staff on mental health issues and de-escalation techniques de-escalation and staff issues correctional and jailers for health mental on health screening, safety, and suicide prevention procedures in correctional settings correctional in procedures prevention suicide and safety, screening, health

and Housing Issues Housing and A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation alth Services and Programs in the State Criminal Justice System Justice Criminal State the in Programs and Services alth Services alth oncerns Prevention and Diversion Programs Programs Diversion and Prevention eer Support eer sault and Prison Rape Elimination Act (PREA) Investigations (PREA) Act Elimination Rape Prison and sault ation Community-Based Services Community-Based ation on Parole Special Programs Special Parole on Justice Systems Justice ocal Jails ocal C the Texas Criminal Justice System Justice Criminal Texas the Services

Funding Summary Funding the use of prolonged solitary confinement, repeated restraints, and other aversive interventions on interventions aversive other and restraints, repeated ofuse the confinement, solitary prolonged external oversight within prisons, jails, and other incarceration settings to ensure that persons with mental with persons that ensure to settings incarceration other and jails, prisons, within oversight external Commission on Jail Standards Standards Jail on Commission acts Administrative Segr Administrative As Sexual Recommended Medically Release Examples Community Courts Specialty Health Mental P Reentry Relevant Riders Relevant Bland Sandra Major Legislation Legislation Major exas Department ofDepartment exas Justice Criminal Cost and Cost Texas TDCJ Facilities Facilities TDCJ He Behavioral to Access He Behavioral Post-Incarcer Concerns Special L in Suicide Incarceration Policy Concerns Policy Fast F Fast Chart Organizational atment settings atment settings Expanding training training Expanding mental Improving Decreasing Increasing Diverting people with mental illness who commit low-level offenses away from correctional facilities and into facilities and correctional from away offenses low-level commit who illness mental with people Diverting tre illness mental with incarcerated persons ofconditions humane and constitutional experience illness confinement Local Criminal Local Overview ofOverview T The Changing Environment Changing olicy

· · · P · · At a Glance Criminal Criminal AgenciesJustice Agencies Justice Criminal ofand Local Justice Department Criminal Texas Criminal Justice and Local and Justice Criminal Texas Department of Department Texas · Improving access to jail diversion opportunities and a full range of psychiatric medications, especially within rural jail facilities · Increasing access to intensive support services as individuals with mental illness transition from jail or prison into the community, including jail in-reach programs, forensic assertive community treatment (FACT) teams, and reentry peer support Fast Facts

· Studies estimate that over half of all adults who are incarcerated in U.S. prisons and jails have at least one mental health condition.1 · On May 31, 2016, there were 146,746 people incarcerated in Texas prisons, which accounted for 98% of TDCJ’s operating capacity.2 · In FY 2014, the average cost for an adult in a Texas prison was $54.89 per day.3 In contrast, adults on parole cost $4.04 per day, and adults under community supervision (formerly called adult probation) cost $3.20 per day.4 · The average daily cost per person who requires medical care in Texas prisons is between $96 and $104,5 while the average daily cost per person in a psychiatric correctional facility is $145.6 · On June 1, 2016, Texas county jails collectively operated at 70.5% capacity with a total jail population of 65,793.7 · In FY 2015, about one million people cycled through local jails in Texas.8 · In 2015, 50% of grievances submitted by incarcerated people to the Texas Commission on Jail Standards (TCJS) involved complaints regarding medical services, including mental health services.9 Organizational Chart

Source: Texas Department of Criminal Justice. (n.d.). Organizational Charts: Texas Department of Criminal Justice. Retrieved from https://www.tdcj.texas.gov/org_chart/org_chart_tdcj.html.

294 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas TDCJ 295 Texas Texas 16 Almost Almost 10 Mental Health Problems of Problems Health Mental Instead, their alleged Instead, 14 Figure 112 demonstrates that a large proportion Figure 112 demonstrates The percentage of justice-involved individuals with less The percentage of justice-involved 13 12 http://www.bjs.gov/content/pub/pdf/mhppji.pdf or to social factors (such as poverty and homelessness). or to social factors (such as poverty In 2015, about 30% of people in local Texas jails had at least least jails had at in local Texas about 30% of people In 2015, 15 11 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation severe mental health issues, such as mild depression, is even greater; researchers such as mild depression, is even mental health issues, severe at least prisons and jails have half of people incarcerated in U.S. that over estimate one mental health problem. of individuals in jails across the country self-report at least one mental health self-report at least of individuals in jails across the country symptom. Jail by of Self-Reported Symptoms Mental Health Percentage 112. Figure Inmates 50 years later, studies estimate that 15% to 24% of incarcerated persons have a incarcerated persons have of that 15% to 24% estimate studies 50 years later, serious mental illness. The extent to which serious mental illness is connected to dangerous to which serious is behavior The extent to violent behavior, be linked it seems that mental illness may In some cases, unclear. Despite the overrepresentation of people with mental illness in U.S. prisons and jails, and jails, prisons of people with mental illness in U.S. Despite the overrepresentation system justice research suggests that only 7% of these individuals enter the criminal directly to their mental illness. linked because of behavior Source: As used in Hautala, M. (2015). In the Shadow of Sandra Bland: The Importance of Mental Health Screening in U.S. Jails. Jails. ofImportance The U.S. in ofShadow the In Screening Health Mental Bland: Sandra (2015). M. Hautala, in used As Source: (1), 98. Data derived from Bureau of Justice Statistics. (2006). (2006). ofStatistics. Justice Bureau from derived Data 98. 21(1), Liberties, Civil & Rights Civil on Journal from Retrieved 2. . Inmates Jail and Prison Criminal Criminal Agencies Justice Criminal Justice and Local and Justice Criminal live system criminal justice Texas in the of individuals involved A significant number substance co-occurring have and many mental health conditions, with one or more justice mental health and the criminal connection between The strong use disorders. persons in the only 5% of incarcerated In the 1970s, existed. always has not system disorder. such as schizophrenia or bipolar serious mental illness, had a U.S. Texas Department of Department Texas one serious mental illness. criminal behaviors are often tied to behavioral factors (such as hostility, disinhibition, factors (such as hostility, are often tied to behavioral criminal behaviors reactivity) or emotional TDCJ 296 can exacerbatepreexisting diagnoses. abuse, solitaryconfinement,andsexualvictimization. illness aremorelikely thanother incarceratedpopulationstoexperiencephysical thatcanworsentheirmentalhealthconditions.face challenges People withmental and During Their Incarceration Figure 113. Individuals With and Experiencesof Without MentalIllnessPrior to county budgets. unitsecurity, concerningcorrectionalfacilitymanagement, challenges andstate and number ofpeoplewithseriousmentalillnessinthejustice system raisesimportant their incarceration.Inadditiontoindividualmentalhealth impacts, thegrowing thatpeoplewithmentalillnessdisproportionallyfacepriortoandduring challenges commit anestimated 4%ofviolenceintheU.S. but researchshows thatthislinkisweak.Infact,peoplewithmentalillnessonly Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas prioritizing diversion fromincarceration over theconstruction ofnew prisons. In the 80thTexas Legislaturealteredthetrajectory ofcriminaljustice by policy thenation,TexasAcross serves asamodelforcriminaljustice reform.In2007, Changing Environment Prison and Jail Inmates. 4, 10. Retrieved from http://www.bjs.gov/content/pub/pdf/mhppji.pdf Journal on Civil Rights & Civil Liberties, 21(1), 102. Data derived from BureauJustice Statistics. of (2006). Mental Health Problems of Source: As used in Hautala, M. (2015). Sandra Bland: Mental Health ScreeningIn the Shadow of in U.S.The Importance of Jails. Texas illness never engage inanyillness never engage violentactivities. experienced homelessness, orsurvived abuse. more likely thanincarceratedpersonswithoutmentalillnesstohave useddrugs, Prior totheirimprisonment,justice-involved personswithmentalillnessare identify whowillbeviolent. acts. Psychiatrists tobeviolentbetter canruleoutwhoisnotgoing thantheycan sufficiently toallow researcherstoidentifywhichindividualswillcommitviolent acts ofviolence. the absenceofasubstance usedisorder, most mentalillnessesareunrelatedto which agunisused. persons withseriousmentalillnesscommitasmallproportion ofhomicidesin highly publicizedshootings andthediscussionsofmentalillnessthatoftenfollow, 20 Unfortunately, thescienceofriskassessmenthasnot advanced 18 Thevast majorityofpeoplewithadiagnosable seriousmental 21

24 Figure113demonstrates someofthe 19 Statistical evidenceshows that,in 22 17 Onceincarcerated,theyalsotendto Contrarytothefearcreatedby 23 Alloftheseexperiences TDCJ 297 In June, the In June, 26 27 , Garcia/Naishtat) th , Naishtat/Menendez) to improve the to improve , Naishtat/Menendez) th TEXAS LEGISLATURE The training curriculum is meant to TH 28 Together, these legislators worked with with legislators worked these Together, 25 Forensic commitments involve individuals with commitments involve Forensic 29 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation mental illness who have been arrested for a crime and subsequently admitted to admitted for a crime and subsequently been arrested mental illness who have guilty trial or not to stand hospital because they are deemed incompetent a state legislators passed SB 1507 (84 In 2015, reason of insanity. by HB 1338: Training for Peace Officers and First Responders on Brain Trauma Responders on Brain Officers and First for Peace HB 1338: Training legislators passed HB 1338 (84 Texas In 2015, MAJOR LEGISLATION FROM THE 84 FROM MAJOR LEGISLATION 2015, legislators continued that trend. Lawmakers passed legislation to enhance to enhance legislation passed Lawmakers that trend. continued legislators 2015, the and improve opportunities, diversion increase illness, of mental the detection Whitmire (D-Houston), work, Senator their Senator Ellis For reentry process. (D-Houston), (D-San McClendon and Representative Dallas the Antonio) received title. of the Year Texans News’ Morning Texas Board of Criminal Justice selected TDCJ’s deputy executive director, Bryan director, executive deputy selected TDCJ’s Board of Criminal Justice Texas for TDCJ worked Collier has director. new executive as the agency’s to serve Collier, 30 years. over and management positions for in various line staff other senators and representatives across the political aisle to pass reforms that are pass reforms that political aisle to across the and representatives senators other persons with serve and better rates, incarceration decrease to cut costs, projected mental illness. to mental illness and adult criminal riders related and budget The major legislation described in the order by Legislation is explained below. are passed in 2015 justice criminal justice the Texas experience with mental illness may which an individual account of the mental a comprehensive this section is not Information in system. during the 84th legislative legislation passed justice-related health and criminal session. reforms will be implemented 2015 Legislature’s that the Texas It should be noted executive TDCJ’s Brad Livingston, 2016, In April under new TDCJ leadership. announced his retirement. the agencydirector who served years, for 12 detection of brain injury and mental illness at the first stage of the criminal justice stage of the criminal justice first of brain injury and mental illness at the detection Texas HB 1338 requires the enforcement officers. process – encounters with law the HHSC Enforcement to partner with Commission on Law Office of Acquired Traumatic Brain Injury Advisory Council to design Brain Injury and the Texas by brain responders regarding persons affected training for peace officers and first of acquired incorporate information on the direct effects trauma. The training must which can include major depression, bipolar brain injury and traumatic brain injury, disorders. and anxiety disorder, affective improve encounters between first responders and individuals with brain injuries, responders and individuals with brain injuries, first encounters between improve mental illness and HB 1338 presents an opportunity to detect particularly veterans. before they are system in the criminal justice from involvement individuals divert into a local jail. and booked arrested Health Mental of Forensic and Oversight Coordination Statewide SB 1507: Services state of forensic commitments to Texas the number and 2016, 2001 Between hospitals more than tripled. forensic population. The bill efforts to address the growing to expand upon past the forensic director in order to improve required DSHS to appoint a statewide The bill also specified of forensic mental health services. coordination and oversight TDCJ 298 process, Texas lawmakers passedSB578(84 backthrough thecriminaljusticethat theywillcycle system. To easethereentry face stigma andinstitutional barriersuponrelease,whichincreasesthelikelihood but thistransitioncanbechallengingformany. About 95%ofincarceratedindividualsarereleasedbackintotheircommunities, Information SB 578:Providing IncarceratedIndividualswithReentryandReintegration caseload away fromadsegunitsandintomoretherapeuticenvironments. all 1,500individualsinsolitaryconfinementwhoarealsoon TDCJ’s mentalhealth program toinclude420additionalbedsattheMichaelUnit. packets available toindividuals180days beforetheirrelease. the reentryprocessanddecrease recidivism.TDCJisrequiredtomake thereentry housing options, counselingservices, andother relevant resourcesthatcanimprove assistance programs,specific informationabout emergency workforceoffices, who areabouttobereleasedfromincarceration.The packets must includecounty- justice-focused groupsinthedevelopment ofreentryresourcepackets forpeople TDCJ tocollaboratewithnonprofits, faith-basedorganizations, and other criminal HB 1083(84 confined inadsegwerealsoonTDCJ’s mentalhealthcaseload. as anxiety, depression,paranoia,andself-harm. placement inadsegcanboth causeandexacerbatementalhealthissues, such Psychological researchshows that administrative segregationor“adseg”). (known in are disproportionatelyhousedinsolitaryconfinement Texas as Individuals withmentalillnesswhoserve timeinTexas prisonsandjails Segregation HB 1083:Mental Health AssessmentsforIndividualsinAdministrative of thisguide. For andDSHSsections seetheHHSC moreonSB1507andforensicservicesingeneral, aspects offorensicservices authorities (LMHAs),andother involved agencies inthesocial,health,andlegal Justice (TDCJ),theTexas Juvenile Justice Department(TJJD), localmentalhealth workgroup includesrepresentatives fromHHSC, theTexas DepartmentofCriminal to develop recommendationsforimproved forensicservicecoordination.The that theforensicdirectormust workwithagroupofexpertsandstakeholders Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas the general prisonpopulation. the general andintegratingbackinto on-site mentalhealthprofessionalsbefore“graduating” ingrouptherapymonth programallows participantstoengage andmeet with but forwhomadsegisclinicallyinappropriate.Equipped with420beds, thesix- population Hughes Unitforindividualswhorequireseparationfromthegeneral For example,in2014, TDCJbeganamentalhealthdiversion pilot programatthe assign theindividualtoadifferenthousingunit. seg isinappropriatefortheperson’s mentalorphysical healthcondition,TDCJmust individuals beforetheyareconfinedinadseg.Iftheassessment determines thatad mental healthprofessionaltoperformaassessment forincarcerated with mentalillnesswhoareconfinedinadsegunits. Thebillrequiresamedicalor th , Marquez/Whitmire) toimprove healthoutcomesforindividuals 32 Duringthesummerof2016, TDCJwillexpand the th , Hinojosa/Allen). Thebillrequires 34 30 Formerly incarcerated people In2016, about32%ofpeople 33 The goal istodivert Thegoal 31 Legislatorspassed TDCJ 299 health centers to identify to identify health centers , Huffman/Schwertner). For more , Huffman/Schwertner). The controversy highlighted the risks The controversy rd 35 $5 million in both FY 2016 and FY 2017 to the FY 2017 and FY 2016 in both $5 million general revenue funds for FY 2016 and FY and general funds for FY 2016 revenue million per year in generalyear million per funds for revenue Finally, House Speaker Joe Straus appointed Joe Speaker House Finally, 38 ximately $32 million in general ximately $32 million funds to revenue A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation The Texas Senate received an interim charge to evaluate jail safety an interim charge Senate received to evaluate jail safety The Texas , Duncan/Zerwas). For more information on the program, see the DSHS program, see on the more information For , Duncan/Zerwas). rd 36,37 39 appropriated about $1.7 Rider 70 appropriated information on the program, Harris County Jail Diversion Pilot Program later in Pilot Diversion Jail County program, Harris on the information guide. of the this chapter pilot competency restoration a jail-based to implement FY 2017 and FY 2016 be transferred from a jail to a mental who would otherwise for individuals program through SB program in 2013 the pilot created Legislature 83rd The facility. health (83 1475 individuals with mental illness in the justice system and report prevalence data on and report system justice illness in the with mental individuals population. this target from jails away individuals to divert order in plan services state Medicaid expand treatment programs. and emergencyand into community-based rooms appropriated appro Rider 61 appropriated to allocate Rider 66 required DSHS Legislature created Texas The 83rd Program. Pilot Diversion Harris County Jail (83 SB 1185 through in 2013 the program required DSHS and community mental community mental and DSHS required Rider 35 chapter of this guide. of chapter more information on For program. pilot reentry peer support implement a to 2017 of the guide. chapter in this Support section Peer Reentry see the program, appropriated $1 million in Rider 73 appropriated

· guidelines and review law enforcement and correctional officer training as it relates enforcement guidelines and review law to individuals with mental illness. · · RELEVANT RIDERS RELEVANT issues through health-related and mental criminal justice also addressed Legislators (HB 1, Art. II). budget Services (DSHS) of State Health the Department riders to below. riders are listed Relevant · SANDRA BLAND AND JAIL SAFETY CONCERNS SAFETY JAIL AND BLAND SANDRA system criminal justice session concluded, the Texas After the 84th legislative Sandra 28-year-old 2015, In July brought into the national media spotlight. was after failing to use her turn signal when changing lanes. pulled over Bland was at a Waller and booking trooper led to her arrest confrontation with a state Her was Bland later, bail. Three days afford to post County jail where Bland could not apparent suicide. found dead in her cell by · that aggressive arrest procedures and money bail practices pose for people with arrest that aggressive mental for improved the need death also demonstrated Bland’s mental illness. within standards safety health screening procedures and increased adherence to jail incarceration settings. on County Affairs and the Senate Committee death, the House In response to Bland’s jail to discuss the state’s interim hearings convened Committee Criminal Justice standards. representatives to the House Select Committee on Mental Health; Speaker Straus Speaker Health; on Mental Select Committee to the House representatives including health system, behavioral to examine the Texas formed the committee jails and illness in Texas the disproportionate incarceration of persons with mental prisons. TDCJ 300 www.harriscountytx.gov/cscd/faq.aspx Figure 114. Common Criminal Justice Definitions Figure 114 containsaglossary oftermstypicallyusedinthecriminaljustice system. sessions, however, advocates have introducedlegislationtocreatesuchabody. oversight bodydoesnot monitorTexas prisonsandstate jails. Inpreviouslegislative oversees contractswithprivatecorrectionalagencies. Unlike countyjails, anexternal who areconvicted ofmoreseriousoffenses. TDCJoperatesthesefacilitiesand In contrast, state-operated facilities, suchasstate jailsandprisons, holdindividuals crime andwereawaiting trial. 2016, about63%ofpeopleheldinTexas countyjailshadnot beenconvicted ofa awaiting trialandpeoplewhohave beenconvicted oflow-level crimes. InJanuary settings. Localjailsoperatedby countiesormunicipalitiesholddefendantswhoare Individuals involved inthecriminaljustice system may beplacedinavariety of System the Overview of Texas Criminal Justice Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Source: Source: Harris County Community Supervision & Corrections Department. (n.d.). cfm?ty=tdtp&tid=1 municipal jails. across Texas. However, doesnot TCJS provide oversight withincity-operated safe andconstitutional conditionsofconfinementforindividualswhoaredetained and inspectingcountyjailfacilities, assists TCJS localgovernments inproviding county jailsandseven privately-operated municipaljails. By setting jailstandards Commission onJail forall actsastheexternal Standards(TCJS) regulatoryagency be confinedhereforextended periodsoftime. any external agencies, thoughindividuals, includingthosewithmentalillness, may Restitution Prisons State jails Designed to house individuals awaiting trial or serving short-term sentences for Local county or municipal jails Parole probation) (previously known as adult Community Supervision Term Bureau of BureauJustice Statistics. of (n.d.). 41 Instead, themunicipaljailslocatedinTexas arenot regulatedby

usually given in monthly installments. Monies that a court orders an individual to pay to a victim’s family. Payments are punishments ranging from two years to death. third-degree felonies or higher with Designed to house individuals convicted of 180 days to two years. felonies with punishments ranging from Designed to house individuals convicted of misdemeanor convictions. a sentence under supervision in the community.serve the remainder of A Pardons a person from discretionary prison by the Board release of of and Paroles to a regular basis. time. The individual must also meet with his or her community supervision officer on programsnity and ordered and sanctions for a specified period of to a continuum of An alternative to a prison sentence whereby an individual is released to the commu- Definition Terms and Definitions: Corrections. Retrieved from http://www.bjs.gov/index. 40 While county sheriffs manage localjails, Whilecountysheriffsmanage the Texas 42 Frequently AskedQuestions. Retrieved from http:// TDCJ 301 The 52 51 In 49 44 Both exact and probable matches alert Both ry 48 a These incarcerated persons tend to experience tend to experience persons These incarcerated 43 umm S About 7% (73,844) of the queries were exact of the 7% (73,844) About 47 If a match is detected, the jail then contacts the relevant If a match is detected, 46 When individuals are booked at a county jail, correctional officers are booked When individuals 45 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation nd Funding a TDCJ is responsible for providing health services, including behavioral including behavioral health services, TDCJ is responsible for providing 50 , Duncan/Madden), which required DSHS and DPS to replace a 72-hour manual which required DSHS and DPS , Duncan/Madden), th ost ost data exchange process with a real-time identification system for incarcerated persons for incarcerated system identification process with a real-time data exchange with special needs. health services, to people who are convicted and sentenced to state jails, state state jails, and sentenced to state to people who are convicted health services, The Correctional and private correctional facilities that contract with TDCJ. prisons, policies regarding statewide (CMHCC) develops Care Committee Managed Health of those services to correctional health care services and coordinates the delivery members, is made up of nine voting This committee persons in the TDCJ system. and mental health professionals, medical doctors, including a TDCJ representative, director. Medicaid the Texas member who is appointed by and one non-voting must now check each person’s information against the DSHS Clinical Management for information against each person’s check now must as a Continuity known database. The process, Services (CMBHS) Health Behavioral person has been if a particular of Care Query (CCQ), tells jail employees instantly has experienced an facility or if the person psychiatric hospitalized in a state mental health authority (LMHA) a local by authorization, or assessment encounter, three years. within the past matches with information maintained in the DSHS mental health database, and in the DSHS mental matches with information maintained were probable matches. (369,013) about 37% C prisons. in Texas individuals incarcerated there were 146,746 31, 2016, On May TDCJ’s mission is to “provide public safety, promote positive change positive in offender promote public safety, is to “provide mission TDCJ’s victims of crime.” and assist reintegrate offenders into society, behavior, The Texas Department ofDepartment Criminal Texas The Justice During the 80th legislative session, Texas policymakers adopted a new way to identify a new way policymakers adopted Texas session, During the 80th legislative 839 Legislators passed SB needs. health individuals with behavioral justice-involved (80 People receiving public behavioral health services make up a sizeable portion of the of the portion up a sizeable make services health behavioral public receiving People HHSC the estimated In 2016, Texas. in persons of justice-involved population total health the public mental had contact with prisons Texas of individuals in that 37% their incarceration. prior to system addition to confining convicted individuals, TDCJ manages community-based TDCJ manages community-based individuals, addition to confining convicted individuals on community supervision and programs and oversees jail diversion parole. greater functional impairments from mental illness, more housing instability, and instability, more housing illness, from mental impairments greater functional incarcerated groups. support than other and community less family average cost of incarcerating an individual in a state facility was $54.89 per day in $54.89 per day facility was an individual in a state of incarcerating average cost LMHA in order to link the individual to available community resources. to available LMHA in order to link the individual initiated 991,073 234 counties in Texas 2015, and August 2014 September Between for adults. CCQ match requests the local jails and LMHAs to exchange pertinent information. the local jails and LMHAs to exchange TDCJ 302 spent most efficientlyandeffectively acrossthe state. leaders determineand proposal how willhelpagency behavioral healthfundscanbe a five-year section).Theplan strategic plan andexpenditureproposal (See HHSC Coordinating Councilcomprisedof18state agencies, including TDCJ, todevelop within TDCJ. and FY2017 fortheprovision ofbehavioral healthandsubstance useservices The 84thTexas Legislatureappropriatedabout$247.9 millioninboth FY2016 Agency_Operating_Budget_FY2016_Governor.pdf Budget,Office of Planning and Policy and the Legislative Budget Board . 1-2. Retrieved from Source: Texas Criminal Justice. Department of (2015, December 1). Figure 116. TDCJFY 2016Operating Budgetby Agency Goal Note: The “Other Funds” category includes interagency contracts, appropriated receipts, and general obligation bond proceeds. Agency_Operating_Budget_FY2016_Governor.pdf Budget,Office of Planning and Policy and the Legislative Budget Board. 6. Retrieved from Source: Texas Criminal Justice. Department of (2015, December 1). The TDCJoperatingbudget forFY2016 was $3,406,167,380. 2014. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Figure 115. TDCJFY 2016Operating BudgetbyFunding Source goal. agency down TDCJ’s budgetby fundingsource,andFigure116breaksdown thebudgetby community supervisioncost $3.20 perday. 53 Incontrast, individualsonparolecost was $4.04 perday, andindividualson 56 In2015, legislatorsalso createdtheStatewideBehavioral Health

Operating Budget for Fiscal Year 2016 Submitted to the Governor’s Operating Budget for Fiscal Year 2016 Submitted to the Governor’s 54 http://tdcj.state.tx.us/documents/finance/ http://tdcj.state.tx.us/documents/finance/ 55 Figure 115breaks TDCJ 303

58 59 Population 92,475 4,009 2,831 532 621 4,073 816 15,871 690 17,633 4,979 2,680 147,210 ssues I Capacity 96,825 4,210 3,051 566 314 4,118 836 17,106 700 20,056 5,129 2,791 155,702 nd Housing Housing nd a Number ofNumber Units 50 4 4 1 2 7 1 14 2 15 4 5 109 In a 2015 study, the ACLU of Texas and the Texas Civil Rights and the Texas of Texas the ACLU study, In a 2015 57 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation cilities cilities a J F Type of Facility Type Prison Pre-Release DDP / Psychiatric Geriatric Medical Prisons Private Multi-Use Transfer Transfer Pre-Parole Jail State Jail State Private Abuse Substance ofNumber Facilities Totals People with mental health conditions are overrepresented in the population of with mental health conditions are overrepresented People identified isolated population was 30% of TDCJ’s about In 2014, segregated inmates. care. outpatient some form of mental illness treatable by as having TDCJ utilizes two types of solitary confinement for varying lengths of time. TDCJ utilizes two types of solitary confinement for varying correctional officers use short-term disciplinary segregation for punitive First, to house inmates for an segregation uses administrative Second, TDJC purposes. indefinite period of time when they are considered dangerous or to themselves A complete list and map of TDCJ facilities is available at: http://www.tdcj.state. and map of TDCJ facilities is available list A complete tx.us/unit_directory/unit_map.html SEGREGATION ADMINISTRATIVE mental impact on an individual’s a serious Incarceration in TDCJ facilities can have greater risk for mental health even confined in isolation are at health. People than those in likely These individuals are up to eight times more deterioration. the general prison population to engage likely in self-harm and nine times more to commit suicide. Source: Texas Department of Criminal Justice. (2016, April). Data request: TDCJ facility statistics. facility TDCJ request: Data April). (2016, ofDepartment Justice. Criminal Texas Source: TDCJ has a number of facilities located throughout the state and has headquarters and has headquarters the state located throughout a number of facilities TDCJ has population TDCJ’s depicts 117 below Figure Huntsville. and Austin in both type of facility. by and capacity distribution 2015 in FY and Populations Capacities, Types, Facility 117. Figure TDC Project reported that TDCJ holds 4.4% of its incarcerated population in solitary Project reported that TDCJ holds 4.4% average. the national confinement – a proportion that is four times greater than TDCJ 304 almost fouryears, reentry opportunitiesforindividualshousedinadministrative segregation. duringthe2016Corrections alsoreceived interimcharges interimsessiontoreview initiatives, theSenateCommittee onCriminalJustice andHouse Committee on in administrative segregation. Units willbeavailable forASTDPparticipants. investigations ofinmate-on-inmatesexualabuseallegationsinTexas. facilities. In2014, the PREAOmbudsmanOfficereviewed727administrative compliance withfederalregulationscreatedtoeliminate sexualassaults inprison The Texas PREAOmbudsmanisresponsible forensuringthatTDCJisin sexual assault complaints;five ofthoseprisonswerelocatedin Texas. of Justice Statistics ranked thetenU.S. prisonswiththehighest inmate-reported prisonpopulation.A2008studypeople incarceratedinthegeneral by theBureau Traumatic experiences, suchassexualassault, canalsoimpactthementalhealthof INVESTIGATIONS SEXUAL ASSAULT AND PRISONRAPEELIMINATION ACT (PREA) the transitionalprograminFY2014. improve eachparticipant’s reentryprocess;atotal of476 individualscompleted (ASPP) whichusescognitive behavioral interventions andgrouprecreationto use offlatreleasein Texas.Ad SegPre-ReleaseProgram In2012, TDCJcreatedthe In recentyears, TDCJleadersandstate legislatorshave taken steps todecreasethe formerly incarceratedindividualsandtheirfellow communitymembersatrisk. Research shows thatflatreleaseislinked tohigherrecidivismrates, whichplacesboth prison environment (i.e.,isolation)tothestreets withoutsupervisionorsupport. are housedinadseg,causingTDCJtoreleasethemdirectlyfromthemost restrictive practice occurswhenincarceratedindividualsfinishtheirprisonsentenceswhilethey from administrative segregationintothecommunity. Termed “flatrelease,” this Despite theseadverse mental healthoutcomes, individualscanbereleaseddirectly cell forabout22hoursperday. others. Both typesofsegregationinvolve holdingindividualsinasmall,isolated Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas or Aggravated SexualAssault. 40% oftheincidentsmet theelements oftheTexas Penal CodeforSexualAssault Sexual Assault. incidents met theelementsofTexas Penal CodeforSexualAssault orAggravated comply withthefederalstandards “wherever feasible.” standards, hissuccessor, Governor GregAbbott, stated in2015 thatTexas would settings. ThoughformerGovernor RickPerry refusedtocomplywithPREA problem by instituting forprisonrapeincorrectional azero-tolerancepolicy (PREA),afederallaw passedin2003,Rape EliminationAct seekstoaddressthis depression, cognitive disturbances, psychosis, andsuicidalideation. spans oftimecanexperiencenegative mentalhealthoutcomes, includingmajor allegations ofstaff-on-inmate sexualabuseandharassment. and recidivismoutcomes. segregated inmateswithmentalhealthservicesandimprove theirfuturebehavioral Segregation TherapeuticDiversion Program(ASTDP)in2014 tobetter connect 75 61 butin2015, tenTDCJinmatesreached30consecutive years 66 By theendof2016, 840bedsattheHughesandMichael 73 62 60 ThePREAOmbudsman Office alsoreceived 766 Individualsconfinedinisolationforeven short Onaverage, TDCJinmatesremain inisolationfor 65 TDCJthencreatedtheAdministrative 67 Inadditiontothesereform 71 74 About 13%ofthese 63 70 72 ThePrison About 68,69 64 TDCJ 305

79 81 81 The 84 85 ms in ms a 76 rogr P Among other duties, TCOOMMI case TCOOMMI duties, other Among 80 nd nd a ystem S 78 ervices ervices S h l Justice l Justice

a lt 77 a 83 TDCJ may contract with any entity to implement the managed health care plan. care health managed the implement to entity any with contract may TDCJ Description griev- investigates division The of quality the monitor also employees services. those the and contractors care health with collaborates and audits, service conducts ances, (CMHCC). Committee Care Health Managed Correctional mental health TDCJ’s monitors OMHM&L the Division, Services Health the Within health-related mental on offices TDCJ other to guidance expert provides and services issues. Division, Parole the as (such various groups coordinating for responsible is division The School Windham the Division, Services Health Division, Assistance Justice Community of provision the in - organizations) community-based and treat evidence-based District, periods. supervision and incarceration their throughout individuals for services ment managers work as liaisons between correctional staff to LMHAs at correctional between liaisons as work managers providers service and adherence facilitate and services, management case provide continuity of improve care, plans. treatment to a developing with charged authority coordination and oversight the is CMHCC people all for Plan) Services Health Offender the (called plan care health managed TDCJ’s between arrangement partnership a manages committee The TDCJ. by confined (UTMB), Galveston at Branch Medical Texas of University the Division, Services Health for responsible is TTUHSC (TTUHSC). Center Sciences Health University Tech Texas and ofwestern part the in care) health mental (including services medical providing the of22% incarcerates TDCJ same the for responsible is UTMB population; its where state of78% incarcerates TDCJ its population. where half eastern the services in Texas of Within the Health Services Division, the Office ofOffice the performs Monitoring Services Health Division, Services Health Within the includ- ofquality and to access monitor to audits compliance onsite care, health inmate care. health mental ing Comprised of representatives from 21 agencies and organizations, TCOOMMI provides provides TCOOMMI of organizations, and agencies 21 from Comprised representatives affected other and services, human and health justice, criminal for structure formal a affecting issues programmatic and policy, legislative, on coordinate to agencies needs. with special individuals incarcerated rimin l He C a A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation As the number of people with mental illness in state prisons rises, prisons rises, mental illness in state with As the number of people 82 te a t vior S e ha e h Rehabilitation Programs Programs Rehabilitation Division Health Services DivisionServices Health services; care health to access have persons incarcerated that ensure must division The ofOffice Health Mental Liaison and Monitoring (OMHM&L) Entity Correctional Managed Health Health Managed Correctional (CMHCC) Committee Care Office ofOffice Services Health Monitoring Texas Correctional Office for Office Correctional Texas and Medical with Offenders Mental Impairments (TCOOMMI) average daily cost in a psychiatric correctional facility is $145 per person. correctional facility is $145 in a psychiatric average daily cost To meet an individual’s behavioral health needs, TDCJ operates a managed health health needs, behavioral an individual’s meet To for people who daily cost average plan. The care plan rather than a fee-for-service $96 and $104 per person. prisons is between requires medical care in Texas In Estelle v. Gamble (1976), the U.S. Supreme Court determined that prison officials that Court determined Supreme U.S. the (1976), Gamble v. In Estelle individuals with appropriate incarcerated required to provide are constitutionally cruel and unusual constitutes of such services denial and that care services health punishment. TDCJ is comprised of many subdivisions that manage and operate the agency, that manage subdivisions and operate the agency, comprised of many TDCJ is Within to crime victims. services and provide incarcerated individuals, supervise offices and there are several for meeting responsibility that hold the agencies TDCJ, a brief 118 provides Figure inmates. health needs of and behavioral the physical of each office or agency. description TDCJ Divisions within Mental Health-Related and Behavioral 118. Figure B t however, maintaining a constitutional level of care becomes challenging. Research challenging. Research care becomes of level a constitutional maintaining however, across and 75% of women in prisons 50% of men that decade estimates past the over or mental that requires behavioral health problem a mental experience the U.S. services each year. health TDCJ 306 · · · · · needs: diagnostic andtreatmentservicesforincarceratedindividualswithbehavioral health Qualified mentalhealthproviders may recommendthefollowing mentalhealth B receive mentalhealth-relatedtraining. mental illnessduringtheintake processoruponreferralsfromsecuritystaff who health careserviceswithintheirassignedfacility. Facilities may identifypeoplewith care. At intake, incarceratedpersonsareprovided informationonhow toobtain are incarceratedcangainaccesstomedical,mentalhealth, substance use,anddental Additionally, eachTDCJfacilitymust develop aprocessby whichindividualswho Source: Correctional Managed Health Care Committee. Figure 119. Health Level Service of classifications arelisted inFigure119below. classifications ofhealthservicesformedical,dental,and mentalhealthneeds. The made available toincarcerated individualswithinTDCJ. Theplanspecifiestwo Health CareCommittee (CMHCC)describesthelevels ofhealthcareservices The Offender Health ServicesPlandeveloped by theCorrectionalManaged Access to Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas a mentalillnessordevelopmental disability. Figure120describestheseprograms: TDCJ alsoadministers specialized programsforcertainincarceratedindividuals with · · tdcj.state.tx.us/divisions/cmhc/docs/Offender_Health_Services_Plan.pdf

essary Level II Medically Nec- datory Level I Medically Man- Level of Service Level of e Professional services, and including diagnostic evaluations, acute care, transitionalandextended care; Inpatient services pro Crisis management/suicide Psychosocial Continuity of care services; Professional services, mental Emergency ha vior services; a S l He ervices reduction in the possibility of repair later without treatment.reduction in the possibility of serious deterioration,risk of or where there is a significant which thepatientcouldnotbemaintainedwithoutsignificant Care that is not immediately essential to life, but without very cost effective. intervention is expected to make a significant difference or be rapid deterioration is expected. The recommended treatment Care that is essential to life and health and without which Description health services (available 24 hoursaday, seven days per week); such asmedication monitoring and management. andmonitoring; such asmedication management vided by acorrectional health care approved facility, a lt prevention; h

S (2015, September). ervices 87 86

Offender Health Services Plan. 4. Retrieved from extent of service. extent of guidelines control the ing standards and practice Provided to all, but evolv- ated individuals. Provided to all incarcer Availability 88 http:// - TDCJ 307 http://tdcj. 90 http://www.tdcj.state.tx.us/ Ranging from the least restrictive to the most the to restrictive least the from Ranging 89 Retrieved Retrieved Manual. Policy Care Health Managed Correctional . Retrieved from from Retrieved Division. Programs Rehabilitation Description three by followed programs, treatment in-prison six-month, are IPTC and SAFPF Both up and ofmonths nine to six aftercare, outpatient ofmonths aftercare, residential to individuals sentence can Judges of year one to supervision. and groups support Parole and ofBoard the or lieu ofin Pardons IPTC or SAFPF time, jail state or prison ofcondition a as participation program parole. require can are who individuals for intended programs six-month intensive are PRTC and PRSAP - “crimi or dependency, chemical conditions, use substance serious with incarcerated these in inmates place to votes Parole and of Board The Pardons issues.” ideology nal collaboration involves PRTC The community. the into release their to prior programs the and District, School Windham the Division, Programs Rehabilitative the between Division. Parole to 90- a or program 90-day to 60- a either in placed are inmates jail state Eligible assessment (ASI) Instrument Severity Addiction an on based program 120-day and counseling, rehabilitation, provided are Participants history. criminal their and needs. unique their meet to designed services related ofvariety a and component education aftercare an uses program six-month The ofrisk the reduce to activities incarcerated people among treatment and recidivism on focus that practices evidence-based in engage Participants offense. DWI a for therapies. cognitive and awareness, victim disorders, use substance engages individuals living in a single-cell housing housing single-cell a in living individuals engages track housing sheltered outpatient Description and evaluate to techniques behavioral cognitive utilizes program treatment voluntary This and status,* security G5 or G4 a with those segregation, administrative in individuals treat individuals Enrolled ofhistory a have who others behavior. aggressive and illness mental of program. the complete to years two order in at least have must left sentence their ofsuspected individuals Incarcerated borderline or disability intellectual an having judged is functioning adaptive whose individuals and diagnosis functioning intellectual (DDP) Program Disabilities Developmental a to referred be may impaired significantly services. and evaluation further facility for inpatient The ofone in participants tracks. enrolls treatment program CMI separate two The those or segregation administrative in illness mental with people serves track treatment management. medication and monitoring close require who status security G5 G4 or a with The programming. therapeutic in stable psychiatrically are who unit A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Program Abuse Substance Felony and (SAFPF) Facility Punishment - Therapeutic Commu In-Prison (IPTC) nity Abuse Substance Pre-Release - Pre-Re and (PRSAP) Program Therapeutic lease Community (PRTC) Jail State Abuse Substance Program While Driving Intoxicated Program In-Prison Level of Level Service - Aggres the for Program Offender Mentally-Ill sive (PAMIO) Disabili- Developmental (DDP) Program ties Ill Mentally Chronic (CMI) Program divisions/rpd/rpd_substance_abuse.html Source: Texas Department of Criminal Justice. (n.d.). (n.d.). ofDepartment Justice. Criminal Texas Source: TDCJ also manages a number of programs within its Rehabilitation Programs Division to describes these programs. Figure 121 below use conditions. people with substance serve Substance Use Service Descriptions 121. Figure Source: Correctional Managed Health Care Committee. (n.d.). (n.d.). Committee. Care Managed Health Correctional Source: state.tx.us/divisions/cmhc/cmhc_policy_manual.html custody levels. six into prisons state in housed individuals classifies TDCJ *Note: Figure 120. Specialized Programs for Individuals with Mental Illness or a Illness Mental with Individuals for Programs Specialized 120. Figure Disability Developmental restrictive, these levels include: G1 (General Population Level 1), G2, G3, G4, G5, and Administrative Segregation. Individuals with a G4 a with Individuals Segregation. Administrative and G5, G4, G3, G2, 1), Level Population (General G1 include: levels these restrictive, Individuals supervision. without armed fence security the outside work not may and they dorms, than rather cells in live status security security the work outside ofnot histories may have and status cells security in G5 live a they with behavior; aggressive or assaultive supervision. armed without fence TDCJ 308 Figure 122. Reentry Assistance ServicesProvided by TCOOMMI andLMHAs utilizing TCOOMMI case management services.utilizing TCOOMMIcasemanagement the RiskNeedsResponsivitymodeltoreducerecidivism amonghigh-riskindividuals prevent reentryintothecriminaljustice system. In2013, TCOOMMIimplemented address theroot causesunderlying aperson’s previouscriminalbehavior inorderto Linking formerlyincarceratedindividualstocommunity servicescanhelpto TCOOMMI’s transitional supportscanbeinstrumental inreducingrecidivism. eligibility services(includingfederalentitlementapplication processing). psychological andpsychiatric services, medicationandmonitoring,benefit with mentalillnessarereferredtoLMHAsforservices, suchascasemanagement, which aretypicallydelivered by LMHAs. Uponreleasefromincarceration, people incarcerated clientsandprovide referralsforaftercarepsychiatric treatmentservices, Continuity ofcareprogramsaredesignedtoincludepre-releasescreenings Source: Texas Criminal Justice Department. (2016, April). Personal communication: Reentry services. illness, and/or intellectualdisabilities. include olderadultsandpersonswithphysical disabilities, terminalillness, mental people withspecialneedsintothecommunity. Individualswithspecialneeds institutional andcommunity-based servicestofacilitatethereentryofincarcerated Offenders with Medical and Mental Impairments(TCOOMMI)provides avariety of As partofTDCJ’s ReentryandIntegrationDivision,theTexas CorrectionalOfficefor P Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas with mentalillness. health authorities(LMHAs)toprovide threetiersofreentryassistance forpeople with oneofthree specificmentalhealth diagnoses–bipolar disorder, major The majorityofTCOOMMI’s servicesweretraditionallyreserved forindividuals TDCJ’s recidivismratewas 21.4%. general were served foratleast programs, oneyearinTCOOMMIcasemanagement while rate was 12.4% riskandhighclinicalneedswho for clientswithhighcriminogenic management Adult transitional case agement Adult intensive case man- These services are available for 90 days after a person’s release from incarceration. Eligi- care services Continuity of Reentry Assistance ost- I nc a rcer 92 Figure122describeseachtypeofreentrysupport. package and who have moderate or low criminogenic risk. ment. This caseload also serves individuals who do not qualify for an intensive service uals on supervision who require step-down services from adult intensive case manage- Transitional case management services are available on an as-needed basis for individ- group services. staff, medication management, skills training, assistance with benefits applications, and vices may be granted. contact with LMHA Services include at least 3.5 hours per month of disorder that is severe or persistent in nature. On a case-by-case basis, ser an extension of depressive disorder, schizophrenia, post-traumatic stress disorder, psychosis, or any other from incarceration. Eligible participants include those with bipolar disorder, major Individuals may receive intensive case management for up to two years after their release link individuals to community supports and medication assistance. persistent in nature. LMHA meet face-to-face with participants at least three staff times to phrenia, post-traumatic stress disorder, psychosis, or any other disorder that is severe or ble individuals include those with bipolar disorder, major depressive disorder, schizo- Description a tion C ommunity- 91 TCOOMMI partnerswithlocalmental 94

93 In2015, thethree-year recidivism Ba sed S ervices - TDCJ 309 After a 100 102 The remaining 75% of The remaining 95 97 During the 84th legislative 84th legislative During the 96 , Naishtat/Garcia) to revise TCOOMMI’s to revise TCOOMMI’s , Naishtat/Garcia) th That same year, 48 people incarcerated in state jails 48 people incarcerated in state year, That same 98 99 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation For example, individuals who commit a sex offense must be in a persistent be in a persistent example, individuals who commit a sex offense must For 101 individuals with one of these diagnoses did not receive case management receive services not diagnoses did with one of these individuals criminogenic risk TCOOMMI’s failure to meeting of their due to a combination resources. of sufficient lack the agency’s criteria and were also referred for MRIS release, 3 were presented to the presiding judge, 3 were presented to were also referred for MRIS release, and 3 for release. were approved RELEASE ON PAROLE SPECIAL PROGRAMS SPECIAL RELEASE ON PAROLE with Division operates a series of specialized programs for individuals Parole TDCJ’s health issues who are released from incarceration. mental health and behavioral of these programs: an overview provides Figure 123 below for who are referred the number of incarcerated persons Discrepancies between for early release exist are ultimately approved MRIS and the number of people who unit medical including sources, Diverse as a result of the MRIS referral process. TCOOMMI personnel, families of incarcerated persons, attorneys, legislators, staff, initiate an MRIS referral. may and incarcerated persons themselves, MEDICALLY RECOMMENDED INTENSIVE SUPERVISION INTENSIVE SUPERVISION RECOMMENDED MEDICALLY and Supervision (MRIS) is an early parole Recommended Intensive Medically including older needs, incarcerated people with special release program that serves terminal illnesses, disabilities, developmental adults and persons with mental and The purpose of the disabilities. or physical illnesses requiring long-term care, risk individuals who pose minimal public safety program is to release incarcerated individual health outcomes and cut to improve back into the community in order will TCOOMMI specialists for early MRIS release, is approved If an individual costs. case management. and facilitate reentry expedite the release planning process In were referred for correctional institutions incarcerated in state 1,690 people 2015, and (BPP), and Paroles to the Board of Pardons MRIS release, 210 were presented for release. 82 were approved depressive disorder, or schizophrenia. However, even among this narrow target target this narrow among even However, or schizophrenia. disorder, depressive supervision community or parole under individuals of eligible 25% only population, case management TCOOMMI received services in 2013. referral is made, a person’s eligibility must be determined based upon his/her be determined eligibility must referral is made, a person’s described that the current offense and medical condition. TDCJ representatives the program’s meet do not majority of those who are referred for early release vast their cases presented to the BPP for have eligibility criteria and thus cannot strict a vote. eligibility requirements. Now, individuals with mental illness who have diagnoses mental illness who have individuals with Now, eligibility requirements. may or schizophrenia disorder, major depressive than bipolar disorder, other The case management continuity of care and programs. participate in TCOOMMI’s for $6 million general by funding revenue increased TCOOMMI’s 84th Legislature to accommodate the change. biennium the 2016-2017 vegetative state or suffer from an organic brain syndrome that causes significant to brain or suffer from an organic state vegetative of aggravated while persons convicted mobility impairment in order to qualify, total ill or require long-term care to qualify. be terminally offenses must session, lawmakers passed HB 1908 (84 session, lawmakers TDCJ 310 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Figure 123. Specialized Programs within TDCJ’s Parole Division highest intheworld. If Texas were itsown country, itsrate offemaleincarcerationwouldbethesixth S Annual_Review_2014.pdf Source: Texas Criminal Justice. Department of (2015). facilities. Incarceratedwomenare: mental healthneedsthan other peopleboth insideandoutsideofcorrectional Drug TestingProgram (SACP) Counseling Program Substance Abuse nity Program Therapeutic Commu - Program Sex Offender Offender Program Special Needs Initiative Offender Reentry and Violent Serious Centers District Reentry Name peci a l C oncerns

rvdsisatra rgtsig 160,806 drug tests conducted monthly Provides instant-read drug testing. viduals with substance use treatment needs. Provides relapse prevention services to indi- felony punishmentfacility (SAFPF). therapeutic community or a substance abuse individuals who participated in an in-prison issues. a three-phase program Consists for of incarcerated individuals with substance use care services for Offers continuity of Board of PardonsBoard of and Paroles. who are required to participate by the Texas to committing sexually deviant behavior, or sex offense conviction, who have admitted for individuals who have a current or prior treatment, and relapse prevention services Provides supervision, contracted specialized illnesses, or physical disabilities. abilities, mental health conditions, terminal Supervises individuals with intellectual dis- through their supervision in the community. during their incarceration and extending segregation with reentry services beginning Provides individuals in administrative empathy. restructuring, substance use, and victim and address anger management, cognitive approach to promote personal responsibility need individuals using a comprehensive Targets newly-released, high-risk, and high- Description 103 Incarceratedwomenhave distinct andpossiblygreater f Annual Review 2014. 28-29. Retrieved from or I nc a rcer treatment to 815 people. stance useservicesto2,488people, andrelapse intervention services to 1,572 people, sub- residential treatment to 1,481 people, cognitive Two intermediate sanction facilities provided vendors and Parole Division counselors. outpatient treatment services from contracted 804 individuals per month received Level II prevention services in FY 2014. Approximately 22,269 individuals receivedA Level I total of 6,507 individuals 5,443 individuals · · · · released to the Parole Division in FY 2014. 58 SVORIA program total of participants were 1,115 individuals Supervision Program in FY 2014 Monthly Individuals in Average Number of

supervision conditions 129 individuals on physical disabilities 831 individuals with 5,941 individuals with mental ment disorders 147 individuals with a ted Fem http://tdcj.state.tx.us/documents/ medically recommended terminal illnesses or intellectual develop- a les health TDCJ 311 In FY 2015, In FY 2015, 114 In its first five five In its first 108 but the program can only

115 TDCJ estimates that about 250 TDCJ estimates 109,110 This population figure, however, masks the This population figure, however, 113 and

105 106 111,112

tent to stand trial who are awaiting a placement for are awaiting trial who tent to stand 104 ely to be dependent on drugs than women without experience experience without women than on drugs be dependent ely to ve not been convicted of a crime and are awaiting trial; and are awaiting of a crime been convicted not ve A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation more likely to experience physical abuse prior to their imprisonment their imprisonment to abuse prior physical experience to more likely victed of low-level offenses who are sentenced for short durations; sentenced who are offenses low-level victed of state facilities; and transport to awaiting who are an offense victed of times more likely to experience sexual abuse prior to their imprisonment imprisonment prior to their sexual abuse experience to more likely times n TDCJ has a number of programs designed to accommodate for the special of programs designed to accommodate TDCJ has a number times more lik more times 107 times Four males. than incarcerated competency restoration. competency People con People con People found incompe People People who ha People Ten system; justice in the Seve males;, than incarcerated

· On June 1, 2016, Texas county jails operated at 70.5% of their collective capacity of their collective county jails operated at 70.5% Texas 1, 2016, On June of 65,793. jail population with a total · · · Local Criminal Justice Systems Justice Criminal Local prosecutors, enforcement agencies, of law consist systems Local criminal justice public that are responsible for promoting and probation departments courts, jails, systems Local in a specified region. and local laws state, enforcing federal, by safety through the trial and from the point of arrest are responsible for criminal cases Local jails hold four groups of individuals: sentencing stages. · · total number of people who cycle through jails each year. A daily population statistic A daily population statistic number of people who cycle through jails each year. total in of the number of people detained a snapshot gives (like above) the one provided the total number of people who spend that shows statistic A jail on a specific day. the during one year more clearly captures if only for a few hours, time in jail, even time. In 2016, over a jail of people who experience confinement in high volume every in the U.S. 11 million times people go that to jail over researchers estimated day. given people are jailed on any though only about 646,000 year, about one million people cycled through Texas jails. about one million people cycled through Texas babies are born to incarcerated women in Texas each year, in Texas babies are born to incarcerated women 20 women at a time. serve · needs of its female population. For example, in 2010, TDCJ started the Baby and the Baby TDCJ started example, in 2010, population. For needs of its female and health (BAMBI) emotional, Initiative Bonding the physical, to address Mother experiencing pregnancyneeds of women Housed or giving birth while incarcerated. Unit, BAMBIteaching to combat recidivism by seeks Hostel at the Santa Maria women participants typically include the basics of parenting. Eligible new mothers have who their due date. Women within 12 months following scheduled for release a child against of arson, a violent offense, a sex offense, or an offense been convicted participate in BAMBI. cannot that caused harm or bodily injury Research shows that women with histories of trauma and abuse require more of trauma and abuse require histories that women with Research shows care typically of models than traditional, male-oriented specialized treatment offer. years of operation, the program produced an 8% recidivism rate, and as of May 2016, 2016, rate, and as of May an 8% recidivism years of operation, the program produced been enrolled in the program. 197 women have TDCJ 312 · · · · · · responsibilities include: minimum standards andoperationofTexas forthemanagement jails. TCJS’s key and createsaddedpolicingincarcerationcosts forlocalcommunities. an individual’s inandoutofjail,whichdiminishesmentalhealthoutcomes cycling mental healthneedsandalackofpost-incarceration treatmentplanningcanleadto while thoseinlessaffluentcounties may not receive any medicationsatall.Untreated affluent counties may receive over aweek’s worthofmedicationsupontheirrelease, must travel to235countiesinadditionseven privately-operated facilities. Out ofthe254countiesin Texas, allbut19operate atleast onejail;therefore,TCJS for allcountyjailsandseven privately-operated municipaljails. The Texas CommissiononJail isanexternal Standards(TCJS) regulatoryagency T their releasefromcountyjailsdonot exist. standards dictatingtheprovisionexample, TCJS ofmedicationstoindividualsupon practices inordertomeet theneedsofdetainees withmentalhealthconditions. For areas, may lackthenecessary resourcestoimplementbest trainingandtreatment health treatmentandsupportthattheyneed.Countyjailsystems, especiallyinrural officials oftenlackthetrainingrequiredtoprovide individualswiththemental Despite thehighproportionofpeoplewithmentalhealthneedsinjails, correctional of theirmentalhealthstatus duetoalackofadequatetherapeuticservices. particularly thoseinruralareaswithfewerresources, may experiencedeterioration social servicesinordertoprevent recidivism.Texans detained inother facilities, tend toprovide treatmentandsuccessfullylinkindividualstocommunity-based of mentalhealthservicescanvarywidelybetween facilities. urbanjails Large legally mandatedtoprovide healthservicestodetainees, thequalityandavailability their entrance(orre-entrance)intothecriminaljustice system. Thoughjailsare substance useissues. Theiruntreatedneedscanleadtobehavior thatresultsin Many peopledetained inlocaljailslive withco-occurringmentalhealthand services, includingmentalhealthservices. Texas CommissiononJail involved Standards(TCJS) complaintsregardingmedical populations. In2015, 50%ofgrievancessubmitted by incarceratedpeopletothe Jail detainee administrators indelivering services totheirlarge facechallenges Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas county isvisitedforacompliance inspectionatleast onceeachfiscalyear. adequate medicalcare. complaints theyreceive frominmatesandtheirfamiliestypicallyinvolve alackof a nonprofitthataimstoimprove jailconditions, reportedthatabout80%ofthe TCJS standardsTCJS includerequirementsfor thecustody, care,andtreatmentof jail does not performoversight inmunicipaljailslocated inTexas.

ex Performing o Providing manag Auditing and reporting Reviewing proposed jail cons Providing technical assis Performing on-siteinspectionsofjailstoverify a s C ommission onJ ther activities relating to policy development andenforcement. ther activities relating to policy ement consultation; and 117 on jailpopulations; tance andtraining regarding jail management; truction and renovation plans; a 118 116 il As a result, people with mental illness in Asaresult,peoplewithmentalillnessin LeadersfromtheTexas Jail Project, S compliance withminimumstandards; t a nd a rds 120 TCJS establishes TCJS 119 123

TCJS TCJS 122 Each 121 TDCJ 313 However, However, 126 130 125 This information may include details about include details This information may 128 ils a l J a oc L A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation People with mental illness who are awaiting trial (and thus have not been not trial (and thus have with mental illness who are awaiting People 129 Each facility must also create and implement a written health services plan health a written and implement also create must Each facility Furthermore, the Texas Health and Safety Code requires various agencies, Code requires various agencies, and Safety Health the Texas Furthermore, 124 127 uicide in convicted of a crime) are at even greater risk. National data show that pretrial individuals that pretrial greater risk. National data show of a crime) are at even convicted peers do. times higher than their convicted suicide at a rate seven complete TCJS does require jail administrators to send a Texas Uniform Health Status Update Uniform Health to send a Texas TCJS jail administrators does require correctional other transferred from one jail to any form when incarcerated persons are facility. an incarcerated person’s treatment needs; social, criminal, and vocational history; treatment needs; social, criminal, and vocational an incarcerated person’s history. and medical and mental health supervision status; for the jail population’s medical, mental health, dental, and pregnant inmate services and pregnant inmate health, dental, medical, mental population’s for the jail These health incarcerated person. record for each a separate health and maintain by administered and a mental health evaluation include a health screening records must At jail. a entry into the officer upon a person’s a trained booking or by medical personnel and mental health treatment should also contain current medical minimum, each record of state the incarcerated individual’s including observations, information and behavioral of suicide, and mental health status. risk consciousness, Source: Texas Commission on Jail Standards. (2016, May 18). Data request: Suicides in county jails. in Suicides request: Data 18). May (2016, Standards. Jail on Commission Texas Source: In Texas, the number of jail suicides increased by about 43% between CY 2014 and CY 2014 about 43% between suicides increased by the number of jail In Texas, the number of suicides that occurred within demonstrates Figure 124 CY 2015. and 2015. 2011 county jails between Between CY Jails County Texas Number of Suicides in Completed 124. Figure 2015 2011 and CY S times more frequently in jails than that suicide occurs roughly three National data show in prisons. Correctional administrators may use inmate health records when individuals are health records when individuals use inmate may Correctional administrators state. TCJS across the doesre-incarcerated within different facilities transferred to or persons’ health records to share incarcerated formally require jail administrators not these records with a signed release. do obtain but many entities, with other detainees. Upon admission to jail, each individual receives a “health receives individual jail, each to admission Upon tag”detainees. a that notes needs Those record. medical the individual’s need in health or mental medical special supervisor the admissions personnel and/or of health brought to the attention are then on duty. including local jails, TCJS, and TDCJ, to disclose and accept information relating to to disclose and accept and TDCJ, TCJS, including local jails, special needs in other and/or disabilities, illness, incarcerated persons with mental law state other continuity of care services “regardless of whether order to improve that information confidential.” makes TDCJ 314 services. still haddiscretion when determining whether toreferthepersontreatment to self-reporttheirmedicalproblemsandmentalhealthhistories, butjailemployees form’s impactonjailsuiciderates. screening form.InDecember2016, willconductananalysistoassessthenew TCJS 1, 2015, allTexas countieswererequiredtoimplementtheupdatedmentalhealth notify asupervisor, magistrate, andmentalhealth professional. to lookforward to?” Ifthedetained personanswers “yes,” jailersmust immediately new screeningformcontainsthequestion: “Are youfeelinghopelessorhave nothing individuals provide certainresponsestopredetermined questions. For example,the process. Jail employees must now follow explicitinstructions whendetained involved Xinthischapter individualswithspecialneeds(Seepage oftheguidefor with all39LMHAstoprovide multi-service alternatives toincarceration forjustice- interventions toprevent criminal justice involvement. TCOOMMI alsocollaborates For example,localmentalhealthauthorities (LMHAs)provide community-based has pushedstakeholders to develop opportunitiesfordiversion fromincarceration. Increased demandformentalhealthserviceswithin state prisonsandcountyjails P I placed onsuicidewatch afterthenewprocedurewas putinplace. administrators intested facilities reportedincreasesinthenumberofindividuals In October2015, thenewformwas tested inseveral counties acrossthestate. Jail screening instrument. mentaldisabilities/suicide prevention evaluated immediatelywithaTCJS-approved who areatriskforsuicide.Uponadmissiontothejail,each individualmust be Jail administrators inTexas alsouseanapproved screeningtooltoidentifydetainees · · · · construct theseplans, butataminimum,eachplanmust addressthefollowing: disabilities/suicide prevention plan.Jail officialsaregiven flexibilityin howthey requires countysheriffsandjailoperatorstodevelop andimplementamental To decreasetheincidenceofsuicideinjailsettings, theTexas Code Administrative Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · fails toinitiateanimmediatereferral. mental healthprofessionaliftheysuspectsuicidalriskbutthe screeninginstrument uses agradingsystem toprovide furtherguidanceonwhenjailersshouldcontacta

nc rogr suicide and during the process ofasuicide attempt; Intervention and information about suicidal individuals; Communication and documentation Intake trainingprocedures to identify Staff training procedures regarding following all attempted andcompleted suicides. Review mechanisms for jail adminis completed suicides;and Reporting procedures to inform potentially suicidal; of incarcerated individuals who havemanagement a mentaldisability and/or are a rcer 133 Thenewformthatwas createdin2015 removes subjectivityfromthe a ms a tion emergency treatment procedures prior tothe occurrence of a emergency 132 Thepreviousinstrument asked newlyincarceratedpeople P revention 137 outside authorities and familymembers about 135 the identification, supervision,and trators and medicalmentalhealthstaff procedures to relay andmaintain persons who aresuicidal; a 131 nd D iversion 134 136 Theformalso OnDecember TDCJ 315 http://www.safetyandjusticechallenge.org/ The aim of these prevention of these prevention The aim 138 estoration (OCR) programs for individuals who do not do who individuals for programs (OCR) estoration

that prioritize therapeutic dispositions over traditional traditional over dispositions therapeutic prioritize that alth deputies and crisis intervention teams (CITs) staffed by staffed (CITs) teams intervention crisis and alth deputies each teams (MCOTs) staffed by mental health professionals who professionals health mental by staffed (MCOTs) teams each instant messaging programs that enable law enforcement and jail and enforcement law enable that programs messaging instant osecution programs that allow people charged with low-level crimes to crimes low-level with charged people allow that programs osecution corrections and support services. services. support and corrections Specialty mental he mental Specialty outr crisis Mobile with interact they as illness mental with people to assistance on-site provide can paramedics. and officers police local police officers who can identify and divert individuals experiencing mental experiencing individuals divert and identify can who officers local police crises. have their criminal cases dismissed and arrests expunged. arrests and dismissed cases criminal their have Deferred pr Deferred diversion Jail staff to access a person’s medical and behavioral health history more efficiently. more history health behavioral and medical staffperson’s a access to pose a threat to public safety. public to threat a pose Mental health courts Mental health r competency Outpatient sentences. tention and court hearings; tention and court into the community; and community; into the

Examples ofExamples Strategies Diversion · · · · · · - w enforcement and emergency w enforcement and services; ails and courts; A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation The sequential intercept model, developed in conjunction with the model, developed The sequential intercept 139 Intercept 1: La Intercept 2: Initial de Intercept 3: J Intercept 4: Reentry Intercept 5: Community Intercept Intercept 1: Intercept emer and enforcement Law services gency Intercept Intercept 2: Intercept and detention Initial hearings court Intercept 3: Intercept courts and Jails

and diversion programs is to use cost-effective, safe, and clinically appropriate appropriate safe, and clinically cost-effective, is to use programs and diversion illness charged of people with mental that curb the over-incarceration strategies crimes. with low-level Services Administration (SAMHSA) Health and Mental Abuse The Substance and jail diversion to organize prison model as a way the sequential intercept promotes strategies. Figure 126 below describes specific diversion strategies that can be implemented at describes specific diversion Figure 126 below model. of the sequential intercept each step Point Sequential Intercept at Examples of Diversion Strategies 126. Figure Source: H. Steadman. (2014, July). “When Political Will Is Not Enough: Jails, Communities, and Persons with Mental Health Disorders.” Disorders.” Health Mental with Persons and Communities, Jails, Enough: Not Is Will “When Political July). (2014, Steadman. H. Source: from Retrieved 4. . Initiative Reform Justice Criminal MacArthur T. Catherine and D. John wp-content/uploads/2015/05/when-political-will-not-enough.pdf more information on TCOOMMI.) Finally, TDCJ awards grant funding to county to county funding grant awards TDCJ Finally, TCOOMMI.) on information more plan: strategic goal the top to pursue in order 2017-2021 in its outlined stakeholders traditional incarceration.” to diversions “to provide · · · · Model Sequential Intercept The 125. Figure GAINS Center, emphasizes five “intercept points” at which individuals may be may points” at which individuals “intercept emphasizes five GAINS Center, in Figure 125 include: points illustrated The intercept system. from the justice diverted · TDCJ 316 both pre-andpost-booking diversion methods. community. services forpeopleinneed ofassistance whoarereleasedfromincarceration intothe programs, suchasHaven forHope, thatprovide continuity ofcareandhousing community treatmentsor mentalhealthbonds. Finally, BexarCountyoffers system andrecommendsappropriatealternatives tojail,suchascourt-supervised booking, thediversion programidentifiespeoplewithmentalillnessalreadyinthe away fromjailsettings beforetheyarearrested and booked inalocaljail.After and CrisisIntervention Teams (CITs) worktodivert individuals withmentalillness experiencing amentalhealthcrisis. Then,Mobile CrisisOutreachTeams (MCOTs) crisis centertoprovide county residentswithimmediateintervention whentheyare city, county, andstate dollars;and federalblockgrants. Health CareServicesusingdiverse fundingsources, includingprivatedonations; a nationalservicemodel.Bexar’s diversion initiative was createdby theCenterfor In 2003, BexarCountyimplementedajaildiversion programthatisnow viewedas Bexar County Jail Diversion Program diversion programmingactuallyreceive diversion services. all. Asaresult,onlysmallfractionofTexans withmentalillnesswhoare eligiblefor however, donot have theresourcestoimplementany typeofdiversion strategy at multiple intercepts ofthesequentialintercept model.Otherruralandurbanareas, Harris counties(describedbelow), offerrobust diversion opportunitiesthataddress with mentalillnessvariesfromcountytocounty. Somecommunities, like Bexarand judicial systems, andlocalpersonnel.Thetypeofprogramsavailable topersons funds forthecreationofcollaborative jaildiversion programs withlaw enforcement, Section 533.108 oftheTexas Health andSafety CodepermitsLMHAstoprioritize mental healthoutcomes, save money, andincreasepublicsafety. oriented treatmentassoonpossible.Jail diversion effortscanthenimprove mental illnesswhocommitminoroffensesarelinked tocommunity-based, recovery- system. Collaboration amongkey stakeholders helpstoensurethatpeoplewith collaborationbetweenencourages LMHAs, law enforcementagencies, andthecourt At eachstep ofthecriminaljustice process, thesequentialintercept model COMMUNITY EXAMPLESOF JAIL DIVERSIONSTRATEGIES watch?v=LRgNJh2aZuY&index=2&list=PLu2WuYWXjUtcxvWsUGuF3KXhTuUJZ2c1t Police, Jails, and Vulnerable People Symposium. See Dr. Frost’s presentation at Source: Frost, L. (2016, January 22). Mental Health Diversion from Jail. Houston Law Center University of Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas and support services Community corrections Intercept 5: community Reentry into the Intercept 4: Intercept 144

· · · · Diversion Strategies Examples of

of people with mental illness. of Modifications of departments to prevent supervision revocation. Forensic support and treatment providers prior to release. lived experience with incarceration, mental illness, and successful recovery. Peer support Jail in-r each programs that connect incarcerated individuals with community assertive community treatment (FACT) teams that work with probation services that pair justice-involved individuals with peers who have community supervision requirements to better match the needs 143 First, BexarCountyusesa24/7 https://www.youtube.com/ 142 Theprogramemploys 141 140 TDCJ 317 150 The cost per The cost 151 In FY 2016, In FY 2016, 153 Mental health-related training also helpedhealth-related training Mental 146

147 149 Since 2003, program administrators estimate program administrators Since 2003, 145 , Huffman/Schwertner) to create a mental health jail to create a mental health , Huffman/Schwertner) rd DSHS is required to submit a formal program evaluation 152 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Between 2014 and 2017, the state and county both appropriated $5 and county both the state and 2017, 2014 Between 148 to decrease the use of physical force by Bexar County law enforcement officers against enforcement law Bexar County by force the use of physical to decrease 50 times per yearphysical force about used officers In 2009, illness. people with mental officers 2009 and 2015, between with mental illness into custody; when taking a person only three times total. used similar force diversion pilot in Harris County. The ongoing and goal of the program is to promote Harris County. in pilot diversion expanding individuals with mental illness by for justice-involved recovery sustain and peer employment, supportive services in the areas of housing, education, advocacy. million each year to support the pilot. Between August 2014 and April 2016, the pilot program served 1,107 people, program served the pilot and April 2016, 2014 August Between which includes persons who were screened, assessed, and enrolled. Harris County Jail Diversion Pilot Program Pilot Diversion Jail Harris County in the nation, has jail the third largest home to Harris County, In recent years, state program. In 2013, to Bexar County’s similar strategies diversion adopted SB 1185 (83 legislators passed people divert to safely program uses two local providers The Harris County pilot the Harris Center First, system. from the criminal justice with mental illness away uses a jail-based team, and IDD (formerly MHMR of Houston) Health for Mental services; (CTI) and clinic-based team, and critical time intervention a community- initiate pre- mental illness, identify incarcerated people with these strategies together, community support networks. and link participants to established release treatments, Services enroll and SEARCH Homeless for the Homeless-Houston Second, Healthcare (PSH) program (for more on Housing Supportive eligible participants in a Permanent stage of the program, people with each of this guide). At chapter PSH, see the TDHCA therapy, behavioral including cognitive evidence-based services, mental illness receive case management. support, and intensive peer use interventions, substance Since its implementation, Bexar County’s jail diversion strategies, combined with falling with combined strategies, diversion jail County’s Bexar its implementation, Since the jail population 2003, In population. county jail the reduced significantly rates, crime beds 1,000 over 2016, February people, but by nearly 1,000 capacity by the jail’s exceeded Jail. at the Bexar County were empty the which saves jail to treatment, from been diverted have people 20,000 that about million per year. $10 county approximately to legislators by December 1, 2016. December to legislators by COURTS SPECIALTY people with serious mental illness Counties can also use specialty courts to divert These courts apply problem- from jail settings. away use conditions and substance to incarceration. Each alternatives community-based solving techniques to provide defense prosecutors, type of specialty court requires the collaboration of judges, The most health professionals. and mental enforcement officers, law attorneys, mental health, and common types of specialty courts relevant to criminal law, courts, DWI family drug courts, mental health courts, use are drug courts, substance courts. and veterans’ there were 191 specialty courts operating in Texas. 2016, In July participant was $5,401.53. participant was the Criminal Justice Division (CJD) of the Office of the Governor allocated $11.6 Governor Division (CJD) of the Office of the the Criminal Justice TDCJ 318 only thosefundedthroughCJDgrants)andtheiroverall outcomesdidnot exist. centralized dataonthenumberofindividualsserved inallspecialtycourts(not collection andanalysisamongexisting specialtycourtprograms. AsofJuly 2016, could potentially benefitfromsuchservicesdemonstrate theneedforimproved data who areserved withintheseresource-intensive programscomparedtothosewho the Hogg Foundation’s attempts togatherdataonthetotal numberofindividuals particularly drugcourts data alsohighlightracialandethnic disparitiesinaccesstosomespecialtycourts, Further, althoughresearchshows thatthecourtsproducepositive outcomes, recent participants, 61%ofwhomcompleted theirprogramsuccessfully. of treatmentsteps andtoemploy punitive sanctions fortreatmentnoncompliance. because drugcourtsaremorelikely thanmentalhealthcourtstouseaformalizedset mental illnessandsubstance useconditions. Thetwotypesofcourtsdiffer, however, judicially-supervised treatmentplanstoreducerecidivismthatisfueledby untreated low-level offenses. Like drugcourts, mentalhealthcourts usenon-adversarial, standard adjudicationprocessforpeoplewithmentalillnesswhohave committed Mental healthcourtsweredeveloped acrossthecountryasanalternative tothe Mental HealthCourts forms ofcommunitysupervision. Drug courtsprovide supervisionthatismorecomprehensive andintensive thanother Drug Courts number ofpeoplewithmentalillnesswhoareincarcerated inthestate. overview ofTexas specialtycourts, whichstated thatthesecourtshave reducedthe In2013, theCriminalJustice DivisionoftheOffice Governor producedan courts acrossTexas. revenue-dedicated fundsfordiscretionarymillion ingeneral grantsto89specialty Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · · · the BureauofJustice Assistance. Componentsofthecourtprograminclude: In 2012, HarrisCountyimplementedafelony mentalhealthcourtusingagrantfrom · · · (not includingDWI courts)incountiesthroughoutTexas. use andcrimethaneithertreatmentorjudicialsanctions canachieve separately. treatment incombinationwithjudicialmonitoringcanmoreeffectively reducedrug can decreasethree-year recidivismratesby upto50%. Data show thatthismodelworks;researchershave foundthatdrugcourtparticipation establish drugcourts. with populationsexceeding 550,000 toapplyforfederal andother fundsinorderto passed HB1287(77

future criminal behavior; Random alcohol anddrug testing. substance use conditions; and Substance use treatment Intensive treatment b Regular visits with speciallytrained community Frequent appearances needs; Clinical psychosocial evaluations to de riskassessments Comprehensive criminogenic th 154 , Thompson/Whitmire),whichmandatedallTexas counties 163 In FY 2015, CJD-funded courtsserved approximately 3,570 InFY2015, CJD-funded In February 2016, therewereapproximately 80drugcourts 158 y mental health professionals; before the felony mental health court judge; andmentalhealthcourts. for participants with co-occurringmental health and 160 The drug court model assumes that supervised The drugcourtmodelassumesthatsupervised 166 termine each participant’s strengths and to determine the likelihood of supervision officers; 159 162 In2001, the77thLegislature 164 155 156 However, 161 157

165

TDCJ 319 By February February By 170

172 171 169 Figure 127 shows the percent Figure 127 shows 173 als among defendants with mental illness; als y providing attorneys with the specialized with the specialized attorneys y providing ys that people with mental illness spend in jail;. mental illness people with ys that viding intensive case managementviding intensive services;and The court team then holds two graduation ceremonies each year in ceremonies each two graduation team then holds The court A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation The court’s typical caseload is about 55 to 60 cases. Once participants about 55 to 60 cases. caseload is typical The court’s 168 167 knowledge they need to defend persons with mental illness. with mental persons to defend they need knowledge Minimize the number of da the number Minimize of case dismiss the number Increase pro recidivism by Reduce b legal representation Enhance

are accepted into the program, they must work with the court team for a minimum work with the court they must into the program, are accepted of 18 months. 2016, 39 participants had successfully graduated from the program and another six had successfully graduated from the program and another 39 participants 2016, the spring of 2016. by participants were on track to graduate · · · More information on mental health courts is available at https://www.bja.gov/ information on mental health courts is available More Publications/mhc_essential_elements.pdf PUBLIC DEFENDER OFFICES HEALTH MENTAL present unique people with mental health conditions often Criminal cases involving a that have Jurisdictions knowledge and skills. legal issues that require specialized health-related issues in orderattorneys on mental public defender office can train such an have however, all counties, Not clients with mental illness. serve to better some areas without designated countywide public defenders office in place. Thus, Public Defender (MHPD) Office that specializes Health in a Mental established have addressing the legal needs of people with mental illness who are charged with crimes. a four- a public defender office, received have which does not County, Travis In 2007, set MHPD Office.stand-alone Administrators first year grant to begin the nation’s four major goals for the office: · Because of court team’s services are so intensive and time-consuming, Harris and time-consuming, are so intensive services Because of court team’s of defendants with a small fraction court can only serve mental health County’s of 75.4% 130 participants, the court had served As of March 1, 2016, mental illness. use conditions. and substance whom had co-occurring mental health The court team is comprised of a diverse group of professionals, including: two district district two including: of professionals, group a diverse of is comprised court team The two clinicians, health mental licensed full-time three director, a project judges, court assistant part-time two dedicated attorneys, district part-time assistant dedicated a clerk, officers, community supervision full-time three dedicated public defenders, and a bailiff. which past, current, and potential graduates may participate. graduates may current, and potential which past, members connect clients to staff graduation from the program, In order to promote strengths. unique needs and that reflect the participant’s services community-based attempt members first staff requirements, the program’s to meet If the client fails can use graduated if that is unsuccessful, staff but to success, to identify barriers also works with clinical team court’s The behavior. to address the client’s sanctions main plan that focuses on five an individualized reentry participants to develop medication management, mental health treatment, housing needs, areas of interest: benefits. use treatment, and access to income and substance A 2011 cost benefit analysis of the Travis County MHPD found that 41.2% of benefit analysis of the Travis cost A 2011 to jail for up returned had not and/or misdemeanor clients remained out of custody after receiving MHPD Office services. years to five TDCJ 320 locations hadhiredareentry peerspecialist toimplement the program. process. to mentorothers inthejustice system whoarebeginningtherecovery and reentry programs allow peoplewithlived mentalhealthandcriminaljustice experience growing fortheuseofpeersupportinincarcerationsettings. Reentrypeersupport service inother contexts (e.g.,reentryfromstate hospitalization),andinterest is incarcerated peoplewithacriminalrecord.Peer supporthasbecomeanestablished forformerly Successful reintegrationintothecommunitycanbeachallenge REENTRY PEERSUPPORT felonies. also provide referralstoavariety with ofsocialservicesfor defendantscharged withmisdemeanors.defendants charged TheTravis andFort BendMHPDOffices Fort Bend,andTravis counties. As ofMarch2016, therewerefourMHPDOfficesin TexaslocatedinBexar, El Paso, criminal_justice/Doc/cost_ben_MHPD_110922.pdf Performance the of Texas Task Force on Indigent Defense Grant. 2-3. Retrieved from Source: Travis County Attorney’s Office. (2011). Mental Health Public Defender Office Cost Benefit Analysis, of Part 1: Analysis Figure 127. Travis County MHPDOffice OutcomesbetweenFY 2011andFY 2011 Office alsobeganconductingasecondcost benefitanalysis. among differenttypesofclients. Inthespringof2016, theTravis CountyMHPD by whichtheMHPDOfficealsodecreasedjailbookingsandbed days consumed Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas formal results inDecember2016 andSeptember 2017. Foundation forMental Health willoversee theprogram’s evaluationand release individuals completed thereentrypeertrainingprogram, reentry skillsandservice provision attheendofMarch2016. AsofJuly 2016, 26 the pilot’s peersupportspecialists andbegan trainingpeerspecialists inadvanced individuals livingwithmentalillness. ViaHope thendeveloped thecurriculumfor a specialization)topreparepeerspecialists fortheirworkwithjustice-involved communities. Thenon-profitVia Hope createdareentryendorsementtraining (i.e., individuals withmentalillnesssuccessfullytransition outoflocal jailsandintotheir and LMHAsineachlocationwillusecertifiedpeer support specialists tohelp Texas (whichserves Cameron,Hidalgo, counties). and Willacy pilot programsinthreelocations:HarrisCounty, Tarrant County, andTropical support reentrypilot programinTexas. InApril2016, DSHSbeganfunding In 2015, legislatorsapproved Rider73totheDSHSbudget,whichcreatedapeer see theTexas Environment chapter ofthisguide). transition backintothecommunity(formoreinformation inpeersupportservices, state mentalhealthsystem tohelpparticipantssuccessfullynavigate thedifficult client Case management Legal client Client Type 176 Peers areabletosharestrategies, copingskills, andexperienceswiththe ubrSre eraei alBoig Decrease in Jail Bed Days 562 735 Decrease in Jail Bookings Number Served 175 These countiesallhave aMHPDrepresenting 57% 38% https://www.traviscountytx.gov/images/ 180 178 174 andallthreepilot Consumed 20% 13% 177 Countysheriffs 179 TheHogg TDCJ 321 . Page 4. Retrieved 4. Retrieved Page and Policy. Prevention Prediction, 13). Gun Violence: . Retrieved . Retrieved League. Dallas Morning News Justice Texas exan of the Year: Page 9. Retrieved Retrieved Report for 9. Population Page 6/1/2016. Abbreviated 2016). . (June churn in Texas. communication: Jail Personal 2016). 18, . (May 13. 2015 Annual Report. Page 2016). . (February Disorders? Injury Cause Psychiatric Brain (2000). Can Traumatic ong, J. tics has not published an updated version of their 2006 analysis of mental issues of an updated version published tics has not Firearms. of American Shootings, and the Politics Mass Mental Illness, ., (2015). of American Firearms. Politics Shootings, and the Mass Mental Illness, ., (2015). y adding the average daily cost of an adult within Texas prisons ($54.89) to the to ($54.89) prisons within Texas of an adult daily cost y adding the average . Page 2. . Page Criminal Justice Committee to the Senate 22). Presentation , September Treatment of Persons with Mental Illness in Prisons and Jails: A in Prisons and Jails: with Mental Illness of Persons Treatment (April 2014). y Center. Psychiatric Disorders and Repeat Disorders Psychiatric (2009). O. & Murray, B., Williams, J., I., Penn, wanger, Psychiatric Disorders and Repeat and Repeat Disorders Psychiatric (2009). O. & Murray, B., Williams, J., I., Penn, wanger, The Journal of The Journal and Just Desert: A Theory of Sentencing and Mental Illness. 13). Vulnerability Monthly Tracking of Adult Correctional Population Indicators (June Indicators Population of Adult Correctional Monthly Tracking 2016). t Board. (June 2013 and 2014. Years Report Fiscal Uniform Criminal Justice 2015). Cost t Board. (February and 2014. 2013 Years Report Fiscal Criminal Justice Uniform 2015). Cost t Board. (February American Journal of Justice, and Social Justice. American Journal Poverty, Mental Health, Mental Illnesses, A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Mental Illness and Reduction of Gun Violence: Brining Epidemiologic Research to Brining Epidemiologic Research and Reduction of Gun Violence: Mental Illness t al. (March 2014). . American Journal of Psychiatry, of Psychiatry, American Journal Behind Bars. Out of Sight, Out of Mind: Mental Illness . (2014). . Retrieved from http:// . Retrieved Prisons Chief. Houston Chronicle Bryan Collier Named Texas 2016). une 24, 1. Retrieved from http://www.lbb.state.tx.us/Documents/Publications/Info_Graphic/812_Monthly_ from 1. Retrieved Analyzing Offense Patterns as a Function of Patterns as a Analyzing Offense(2010). F. & Keith, Hart, E., Vidal, S., J., ., Skeem, . Retrieved . Retrieved Item The Huntsville Director of TDCJ. Collier Selected as New Executive 2016). une 27, 1. Retrieved from http://www.lbb.state.tx.us/Documents/Publications/Policy_Report/1440_Criminal_ 1. Retrieved Ward, M. (J Ward, and W Reekum, R., Cohen, T., Van Johnston, E. L. (20 Johnston, 179 Ibid, Page T 2015). Editorial Board. (December 26, from http://interactives.dallasnews.com/2015/texan-of-the-year/ (J Stark, C. from http://www.itemonline.com/news/collier-selected-as-new-executive-director-of-tdcj/article_26aa076a- . 3a37-11e6-975b-ebac5b240e5a.html www.chron.com/news/politics/texas/article/Collier-selected-new-Texas-prisons-chief-8323572.php http://neuro.psychiatryonline.org/doi/ 12(3), 324, and Clinical Sciences, of Neuropsychiatry The Journal pdf/10.1176/jnp.12.3.316 American Journal of Public Health, 105(2), 241. Retrieved from http://ajph.aphapublications.org/doi/ Retrieved 105(2), 241. of Public Health, American Journal pdfplus/10.2105/AJPH.2014.302242 e J., Swanson, Statis The Bureau of Justice of Prison 2006). Mental Health Problems (September Statistics. See Bureau of Justice within prisons and jails. from http://www.bjs.gov/content/pub/pdf/mhppji.pdf 1. Retrieved Inmates. Page and Jail 103(1), 158-174. & Criminology, Criminal Law Metzl, M., & MacLeish, K. T Metzl, Association. (20 American Psychological from http://www.apa.org/pubs/info/reports/gun-violence-report.pdf 4. Ibid, Page M., & MacLeish, K. T Metzl, from http://www.sciencedirect.com/science/article/ Retrieved 25(5), 366-376. . Annals of Epidemiology, Policy pii/S1047279714001471 Peterson, J Peterson, 1221. Ibid, Page (2013). Draine, J. doi:10.1080/15487768.2013.789684. Rehabilitation, 16(2), 88. Psychiatric from http://ajph.aphapublications.org/doi/ Retrieved 105(2), 241. of Public Health, American Journal pdfplus/10.2105/AJPH.2014.302242 171(10), 1041. Retrieved from http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2014.14060712 171(10), 1041. Retrieved Treatment Advocac L. (2015 Lacefield Lewis, Bins Baillargeon, J., from http:// Retrieved 61, 1217. Services, Psychiatric Hypothesis. the Criminalization to Test Mental Illness ps.psychiatryonline.org/doi/full/10.1176/ps.2010.61.12.1217 Legislative BudgeLegislative Standards Commission on Jail Texas Standards Commission on Jail Texas Standards Commission on Jail Texas D Runinow, from http://www.tacreports.org/storage/documents/treatment-behind-bars/ Retrieved 13. . Page State Survey treatment-behind-bars.pdf from http://www.dshs.state.tx.us/legislative/default.shtm Retrieved http:// from Retrieved 166(1), 103. of Psychiatry, American Journal Prison Door. The Revolving Incarcerations: dx.doi.org/10.1176/appi.ajp.2008.08030416 Ibid, Page 1. Ibid, Page b was estimated This figure from http://www.tcjs.state.tx.us/docs/AbbreRptCurrent.pdf Legislative BudgeLegislative BudgeLegislative information about average prisons (between For $42 and $49). Texas of medical care within average daily cost Report Fiscal Criminal Justice Uniform 2013). Cost Board. (January Budget see: Legislative medical care costs, from http://www.lbb.state.tx.us/Documents/Publications/Policy_Report/ 2010 to 2012. Retrieved Years Criminal%20Justice%20Uniform%20Cost%20Report%20Fiscal%20Years%202010%20to%202012.pdf Baillargeon, J., Bins Baillargeon, J., 2016). Page Report_June_2016.pdf Page Juvenile_Justice_Uniform_Cost_Report.pdf from http://www.lbb.state.tx.us/Documents/Publications/Policy_Report/1440_Criminal_ 4. Retrieved Page Juvenile_Justice_Uniform_Cost_Report.pdf 166(1), 103. Retrieved from http:// Retrieved 166(1), 103. of Psychiatry, American Journal Prison Door. The Revolving Incarcerations: dx.doi.org/10.1176/appi.ajp.2008.08030416

28 26 27 21 23 24 25 19 20 22 16 17 18 11 15 12 13 14 5 8 9 10 6 Endnotes 1 3 4 7 2 TDCJ 322 61 60 39 57 55 54 49 48 47 46 45 44 43 42 41 38 37 36 35 34 33 32 31 30 29 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 59 58 56 53 52 51 50 40

American CivilLiberties UnionofTexas &theTexas Civil RightsProjectofH Ibid, Page 2 Retrieved fromhttp://www.senate.state.tx.us/75r/senate/commit/c590/c590.InterimReport84th.pdf senate/#Criminal_Justice_Committee Legislature. Retrieved fromhttp://www.tcdd.texas.gov/public-policy/texas-legislature/84th-leg-interim- American CivilLibertiesUnionofTexas &theTexas CivilRightsProjectofH legacy-hhsc.hhsc.state.tx.us/about_hhsc/strategic-plan/2017-2021/plans/volume2.pdf 2016). Texas StatewideBehavioral HealthStrategic Plan Fiscal Years 2017-2021. Page 3. Retrieved fromhttps:// Texas Health andHumanServicesCommission,StatewideBeha Texas Department of CriminalJus Ibid. Juvenile_Justice_Uniform_Cost_Report.pdf Page 1.Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Policy_Report/1440_Criminal_ Legislative BudgetBoard. (February Cost 2015). CriminalJusticeUniform ReportFiscal Years 2013and2014. report detailing criminaljustice costs inFY2015 andFY2016 willbepublishedin2017. For FY2014 costs, see The Legislative Budge Legislative Budge Texas DepartmentofCriminalJus Texas DepartmentofCriminalJus Texas DepartmentofCriminalJus Ibid. Ibid, Page 3 Ibid. Mental Illness. Page 2.Retrieved fromhttps://www.dshs.state.tx.us/Legislative/Reports-2015.aspx Texas DepartmentofStateHealth Services download;jsessionid=74968EFFC7DE5D768F98614F320E34F1?doi=10.1.1.422.9296&rep=rep1&type=pdf Involvement inTexas: Correlates andCosts. Page 10. Retrieved fromhttp://citeseerx.ist.psu.edu/viewdoc/ Texas DepartmentofStateHealth Services state.tx.us/video-audio/committee-broadcasts/ Health. To viewGaines’s entirepresentationandtestimony, seeminute18:18to2:18:06athttp://www.house. Gaines, S. (April6 ACLU ofTexas Retrieved from https://www.texastribune.org/2010/09/17/city-jails-unregulated-despite-deaths-complaints/. Grissom, B. (September 17 Retrieved from http://www.tcjs.state.tx.us/docs/AbbreRptCurrent.pdf Texas CommissiononJail Standards Straus, J. (No Texas CouncilforDevelopmental Dis Retrieved fromhttps://www.texastribune.org/2015/09/22/lawmakers-zero-jail-standards-mental-health/ Silver, J http://www.texastribune.org/2015/07/28/coleman-calls-hearing-texas-jail-standards/ Langford, T. (J from http://www.texastribune.org/2015/07/24/officials-release-sandra-bland-autopsy-report Bollag, S. (J csgjusticecenter.org/reentry/facts-trends/ The CouncilofStateGovernments J Ibid. Ibid. confined inadministrative segregation. Texas CriminalJus pt:8008/BiblioNET/Upload/PDF7/005410.pdf#page=44 World Health Organization.(20 System-Presentation-2-18-16.doc Health. P Hellerstedt, J. andLacefieldLewis, L.(February 18, 2016). Presentation totheHouseSelectCommittee onMental Texas SenateCommittee onCriminalJ Ibid, Page 2. org/2015/02/05/a-solitary-failure/ Failure: TheWaste, Cost, andHarmofSolitaryConfinement in Texas . Page 50. Retrieved fromhttp://www.aclutx. http://tdcj.state.tx.us/documents/finance/Agency_Operating_Budget_FY2016_Governor.pdf to theGovernor’s OfficeofBudget,Planningand PolicyandtheLegislative BudgetBoard. Page 2.Retrieved from Report_June_2016.pdf 2016). Page 1.Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Info_Graphic/812_Monthly_ Retrieved on June 27, 2016 fromhttp://tdcj.state.tx.us/divisions/cmhc/index.html. http://www.tdcj.state.tx.us/about_tdcj.html tdcj.state.tx.us/index.html http://www.house.state.tx.us/news/press-releases/?id=5741 . (September 22,2015). Lawmakers ZeroinonJail Standards, Mental Health. TheTexas Tribune. age 27.age Retrieved fromhttp://www.dshs.texas.gov/legislative/2016-Reports/The-Behavioral-Health- uly 24, 2015). Waller CountyReleasesSandraBlandAutopsy Report.TheTexas. Retrieved Tribune . 4. vember 9, 2015). HouseWill Take Comprehensive LookatMentalHealthCare. Retrieved from uly 28, 2015). BlandArrest, DeathPrompt Legislative Hearing. TheTexas Tribune. Retrieved from . (June 30, 2016). Personal communication:Municipaljailoversight. , 2016). Personal communication:Re: Presentation totheHouseSelectCommittee onMental t Board.(June, 2016). MonthlyTracking ofAdultCorrectional Population Indicators (June tice Department.(April27, 2016). Personal communication:People withmentalillness Criminal Justice Uniform Costt BoardreleasesitsCriminalJusticeUniform Reportevery twoyears. Thenext , 2010). CityJails UnregulatedDespiteDeaths, Complaints. TheTexas Tribune. 14). PrisonsandHealth.Page 28. Retrieved fromhttp://bibliobase.sermais. tice. (December1,2015). Operating Fiscal Budget for Year 2016Submitted tice. (n.d.)Correctional ManagedHealthCare Committee (CMHCC). tice. (n.d).AbouttheTexas DepartmentofCriminalJustice.Retrieved from tice. (n.d).Texas DepartmentofJusticeHome.Retrieved fromhttp://www. ustice Center. (n.d.)ReentryFacts andTrends. Retrieved fromhttps:// . (June 1,2016). Abbreviated 6/1/2016. Page Population 9. Reportfor abilities. (n.d.).Senate’s Key InterimCharges theTexas for ustice. (December2014). InterimReporttothe84 . (September, 2015). AnnualReportontheScreening ofOffenders with . (2010). AnotherLookatMentalIllness andCriminal Justice vioral Health CoordinatingCouncil.(May ouston. (February 2015). ASolitary ouston. (February 2015). ASolitary th Legislature. Page 25. TDCJ 323 . Page 23. 23. . Page Legislature th . Page 8. Retrieved Retrieved 8. . Page Legislature th tee. (2013) Offender from http:// tee. (2013) Health Services Plan. Retrieved Offender 16. 2015). Health Services Plan. Page tee. (September ustice. (December 2014). Interim Report to the 84 (December 2014). ustice. . Page 6. Retrieved from Retrieved Offender 6. tice. (April 2016). Orientation Handbook . Page . Page 2. Retrieved from 2. Retrieved . Page Segregation Administrative 2014). tice. (September Correctional Managed Health Care Committee (CMHCC). Committee Managed Health Care tice. (n.d.). Correctional Department of Criminal Justice. Retrieved from from Department of Criminal Justice. Retrieved the Texas tice. (n.d). About Services: Office of the Mental Health Monitoring and tice. (n.d.). Health http://tdcj.state.tx.us/ from Services Division. Retrieved tice. (n.d.). Health http://tdcj.state. from Division. Retrieved tice. (n.d.) Rehabilitation Programs http://tdcj.state. from Division. Retrieved tice. (n.d.). Reentry and Integration (CMHCC). Committee tice. (n.d.). Correctional Managed Health Care Safe Prisons/Prison Rape Elimination Act (PREA) Program Safe Rape Elimination Act (PREA) Prisons/Prison Program 2014). tice. (June ograms Division: In-Prison Driving While Division: In-Prison Programs (n.d.). Rehabilitation ustice. http://bibliobase.sermais. from Retrieved 28. Health. Page Prisons and 14). y adding the average daily cost of an adult within Texas prisons ($54.89) to the prisons ($54.89) of an adult within Texas daily cost y adding the average . Retrieved from http://www. . Retrieved American-Statesman Austin One Room. Years, 15). 30 14). Mental Illness in America’s Jails and Prisons: Toward a Public Safety Health Health a Public Safety and Prisons: Toward Jails Illness in America’s Mental 14). .S. 97 (1976). .S. Sexual Victimization in State and Federal Prisons Reported by Prisons in State and Federal Victimization 2008). Sexual (April 9, tics. Senate Interim Charges Part II: Criminal Justice; Veteran Affairs & Military Installations; & Military Installations; Affairs II: Criminal Justice; Veteran Part Senate Interim Charges . Retrieved . Retrieved Tribune The Texas Rape Law. Prison to Follow Will Work Texas Says 15). Abbott th tice Department. (April 27, 2016). Personal communication: People with mental illness with mental illness People communication: Personal 2016). 27, tice Department. (April Page 371. Retrieved from http://www.lbb. Retrieved 371. 2014-2015 Biennium. Page Size-Up Fiscal t Board. (2014). 2013 Years Report: Fiscal Justice Uniform Criminal and Juvenile 2015). Cost t Board. (February Criminal Justice Uniform Cost Report Fiscal Years 2013 and 2014. Years Fiscal Report Criminal Justice Uniform Cost February). t Board. (2015, A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 15). 84 Interim Committee Charges: Texas House of Representatives, 84 House of Representatives, Texas Charges: 15). Interim Committee Recidivism of Supermax Prisoners in Washington State. Crime & in Washington (2007). Supermax Prisoners Recidivism of Cain, K.C. and ohnson, L.C., Texas Department of Criminal J Texas . Page 1. Retrieved from http://www.senate.state.tx.us 1. Retrieved Security. Page Border (20 J. Straus, Delinquency, 53(4), 643. 53(4), Delinquency, https://assets.documentcloud.org/documents/2089812/texas-adseg-programming.pdf Criminal J on Senate Committee Texas Dexheimer, E. (April 25, 20 25, E. (April Dexheimer, mystatesman.com/news/news/opinion/30-years-one-room/nkycs/#c0b02152.3559866.735714 (20 Organization. Health World J D., Lowell, of Criminal Jus Department Texas . Page 2. Retrieved from http://www.aclutx. 2. Retrieved . Page Texas in Confinement of Solitary and Harm Cost, The Waste, Failure: org/2015/02/05/a-solitary-failure/ pt:8008/BiblioNET/Upload/PDF7/005410.pdf#page=44 Legislative BudgeLegislative BudgeLegislative Texas Department of Criminal Jus Texas Correctional Managed Care Commit Health Department of Criminal Jus Texas http://www.tdcj.state.tx.us/documents/Offender_Orientation_Handbook_English.pdf https://www.tdcj.state.tx.us/divisions/rpd/rpd_dwi.html from Retrieved Program. Recovery Intoxicated (DWI) Legislative BudgeLegislative Correctional Managed Care Commit Health tdcj.state.tx.us/divisions/cmhc/docs/cmhcc_contracts_fy2014-15/696-HS-14-15-A066-Exhibit-A.pdf from http://tdcj.state.tx.us/divisions/cmhc/index.html Retrieved from http://tdcj.state.tx.us/divisions/cmhc/docs/Offender_Health_Services_Plan.pdf Retrieved state.tx.us/Documents/Publications/Fiscal_SizeUp/Fiscal_SizeUp.pdf from http://www.lbb.state.tx.us/Documents/Publications/Policy_Report/1440_Criminal_ and 2014. Retrieved Juvenile_Justice_Uniform_Cost_Report.pdf Estelle v. Gamble, 429 U v. Estelle (April 1, 20 D. Aufderheide, b was estimated This figure about average information prisons (between For $42 and $49). of medical care within Texas average daily cost Report Fiscal Criminal Justice Uniform 2013). Cost Board. (January Budget see: Legislative medical care costs, from http://www.lbb.state.tx.us/Documents/Publications/Policy_Report/ 2010 to 2012. Retrieved Years Criminal%20Justice%20Uniform%20Cost%20Report%20Fiscal%20Years%202010%20to%202012.pdf Texas Department of Criminal Jus Texas Department of Criminal Jus Texas Department of Criminal Jus Texas Department of Criminal Jus Texas . http://healthaffairs.org/blog/2014/04/01/mental-illness-in-americas-jails-and-prisons- Health Affairs Model. toward-a-public-safetypublic-health-model/ from http://www.lbb.state.tx.us/Documents/Publications/Policy_Report/1440_Criminal_ 4. Retrieved Page Juvenile_Justice_Uniform_Cost_Report.pdf Ibid. Ibid. Ibid. Department of Criminal Jus Texas Department of Criminal Jus Texas Bureau of Justice Statis Bureau of Justice from http://www.bjs.gov/content/pub/pdf/svsfpri07.pdf Retrieved 3. Inmates, 2007. Page 22, 20 (May Svitek, P. from http://www.texastribune.org/2015/05/22/abbott-says-texas-will-follow-prison-rape-law/ Department of Criminal Jus Texas http://www.tdcj.state.tx.us/about_tdcj.html http://tdcj.state.tx.us/divisions/hs/Mental_Health_Monitoring. from Liaison (OMHM&L). Retrieved html#Mental_Health_Monitoring divisions/hs/health_admin_services.html#Monitoring tx.us/divisions/rpd/index.html tx.us/divisions/rid/index.html http://tdcj.state.tx.us/divisions/cmhc/index.html from Retrieved from http://www.house.state.tx.us/_media/pdf/interim-charges-84th.pdf from http://tdcj.state.tx.us/documents/PREA_SPP_Report_2014.pdf Retrieved 24. 2014. Page Calendar Year Retrieved from http://www.senate.state.tx.us/75r/senate/commit/c590/c590.InterimReport84th.pdf Retrieved confined in administrative segregation. confined in administrative Texas Criminal Jus Texas (20 D. Patrick,

69 65 66 63 62 64 90 91 87 88 89 92 85 83 84 86 74 75 76 71 72 77 78 79 80 81 82 70 73 67 68 TDCJ 324 128 127 126 124 123 122 121 120 119 118 117 116 115 114 111 110 108 107 106 105 104 103 102 101 100 99 98 97 96 95 94 93 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 130 129 125 113 112 109

Project. Retrieved from https://www.themarshallproject.org/2015/08/04/why-jails-have-more-suicides-than- Texas Health andSafe Ibid. information sharingbetween jails. Texas Commission onJail Standards Texas Jail Project.(F Texas Adminis Ibid. Standards. Texas Commission on Jail Standards Retrieved fromhttp://www.tcjs.state.tx.us/docs/2013-2017TCJSStratPlan.pdf Texas CommissiononJail Standards state.tx.us/index.php?linkID=110 Texas CommissiononJail Standards documents/treatment-behind-bars/treatment-behind-bars.pdf Mental Illness inPrisonsandJails: AStateSurvey. Page 107. Retrieved fromhttp://www.tacreports.org/storage/ Treatment Advocac Texas CommissiononJail Standards Standards. Texas Jail Project.(F Texas CommissiononJail Standards Texas CommissiononJail Standards prisonpolicy.org/reports/pie2016.html Prison Policy Initiativ Retrieved from http://www.tcjs.state.tx.us/docs/AbbreRptCurrent.pdf Texas CommissiononJail Standards Texas DepartmentofCriminalJus Texas DepartmentofCriminalJus Texas CriminalJus www.ksat.com/news/baby-mother-bonding-program-offered-to-offenders Venema, P. (20 Texas DepartmentofCriminalJus WomenSubstance AbuseTreatment for inPrison.Journal ofSubstance Abuse Treatment,38, 98. N. Messina, C Ibid. Women. AbuseHistoryonLongitudinalOutcomesfor CriminalJusticeAccounting for andBehavior, 41(4),418. P. Saxena, N Ibid. http://www.prisonpolicy.org/global/women/ Prison Policy Initiativ Ibid. Ibid. Texas DepartmentofCriminalJus Ibid. documents/rid/TCOOMMI_Biennial_Report_2015.pdf with MedicalorMentalImpairmentsFiscal Years 2013-2014.Page 8. Retrieved fromhttp://tdcj.state.tx.us/ Texas DepartmentofCriminalJus Code_84/Summary_of_Conference_Committee_Report_HB1.pdf the2016-17Biennium.Page 95.for Retrieved fromhttp://www.lbb.state.tx.us/Documents/Budget/Session_ Legislative Budge TCOOMMI serviceprovision. Center forPublicPolicy Priorities Ibid. Texas DepartmentofCriminalJus state.tx.us/documents/rid/TCOOMMI_Biennial_Report_2015.pdf Offender Texas DepartmentofCriminalJustice. (February 2015). BiennialReportoftheTexas Correctional Officeon Chammah, M.andMeagher, T content/pub/pdf/mljsp0013st.pdf United StatesDepartmentofJustice, BureauofJustice Statistics): 8, 24. Retrieved fromhttp://www.bjs.gov/ Noonan, M.(August 20 www.statutes.legis.state.tx.us/Docs/HS/htm/HS.614.htm. Relating toMentalIllness andMentalRetardation, §614.017. Retrieved TCOOMMI onJuly 5, 2016 fromhttp:// TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=37&pt=9&ch=265&rl=5 §265.5 HealthTags. Retrieved onJuly 5, 2016 fromhttps://texreg.sos.state.tx.us/public/readtac$ext. Initiative) Program. Retrieved fromhttp://www.tdcj.texas.gov/TDCJ_BAMBI.html Initiative) Program. Retrieved fromhttp://www.tdcj.texas.gov/TDCJ_BAMBI.html s withMedicalorMentalImpairmentsFiscal Year 2013-2014.Page 4.Retrieved fromhttps://www.tdcj. . P. Messina, andC. E.Grella.(April2014). WhoBenefitsfrom Gender-Responsive Treatment? . Grella,J. Cartier, andS. Torres. (2010). ARandomized Experimental StudyofGender-Responsive 15, July 6).Baby, Mother BondingProgramOfferedtoOffenders. KSAT 12.Retrieved from http:// Title 37 Public Safety andCorrections,trative Code.Title37PublicSafety Part 9Texas Commission onJail Standards, t Board.(May 2015). SummaryofConference Committee HouseBill1:Appropriations Reportfor tice Department.(June 22,2016). Program. Datarequest: BAMBI y Center and National Sheriff’s Association.(April y CenterandNationalSheriff’s 8, 2014). TheTreatment ofPersons with ebruary 19, 2016). Personal communication: Health serviceswithincountyjails. ebruary 2016) Personal communication: Texas Jail ProjectandTexas CommissiononJail ty Code.Title7MentalHealthandIntellectualDisability, SubtitleESpecialProvision e. (March14, 2015). Mass Incarceration: TheWholePie2016 . Retrieved fromhttp://www. e. (November 2015). StatesofWomen’s Incarceration: TheGlobalContext. Retrieved from 15). MortalityinLocalJails andStatePrisons,2000–2013.NCJ248756 (Washington, DC: . (August 4,2015). Why Jails Have More SuicidesthanPrisons. TheMarshall . (May 16, 2016). Personal communication:2015 legislative testimony on tice. (June 2016). Datarequest: MRISreferrals, presentations, andapprovals. tice. (2015). BiennialReportoftheTexas CorrectionalOffenders Officeon tice. (April2016). Datarequest: TCOOMMIservicesandoutcomes. tice. (May 16, 2016). Personal program. communication:BAMBI tice. (June 3, 2015). Five-Year ReunionofBAMBI(BabyandMotherBonding tice. (June 3, 2015). Five-Year ReunionofBAMBI(BabyandMotherBonding . (July 5, 2016). Personal communication:Inmate healthrecordsand . (March2016). Personal communication:Texas CommissiononJail . (June 2012). AgencyStrategic theFiscal Planfor Years 2013-17. Page 5. Compact. (n.d.).AboutTCJS withTexas. Retrieved fromhttp://www.tcjs. . (May 18, 2016). Personal communication:Jail medicationstandards. . (February 1,2016). 2015AnnualReport. Page 13. . (May 18, 2016). Personal communication:Jail churninTexas. . (June 1,2016). Abbreviated 6/1/2016. Page Population 9. Reportfor TDCJ 325 . Retrieved EffectiveDec. 1. Retrieved Tool 15). New Mental Health Screening July 7, 2016). Personal communication: Bexar County Jail Diversion Diversion Bexar County Jail communication: Personal 2016). 7, July Mental Health and Criminal Justice Case Study: Harris County, Mental Health and Criminal Justice Case Study: Harris County, A Cost Analysis of Bexar County, Texas Jail Diversion Program, Program, Diversion Jail Texas County, of Bexar Analysis y 2008). A Cost e. (March 2016). Personal communication: Bexar County Jail Diversion Diversion communication: Bexar County Jail Personal e. (March 2016). . (March 2016). Personal communication: Mental health screening jail Mental communication: Personal . (March 2016). . (March, 2016). Personal communication: Mental health screening jail Mental communication: Personal . (March, 2016). Use of the Sequential Intercept Model as an Approach to the to the Model as an Approach of the Sequential Intercept Use A Way Forward: Diverting People with Mental Illness with Mental Illness People Diverting Forward: A Way (2014). Center. ustice . Page 2. . Page 2017-2021 Years Plan for Fiscal Agency Strategic 2016). 24, tice. (June . (September 15, 2015). State Unveils Measures Aimed at Reducing Jail Suicides. Suicides. at Reducing Jail Aimed Measures State Unveils 2015). 15, . (September Suicides. Jail Aimed at Reducing Measures State Unveils 2015). 15, . (September Criminal Justice Advisory Council Report: Criminal Justice Advisory Council Division. (2013). , Criminal Justice communication: Specialty courts in Personal 12, 2016). Division. (July , Criminal Justice s Office. (July 6, 2016). Personal communication: Harris County mental health jail 2016). 6, (July s Office. ebruary 2016) Personal communication: Texas jail diversion programs. jail diversion communication: Texas Personal ebruary 2016) Specialty Courts: An Issue Brief from the Legislative Budget Board Staff. Budget Board the Legislative Brief from An Issue Specialty Courts: 2016). t Board. (July A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation . Retrieved from San Antonio. Retrieved My Program a Huge Diversion Success. Jail 22, 2016). January Title 37 Public Safety and Corrections Part 9 Texas Commission on Jail Standards Standards on Jail Commission Texas 9 Part Public Safety Code. Title 37 trative and Corrections University of Houston Law University Challenges. New Strategies for Confronting Today’s anuary 22, 2016). of Houston Law University Challenges. New Strategies for Confronting Today’s anuary 22, 2016). University of Houston Law of Houston Law Program. University Diversion Jail Health Harris County Mental anuary 22, 2016). University of Houston Law of Houston Law Program. University Diversion Jail Health Harris County Mental anuary 22, 2016). Ibid, 2. Ibid. Governor Office of the Governor Office of the Harris County Judge’ Ibid. BudgeLegislative from http://www.lbb.state.tx.us/Documents/Publications/Issue_Briefs/3015_Specialty_ 1. Retrieved Page . Courts_0701.pdf from http://governor.state.tx.us/files/cjd/CJAC_ Retrieved 7. . Page Specialty Courts Recommendations for Texas Report_January_2013.pdf http://www.mysanantonio.com/opinion/commentary/article/Jail-diversion-program-a-huge-success-6777745. php R. (J Hicks, (2016). National Association of Counties. R. (J Hicks, https://www.youtube.com/ Hicks’ presentation at . See Dr. Symposium People and Vulnerable Jails, Police, Center watch?v=LRgNJh2aZuY&index=2&list=PLu2WuYWXjUtcxvWsUGuF3KXhTuUJZ2c1t program. pilot diversion . See Mr. Gonzales’ presentation at https://www.youtube. . See Mr. Symposium People and Vulnerable Jails, Police, Center com/watch?v=LRgNJh2aZuY&index=2&list=PLu2WuYWXjUtcxvWsUGuF3KXhTuUJZ2c1t G. (J Gonzales, Gonzales’ presentation at https://www.youtube. . See Mr. Symposium People and Vulnerable Jails, Police, Center com/watch?v=LRgNJh2aZuY&index=2&list=PLu2WuYWXjUtcxvWsUGuF3KXhTuUJZ2c1t ( S. Pamerleau, https://www.youtube.com/ Hicks’ presentation at . See Dr. Symposium People and Vulnerable Jails, Police, Center watch?v=LRgNJh2aZuY&index=2&list=PLu2WuYWXjUtcxvWsUGuF3KXhTuUJZ2c1t from http://www.senate.state.tx.us/75r/senate/commit/c610/h2016/061616-Hicks_ 1. Retrieved . Page Texas . HarrisCountyDiversion-c2.pdf Center for Health Care Services. (Ma Services. Care Center for Health G. (J Gonzales, Initiativ Bexar County Smart Justice 544. Retrieved from http:// Services 54(4), 544. Retrieved Psychiatric with Serious Mental Illness. of People Decriminalization ps.psychiatryonline.org/doi/pdf/10.1176/ps.2006.57.4.544 J The Council of State Governments from http:// Retrieved That Works. Treatment into Community-Based Jails Inhumane and Expensive from csgjusticecenter.org/mental-health/publications/a-way-forward-diverting-people-with-mental-illness-from- inhumane-and-expensive-jails-into-community-based-treatment-that-works/ Project. (F Jail Texas Department. ( Health Bexar County Mental Program. Retrieved 2-5. Pages and Criminal Justice Systems. the Treatment Between of Cost-Shifting Report 2: An Analysis from http://www.naco.org/programs/csd/Documents/Criminal%20Justice/Jail%20Diversion%20Forum%20 Materials/Cost%20Benefit%20Study.pdf Program. Texas Commission on Jail Standards Commission on Jail Texas Department of Criminal Jus Texas P.A. (2006). M.R. & Griffin, Munetz, Texas Commission on Jail Standards Commission on Jail Texas M. and Barned-Smith, S Ward, (December 4, 20 Association of Counties. Texas from http://www.county.org/Legislative/news/Pages/County%20Issues%2012-04-15/New-Mental-Health- Screening-Tool-Effective-Dec--1.aspx form. http://tdcj.state.tx.us/documents/finance/Agency_Strategic_Plan_FY2017-2021.pdf Ibid. M. and Barned-Smith, S Ward, prisons#.0QgWCID5I Adminis Texas 2016 Mental Disabilities/Suicide 6, §273.5 Rule Health Services on July Plan. Retrieved 273 Chapter Prevention from https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ ploc=&pg=1&p_tac=&ti=37&pt=9&ch=273&rl=5 http://www.houstonchronicle.com/news/politics/texas/article/State- from . Retrieved Chronicle The Houston unveils-measures-aimed-it-reducing-jail-6507108.php form. from http://www.houstonchronicle.com/news/politics/texas/article/State- . Retrieved The Houston Chronicle unveils-measures-aimed-it-reducing-jail-6507108.php

155 156 153 154 157 148 151 152 145 147 149 150 140 141 143 144 146 142 137 138 139 133 131 132 134 135 136 TDCJ 326 178 177 174 168 166 165 164 180 179 176 175 173 172 171 170 169 167 163 162 161 160 159 158 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas

support-program-comes-to-texas-jails/ Comes toTexas Jails. Retrieved fromhttp://bettertexasblog.org/2016/02/innovative-mental-health-peer- program-comes-to-texas-jails/ to Texas Jails. Retrieved fromhttp://bettertexasblog.org/2016/02/innovative-mental-health-peer-support- PeerSupport.pdf. in Texas Correctional Facilities . Page 9. Retrievedhttp://forabettertexas.org/images/HC_2014_07_RE_ from Health Court. Criminal_Justice_Interventions.pdf Brooklyn, NewYork. Page 12.Retrieved fromhttp://www.courtinnovation.org/sites/default/files/documents/ Offenders withMentalIllness: Criminal JusticeInterventions for Evaluation ofMentalHealth Courts inBronx and http://gov.texas.gov/files/cjd/Specialty_Courts_By_County_February_2016.pdf pdf Most SignificantLegislative Action.Page 53. Retrieved fromhttp://www.senate.state.tx.us/SRC/pdf/77th_Final. Center forPublicPolicy Priorities curriculum. Department ofStateHealth Services. ( Via Hope. (J CenterforPublicPolicy Priorities Center forPublicPolicy Priorities watch?v=LRgNJh2aZuY&index=2&list=PLu2WuYWXjUtcxvWsUGuF3KXhTuUJZ2c1t Jails, andVulnerable People Symposium . SeeDr. Frost’s presentationathttps://www.youtube.com/ Frost, L.( Health PublicDefenderOffice. Travis CountyMental H Ibid, Page 1 traviscountytx.gov/images/criminal_justice/Doc/cost_ben_MHPD_110922.pdf Analysis ofPerformance oftheTexas Task Force Grant. onIndigentDefense Page 1.Retrieved from https://www. Travis CountyAt Ibid. Ibid. Ibid. Ibid. Felony M www.justex.net/courts/Drug/MentalHealth/Default.aspx Harris CountyDistrict Courts. (20 Rossman, S., Willison,J., Mallik Office ofthe Governor Senate ResearchCenter. (J Justice, 40(1),69. on Recidivism:AMeta-AnalyticReviewofTraditional andNon-Traditional DrugCourts. Journal ofCriminal Mitchell, O., Wilson,D.B docplayer.net/1593837-Overview-of-drug-courts-in-texas.html Criminal Justice P Page 1.Retrieved fromhttp://www.tdcj.state.tx.us/documents/cjad/CJAD_Texas_Drug_Courts_Fact_Sheet.pdf Texas DepartmentofCriminalJus Sociological Quarterly, 54(4),647. Ray, B http://aja.ncsc.dni.us/publications/courtrv/cr49-1/CR49-1Marlowe.pdf Marlowe, D.B Texas. . andDollar, M.B. (2013). Examining MentalHealthCourt Completion: AFocal Concerns Perspective. The ental Health CourtHarrisCounty, Texas. (March2016). Personal communication:Felony Mental January 22,2016). Mental Health Diversion fromJail. University ofHoustonLawCenter Police, 4. uly 2016). Datarequest: Communityreentrytrainingforpeerspecialists. . (2012). AchievingRacialandEthnicFairness inDrugCourts. CourtReview, 49, 42.Retrieved from torney’s Office Office.(2011). MentalHealthPublicDefender CostBenefitAnalysis, Part1: olicy Council.(2002).Overview ofDrugCourtsolicy inTexas . Page 3. Retrieved fromhttp:// , CriminalJustice Division.(February 8, 2016). Texas SpecialtyCourts. Retrieved from ., Eggers, A.,andMacKenzie, D.L. (2012). Assessing ofDrug theEffectiveness Courts ealth PublicDefenderOffice. (February 19, 2016). Personalcommunication: Mental uly 2001). Highlightsofthe77 -Kane, K., Kim, K., Debus-Sherrill, S., andDowney,-Kane, K.,Kim,Debus-Sherrill, P.M. (February 2012). . (2016, February 10, 2016). Innovative MentalHealthPeer SupportProgram . (August 6, 2014). From Peer RecidivismtoRecovery: Support TheCasefor . (February 10, 2016). Innovative MentalHealthPeer SupportProgram Comes 12). Felony MentalHealthCourt Program Description.Retrieved fromhttp:// tice –CommunityJustice Assistance Division.(2003)Texas DrugCourts. July 25, 2016). Personal communication:Recovery coachtraining th Texas Legislature RegularSession: ASummaryofthe TJJD 327

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Funding Summary Funding Programs for Youth with Behavioral Health Conditions Health Behavioral with Youth for Programs fice office Ombudsman Independent the acts ront-End Diversion Initiative Diversion ront-End Intake, Intake, and Rehabilitation State-Funded Trauma-F F TJJD Juvenile Local Arrests Juvenile Courts, Juvenile Release Discharge fr The Closing The Major Legislation Legislation Major exas Juvenile Justice Juvenile exas System exas Juvenile Justice Juvenile exas Department Agencies and Justice Juvenile Local Specialty Juvenile Specialty C Special The Behavioral He Behavioral F The Behavioral He Behavioral He Behavioral Behavior Community-Based Cost and Cost How Juveniles Move Juveniles How in Disproportionality Of The Juvenile Justice and Justice Juvenile Policy Concerns Policy Fast F Fast Chart Organizational Behavioral He Behavioral Diversion The T The The T The Environment Changing At a Glance Juvenile Juvenile AgenciesJustice Agencies Juvenile Justice Juvenile Justice Department and Local Texas The Department and Local and Department The Texas Juvenile Justice Juvenile Texas The Policy Concerns

· Successfully implementing of the Office of the Independent Ombudsman’s expanded oversight role in county-level juvenile facilities · Assessing outcomes for state secure facilities and community interventions · Diverting youth with behavioral health needs away from secure confinement facilities and into their home communities · Decreasing the use of restraints and prolonged isolation of youth in secure confinement facilities · Assessing the impact of detaining youth in adult correctional facilities · Adjusting the upper and lower age limits of juvenile court jurisdiction based on the science of adolescent development · Addressing the school-to-prison pipeline for youth of color and youth with special education needs Fast Facts

· About 70% of youth in the juvenile justice system have a diagnosable mental health condition, compared to 20% of youth in the general population.1 · The majority of youth who are involved in the justice system commit misdemeanor offenses.2 · On May 31, 2016, there were 1,086 youth committed to five state secure facilities, 126 youth in halfway houses, and 114 youth in contract care facilities in Texas.3 · In 2015, the Legislative Budget Board (LBB) estimated that youth in residential facilities cost $437.11 per day, youth on parole cost $31.93 per day, and youth on probation cost $5.40 per day.4 · Texas has 49 pre-adjudication facilities operated at the county level. Nineteen of these facilities offer programs for youth with mental health conditions, and 15 provide programs for youth with substance use conditions.5 · Texas has 36 post-adjudication facilities operated at the county level. Twenty-seven of these facilities offer programs for youth with mental health conditions, and 31 provide programs for youth with substance use conditions.6 · In FY 2015, counties funded 73% of juvenile probation services, while the state and federal government provided 27% of total funding.7 Organizational Chart

Source: Texas Juvenile Justice Department. (2015, September). Organizational Chart. Retrieved from http://www.tjjd.texas.gov/docs/ TJJDOrgChart.pdf

328 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas TJJD 329 , nd

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9 l He a ent M nd a A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Figure 128 shows a side-by-side comparison of mental health needs for youth in the comparison of mental health needs for youth a side-by-side Figure 128 shows population. general justice population and youth in the juvenile Youth in the juvenile justice system are more likely than children in the general are more likely system justice in the juvenile Youth Researchers estimate use conditions. and substance mental health public to have while 60% of justice- a mental illness, youth have that about 70% of justice-involved use disorder. a co-occurring mental illness and substance youth have involved Juvenile Justice Juvenile Justice Juvenile Juvenile Agencies Justice Department Justice Juvenile of the Texas is comprised system justice juvenile The Texas agencies These the state. probation departments throughout and local juvenile (TJJD) youth who commit crimes services designed to rehabilitate work together to provide system, justice used in the juvenile more definitions (For the agesbetween of 10 and 17. section later in this chapter.) System Justice Juvenile the Texas Probation Juvenile Legislature abolished the Texas the 82nd Texas In 2011, agencies the two state (TYC), Commission Youth and the Texas Commission (TJPC) 653 (82 In their place, SB system. justice juvenile that previously managed the state’s Department and Local and Department The Texas Juvenile Justice Juvenile Texas The ultimate goal is to prevent a juvenile’s entrance into the adult criminal justice system system entrance into the adult criminal justice ultimate goal a juvenile’s is to prevent To and needs. unique strengths treatment plans tailored to each child’s providing by probation departments and funding to local juvenile oversight provides this end, TJJD including former responsibilities, and continues to fulfill some of TYC’s across Texas state facilities for youth. secure the operation of five Whitmire/Madden) created TJJD. The new agency charged was the with “increasing Whitmire/Madden) created TJJD. lockups.” to state rather than committed proportion of youth in local custody, TJJD 330 probation hadmentalhealthneeds. proprietary BISQ tool. proprietary BISQ in 2014 hadaccesstothe nolonger whenthepilot ended becausetheagency to bediagnosedwithapsychiatric disorder. individuals withoutabraininjury;theywerealsomore likely thanother juveniles juveniles reportedhigherdistress levels onmentalhealthassessmentsthan Injury ScreeningQuestionnaire (BISQ). 2014, 4,316individualsunder23yearsoldwerescreened for TBIusingtheBrain youth withbraininjuriesinthejuvenile justice system. Between FY2011 andFY delinquency. a braininjury, juveniles in aremorelikely thantheiruninjuredpeerstoengage involved youthhave experiencedatraumaticbraininjury(TBI). Recent meta-analyses alsodemonstrate thatbetween 30%and60%ofjustice- significant treatment. health disorder, about30%have disorderssevere enoughtorequireimmediateand While 70%ofjustice-involved youtharoundthecountryhave adiagnosable mental 1. Retrieved from Future: Key Elements to Developing a Trauma-Informed Juvenile Justice Diversion Program for Youth with Behavioral Health Conditions. Source: National Center for Mental Health and Juvenile Justice & the Technical Assistance Collaborative. (2015). and Traumatic-EventU.S.ExposureAmong Youth Figure 128. Prevalence MentalHealth Conditions, of SubstanceUseDisorders, Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas victimization themselves. been exposedtoviolence,crime,andabuse;theyhave alsoexperienced traumatic settings alsohave ahistory oftrauma.Closeto75%theseyouthhave not only other steps toaddressthetrauma backgrounds ofmany adjudicated youthin Alongside improved screening techniques, juvenile justice leadershave taken youth inthejustice system. of post-traumatic stress whichisdisproportionatelyfoundamong disorder (PTSD), youth sustained theirfirst injurybeforecommitting theirfirst offense. criteria foramildormoderate-severe braininjuries, andmorethanhalfofthose http://www.ncmhjj.com/wp-content/uploads/2016/01/traumadoc012216-reduced-003.pdf 16 In2011, TJJD collaboratedonafederalgranttoidentify andHHSC 11 20 InFY2015, almost 33%ofTexas youth referredtojuvenile

13 Theseexperiencescancontributetothedevelopment 14 12 Thevast majorityofchildreninjuvenile justice 17 About 67%oftheTexas youthmet the 19 TJJD endedmost ofitsTBI screenings 15 Aftersustaining

Strengthening Our 18 These TJJD 331

th In a 2015 In a 2015 22 In 2015, the In 2015, 24 27 23 , White/Whitmire) to prevent , White/Whitmire) to prevent th 25 LEGISLATURE commitments to and populations within commitments TH tate- and county-level juvenile justice systems, systems, justice juvenile and county-level tate- TNOYS’s Creating a Culture Change a Culture Creating initiative TNOYS’s 21 five years of release than youth sentenced to county-level county-level youth sentenced to release than years of five A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 26 While reforms have benefited s While reforms have Youth confined in state-run facilities are two times more likely to be likely more are two times facilities state-run in confined Youth within re-incarcerated probation. Texas can do more to decrease recidivism rates among justice-involved youth. justice-involved rates among recidivism do more to decrease can Texas and county probation CSGTJJD that researchers recommended In particular, risk to with the highest on youth their interventions concentrate departments youth. with low-risk involvement and minimize reoffend state-level secure juvenile detention facilities. detention secure juvenile state-level Legislative reforms helped to decrease reforms helped Legislative

legislative session are explained below. Legislation is described in the order in which Legislation session are explained below. legislative system. justice juvenile confront the Texas youth may account of the mental a comprehensive is not below The information provided legislation passed during the 84th legislative health and criminal justice-related session. THE 84 FROM MAJOR LEGISLATION aimed to assist youth service providers in developing other methods to alter negative to alter negative methods other in developing youth service providers aimed to assist For system. within the justice including those juveniles, among Texas behavior members staff facilities, Probation Department County Juvenile example, in Bexar trauma- to prioritize their use of assistance trainings and technical were given de-escalation) and and verbal listening (such as active informed care practices as a “last of seclusions and restraints minimize their use resort” option. In 2015, Texas lawmakers aimed to further past reform initiatives. The major pieces reform initiatives. past aimed to further lawmakers Texas In 2015, passed during the 84 justice of legislation related to mental health and juvenile · · Beginning in 2007, the Texas Legislature made deliberate efforts to decrease youth Legislature made deliberate efforts to decrease the Texas Beginning in 2007, (D-Houston), Senator Whitmire In 2013, incarceration rates across the state. chair the Council of State Governments asked Committee, of the Senate Criminal Justice efforts. Center to analyze the impact of those reform (CSG) Justice Changing Environment Changing Texas. Between 2011 and 2014, the Texas Network of Youth Services (TNOYS, in (TNOYS, Services Youth of Network the Texas 2014, and 2011 Between Texas. use the to decrease an initiative started Foundation) Hogg with the collaboration to residential who are committed among juveniles and restraints of seclusions and restraint that seclusion Research demonstrates centers (RTCs). treatment or physical already experienced youth who have can re-traumatize practices in the past. harms psychological SB 2398: Truancy Reform SB 2398: Truancy passed HB 2398 (84 Legislature the Texas In 2015, more Texas youth from entering the school-to-prison pipeline. The pipeline more Texas youth of color) (particularly school policies that lead students refers to punitive CSG released 14 key findings, including: findings, key CSG released 14 · evaluation, analysts demonstrated that the initiative decreased the use of restraints the use of restraints decreased that the initiative demonstrated evaluation, analysts and practice of and enhanced the knowledge 25% in participating facilities by care among youth service providers. trauma-informed TJJD 332 operated secure facilities. Asa result,legislatorsexpect toimprove rehabilitative of community-based placementsandprogrammingover commitments tostate- Legislators passedSB1630 (84 reform effortthattargeted both county- and state-level juvenile justice systems. home communities. are morelikely tosucceedwhentheycomplete theirdispositionscloserto students todetermine theunderlyingcausesoftruancy, suchasmentalillness. districts must prevention facilitatorswhoworkdirectlywiththe hiretruancy who repeatedlyskippedschoolcouldbeprosecutedincriminal court.Now, school arrest, against students. in Texas have increasinglyusedpunitive strategies, suchasphysical forceand further combattheschool-to-prisonpipeline.Inrecent years, schoolpoliceofficers local impact of Texas juvenile justice reforms. Public Policy ResearchInstitute releasedananalysisdemonstrating thestate and detention. In2015, Justice CouncilofStateGovernments (CSG) Centerandthe ofsentences,receive awiderange includingcommunity supervisionorstate-level After theiradjudication(i.e.,thejuvenile equivalentofaconviction), youthmay SB 1630:Keeping Justice-Involved Youth ClosertoHome 2684%20Explanation%20FINAL.pdf. by HB2684reforms:https://www.texasappleseed.org/sites/default/files/HB%20 following summarycreatedby Texas Appleseedforalist ofschooldistricts affected 2016, andofficerswererequiredtocomplete theirtraining by June1, 2016. Seethe Over 40schooldistricts wererequiredtoadopt by atrainingpolicy February 1, · · · · must includeinformationon: and any other entitiesthattrainschool-basedpolice officers. Thetrainingmaterials training materialsforschooldistrict policedepartments, law enforcementofficers, Texas CommissiononLaw Enforcement(TCOLE)must createanddistribute The 84thTexas LegislaturealsopassedHB2684(84 HB 2684:Training Police ProgramsforSchool-Based Officers juvenile justice system iftheydefycourtorders. cannot befinedorjailedforskippingschool,buttheycan betransferredtothe the student toattend counselingorother activities. HB2398stipulates thatstudents canorder criminally prosecuted.Instead, tocivilcourt,whereajudge theymay go Texas (TEA).Ifstudents continuetoskipschool,theycannot EducationAgency be School officialsmust alsoadopt minimumprevention standardsdeveloped bythe · toward justice involvement. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas to adopt “youth-focused”trainingprogramsforschool-basedpoliceofficers. environment. Thebillrequiresallschooldistricts with30,000 students ormore and decreaseyoutharrests by matchingpoliceofficers’ tacticswiththeschool and toward thecriminaljustice system. HB2684aimstoimprove schoolsafety

special needs; techniques; and Mental health crisisinterv The behavioral health needs ofchildren, Child and adolescent development Cultural competenc Positive beha vioral interventions, conflict resolution, andrestorative justice 33 The84thTexas Legislaturetranslated thesefindingsinto a y. 30 Thesestrategies tendtopushstudents away fromschool 28 ention; BeforelegislatorspassedHB2398, Texas students th , Whitmire/Turner),which emphasizedtheuse and psychology; particularly those withdisabilities or 32 The research showed that juveniles th , Giddings/Whitmire)to 31 The 29

TJJD 333 TJJD must must TJJD 34 . , Watson/Workman), , Watson/Workman), th 35 illness; violent offenses; and offenses; violent t practices for all local probation departments affected by departments affected all local probation for t practices eness of those programs; and programs; eness of those agesand 12; of 10 w or moderate re-offense risk. re-offense w or moderate A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation plan protocols; JD and local departments in the creation of evidence-based programs, evidence-based programs, creation of in the departments JD and local Youth with an IDD; with Youth the between Youth non- for adjudicated Youth a lo with Youth Youth with a serious mental with Youth Assist TJ Assist effectiv the Monitor and placements on community programs Issue reports Approve Approve on bes training Provide the plan; particularly for youth with behavioral health issues; health with behavioral youth for particularly

· · · · · · also create a new division to assist in the plan’s implementation. The division is is implementation. The division in the plan’s division to assist also create a new required to: · · · youth from state 180 divert collectively the regions must and FY 2017, In FY 2016 categories The task force identified several of youth who are secure facilities. including: particularly appropriate for diversion, · SB 1630 also expanded disposition options for youth. The law requires juveniles requires juveniles youth. The law for SB 1630 also expanded disposition options to undergo validated risk and needs assessments in order to identify individuals also become Once identified, those juveniles health conditions. with behavioral TJJD Further, facilities closer to their homes. eligible for placement in county-level health specialized programs to rehabilitate youth with behavioral develop must SB due to insufficient resources. in their communities be served needs who cannot well-being in order to measure recidivism rates and juvenile 1630 requires TJJD if programs are addressing the underlying factors that influence to determine delinquency. of responsibilities to include the oversight IO’s SB 1630 increased the Finally, see the IO, more information about the For facilities. post-adjudication county-level of the guide. this chapter Office of the Independent Ombudsman section later in Settings Justice IDD in County-Level Illness and/or with Mental Youth SB 1149: (84 passed SB 1149 Legislature the Texas In 2015, outcomes, decrease recidivism, and cut costs. SB 1630 included three main main three included SB 1630 cut costs. and recidivism, decrease outcomes, and youth, for options disposition increased plan, a regionalization components: (IO). Independent Ombudsman Office of the for the powers expanded justice local juvenile a task force with to establish 1630 required TJJD SB First, adjudicated that keeps plan a regionalization order to develop in stakeholders members were charged force with designing a plan Task youth closer to home. facilities post-adjudication the capacity of county-level that would: 1) identify facilities and 2) determine from state-level youth away to divert that can be used these diversions regions will need to complete the seven the resources that regularly to define began meeting the task force 2015, In September successfully. reforms funding for the state how determine for diversion, the target population plans. statewide and finalize the regional and would be allocated, TJJD 334 other states set ofcriminalresponsibility below theage 18. Asaresult,17-year-old Currently,from 17to18yearsold,but theSenateopposedchange. Texas andsix of Representatives attempted ofcriminalresponsibility inTexas toraisetheage One highlydebatedjuvenile justice reformdidnot passin2015. TheTexas House ofCriminalResponsibilityRaising theAge CHIP orMedicaid benefits. facility employees may determine whether adjudicatedyouthareorwerereceiving todevelop meansbydetention. whichjuvenile ThelegislationalsorequiredHHSC and toreinstate eachyouth’s eligibilitywithin48hoursofhisorherreleasefrom juvenile’s eligibilityforthechildhealth planprogram(CHIP)orMedicaid services coverage gap. tomerelysuspend(ratherthanterminate)a ThebillrequiresHHSC coverage andrehabilitative progress. LegislatorspassedHB839toeliminatethis benefits upontheirrelease.Asaresult,youthexperienced agapintheirhealthcare for juveniles whoweresenttodetention facilitiesandrequiredthemtoreapplyfor health needs. terminatedmedicalbenefits Beforelegislators passedthebill,HHSC continuity ofcareservicesforjustice-involved youthwithphysical andmental The Texas LegislaturealsopassedHB839(84 HB 839: CHIPandMedicaid Eligibility forNewly-Released Youth supervision inthecommunity. the Texas DepartmentofCriminalJustice (TDCJ),or3)releasetheyouthunder youth toacounty-level juvenile probationdepartment,2)transfertheyouthto end ofhisorherdeterminate may sentence,ajuvenile either: 1)transferthe judge birthday). Ifayouth’s commitmenttoamentalhealthfacilityexpirespriorthe sentence thatallows forayouth’s transfertotheadultsystem uponhisorher19th commitment proceedingsforyouthwithdeterminate sentences (i.e.,ablended departments topetition juvenile courtsfortheinitiation of mentalhealth Determinate-sentenced youth: Thebillallows juvenile boardsandprobation Offenders with Medical or Mental Impairments(TCOOMMI). These juveniles may alsoreceive reentryservicesfromTexas CorrectionalOfficeon or departmentmust referyouthwithIDDtoappropriatecommunityservices. needs andrefertheyouthtoappropriatetreatmentservices. Similarly, theboard department must allow apsychiatrist toexamineeachjuvenile withmentalhealth their mentalillnessand/or IDD. thejuvenile boardorprobation Beforedischarge, that thejuveniles cannot progressintheircurrenttreatmentprogrambecauseof committing offense,and2)thejuvenile boardorprobationdepartmentdetermines if: 1)theyhave completed theirminimumlengthofstay determined by their sentence thatmay not extend beyondtheyouth’s 19thbirthday) must bedischarged Indeterminate-sentenced youth: Juveniles withanindeterminate sentence(i.e.,a determinate sentence. treatment thatthosejuveniles shouldreceive whentheyhave anindeterminate or illness and/or IDDintotheircustody. Then,thebilldifferentiatesbetween the requires juvenile boardsandprobationdepartmentstoaccept youthwithmental development disabilities (IDD)incounty-level justice settings. First, thebill provisions aboutthetreatmentofyouthwithmentalillness andintellectual a regionalizationplanforalljustice-involved youth,SB 1149 includesspecific which complementsthereformspassedinSB1630. WhileSB1630addresses Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas th , Naishtat/Rodriguez) toimprove TJJD 335

41 43 36 If prison and jail officials fail If prison and jail 38 In 2012, the facility housed only 10% In 2012, 40 The McLennan County facility now serves as the serves now County facility The McLennan 42 Between 2009 and 2012, Corsicana reported twice as many Corsicana reported twice as many 2009 and 2012, Between 39 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation This PREA standard creates logistical and financial challenges for creates logistical This PREA standard 37 of TJJD’s juveniles but experienced 32% of all violent incidents reported by TJJD. but experienced 32% of all violent incidents reported by juveniles of TJJD’s Texas’ age federal age also contradicts responsibility of criminal standards Texas’ According Act Prison Rape Elimination the to by of 2003. (PREA) established are incarcerated under 18 who individuals any Inmate Standard, Youthful PREA’s and sound” from adult “sight be separated by must settings in adult correctional prisoners. Texans are automatically treated as adults if they commit a crime. Then, they may be they may Then, a crime. if they commit as adults treated automatically are Texans teenagers where and educational treatment face inadequate prisons, in adult placed victimization. risks of sexual and heightened opportunities In the years before the facility’s closure, TJJD reviewed Corsicana youth to closure, TJJD In the years before the facility’s In setting. in a less restrictive their needs could be met whether determine Residential all 65 youth were transferred to a the McLennan December 2013, Treatment Center in Mart, Texas. primary mental health treatment center for youth committed to state confinement. state to primary mental health treatment center for youth committed members three staff Though Corsicana closed as a normal operations facility in 2013, the As of March 2016, tasks. administrative remained at the facility to complete the closing of the formally approved Budget Board (LBB) had not Legislative secure from other employees TJJD however, 2016, In February Corsicana facility. the Corsicana facility of its equipment. facilities were sent to strip correctional administrators, especially those managing small jails who do not have have small jails who do not especially those managing correctional administrators, other than solitary confinement any means by to separate youth sufficient resources anxiety, such as mental health problems, that creates long-lasting – a housing option rage. and uncontrollable depression, hallucinations, violent rule violations as any other TJJD facility. TJJD other violent rule violations as any to comply with PREA’s Youthful Inmate Standards, the federal government may may the federal government Inmate Standards, Youthful to comply with PREA’s of Texas. from the state withhold funding commit crimes who Texans 17-year-old raising the age of criminal responsibility, By default; only those who commit by system justice would be handled in the juvenile transferred to the adult serious offenses would be certified as adults and the most The policy changemanagement could ease the mental health and system. challenges further study The Senate requested Inmate Standard. Youthful PREA’s created by action to raise the age Legislature takes of criminal of the issue before the Texas responsibility. FACILITIES TJJD THREE OF THE CLOSING Center The Corsicana Residential Treatment to reduce the TJJD session, the Legislature directed legislative During the 2013 a decline following facilities from six to five detention number of state-operated recommended closing the TJJD 2013, population. In June justice in the juvenile a secure facility located south of Dallas in Center, Corsicana Residential Treatment with significant mental health designated solely for youth County that was Navarro psychotherapy, Some of the services offered at the Corsicana facility included needs. and use treatment, mental health assessments, substance interventions, behavioral medication management. TJJD 336 treatment attheBeto House weresenttotheEdnaTamayo House inHarlingen. House weresenttotheAyresHouse inSanAntonio;youthwhowouldhave received After closing,youthwhotypicallywouldhave received treatmentattheTurman to committed youth. Treatment formallyrequiredallpsychiatry staff toprovide evidence-basedtherapy 2016, atreatmentdeveloper trained40clinicalstaff at TJJD facilitiesinTF-CBT, secure residentialfacilitiesby 44%. Between 2009and2013, TJJD decreaseditsuseofcommitmentstosecureandnon- and monitoringastheybegintheirreentryprocess. and 57youthwereenrolledinthepilot program. with trauma-relateddiagnoses, werereceivingtherapy servicesby psychiatry staff. responsibilities inlocalcountiesinclude: to enhancecommunity-based programming,placements, andsupervision.TJJD’s county level, TJJD workswithlocal juvenile boardsandprobation departments TJJD alsopartnerswithlocaljuvenile justice systems acrossthestate. At the lives andcreatesafer communities”throughoutTexas. The Texas Juvenile Justice Department’s (TJJD) missionisto“transformyoung The TexasSystem Juvenile Justice was provided toyouthwithhistories oftrauma. that theprogramincreasedconsistency andsophistication withwhichtherapy However, since thepilot’s inception, TJJD mentalhealthproviders have reported the measuredimpactthatprogramhashadonservice delivery andoutcomes. evaluation oftheTF-CBT pilot program.Therefore, theCentercannot yet state As ofMay 2016, theUTCenterforSocialWork Researchhadnot yet releasedan halfway houses:theTurmanHouse inAustin andtheBeto House inMcAllen. In 2013, theTJJD BoardofDirectors alsovoted toclosedown twounderused The Turman andBeto Halfway Houses Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Giddings StateSchool. Correctional Complex,McLennan CountyStateJuvenile CorrectionalFacility, and Cognitive Behavioral Therapy (TF-CBT) programatRonJackson StateJuvenile specifically forjuvenile correctionalsettings. TJJD piloted theTrauma-Focused Work Researchtoadopt anevidence-basedtreatmentfortraumadesigned In 2011, TJJD partneredwiththe University ofTexas atAustin CenterforSocial TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY PILOT youth, whiletheBeto House served anaverage dailypopulationof15.58 youth. closing in2013, theTurmanHouse served anaverage dailypopulationof16.98 members decidedtocondensehalfway houseservicesfrom10to8facilities. Before committed totheagency’s five secure state facilitiesandeighthalfway houses. TJJD provides educationaland behavioral healthservicesto justice-involved youth negative emotional andbehavioral responsesfollowing traumaticevents. from asecureinstitution. halfway houseisaresidentialcenterwherejuveniles may live following theirrelease 54 By 2016, allyouthwithamentalhealthneed,includingthose 49 TF-CBT isanevidence-basedtreatmentdesignedtoreduce 45 Youth placedinthesecenterscontinuetoreceive support 46 Following thispopulationdecline,TJJD board 58

53 52 In2013, TJJD’s Directorof 56 To accomplishthismission, 50 By March 44 57 47 A

48 51

55 TJJD 337 As a result, the 59 tice boards and probation and probation tice boards Analogous Adult Criminal Term/Concept Justice conduct Criminal Arraignment trial before detained are individuals where jail Local Trial Sentence between state and local leaders. and state between Definition act an committed she or he time the at old years 17 and 10 between person A supervision.” for need a indicating “conduct conduct”“delinquent or as defined confinement. or fine, a only in result could if adult, an by committed that, conduct Generally ofor violation truancy a as not such is that conduct iflaw the adult, an by committed home. from away running equiva- is It conduct. CINS or delinquent committed has youth a that finding court A court. adult in “conviction” a to lent If be may case the ofterms the meets juvenile the date. later supervision, her or his dismissed. of due distinct and each in felony one separate least at three least at committed hearings. process verseeing standards of operation in county facilities; in county operation of standards verseeing A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation departments; and departments; Establishing and o and Establishing local jus data to and disseminating Analyzing communication Facilitating Providing funding, technical assistance, and training to county justice officials; justice county to and training assistance, technical funding, Providing Term Juvenile ConductDelinquent for Need a Indicating Conduct (CINS) Supervision or imprisonment in result could if adult, an by committed that, conduct Generally Adjudication adjudication Deferred OffenderSerious Chronic a to deferred is adjudication her or his and supervision, under placed is youth A have to found been has who and felony a is offense classifying TJJD whose youth A Delinquent conduct Delinquent hearing Detention facility Pre-adjudication hearing Adjudication of Finding hearing adjudication at true” “true/not trial at of Finding “guilt/innocence” Disposition Juvenile Term/Concept Justice

legal terms and concepts used in juvenile justice procedures differ from those procedures differ justice used in juvenile legal terms and concepts 130 offer a point of Figure 129 and Figure setting. criminal justice used in the adult as well as systems, justice terms used in the adult and juvenile reference for parallel system. for terms used in the juvenile common definitions and Concepts Terms 129. Figure Common Juvenile Justice Definitions Common 130. Figure · · · punishment, the that emphasizes system is a criminal While the adult system that emphasizes rehabilitation. is a civil system system juvenile · TJJD 338 www.tjjd.texas.gov/about/glossary.aspx For afulllist oftermsanddefinitionscommonlyusedthroughout TJJD, see:http:// about/how_class.aspx Source: TexasDepartment. Juvenile Justice (n.d.). texas.gov/about/glossary.aspx Source: TexasDepartment. Juvenile Justice (n.d.). Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas niiulCs lnA youth’s individualized plan for treatment and education, based on his or her Halfway House Individual Case Plan Juvenile Probation time youth with an indeterminate sentence must stay in Minimum period of TJJD. Juvenile Parole Stay Minimum Length of ment Minimum Period Confine- of sentence that commits a youth to A type of TJJD time, for an indefinite period of not Indeterminate Sentencing A blended sentencing system for the most serious offenses that provides the possi- Determinate Sentencing Term compared to a direct release into the community. recidivismin a or halfway relapsehouse is generally believed to reduce the risk of community, while still providing people with monitoring and support. Placement reintegrationa halfway house is to allow the persons to begin the process into the of primary institution such as a prison, hospital, or rehabilitation facility. The purpose of sex offenses, or commit felonies are placed immediately after their release from a A residential center where individuals who have a mental illness, use drugs, commit specific strengths and risks. and prevent their progression into more serious problem behavior. communities may even use probation as a way to informally monitor at-risk youth committed their first offense or a status offense away from the court system. Some adjudicated in court. In many cases, probation is used to divert youth who have A mechanism used by juvenile justice agencies that serves as a sanction for juveniles ending with discharge from TJJD. supervision beginning afterA release period of from a residential program and This is set by TJJD policy. the youth to go on adult parole, rather than serve in adult prison. confinement and allow juvenile judge may choose to waive the minimum period of confinement before their 19th birthday,do not meet their minimum period of a TJJD facility before he or she is eligible for parole. This is set in state law. juveniles If time a youth with a determinate sentence must be held in a The minimum period of to exceed his or her 19th birthday. up to 40 years. sentence of they may be transferred to an adult prison. A youth may receive a determinate finement in a juvenile detention facility. they are unsuccessful in their treatment, If to transfer from TJJD con- to adult parole after they serve their minimum period of determinate sentences are successful in their TJJD treatments, they may be allowed upon the youth’s behavior while he or she is under TJJD’s custody. juveniles with If system in order to complete their sentence. Transfer to the adult system depends transferring juveniles on or before their 19th birthday from bility of TJJD to the adult Definition Determining How Long Youth Stay in TJJD. Retrieved from Definitions for Common TJJD Terms & Acronyms. Retrieved from http://www.tjjd.texas.gov/ http://www.tjjd. TJJD 339 http://www. In 61 63 In 2015, the In 2015, 60 $437.11 $31.93 $5.40 https://www.tjjd.texas.gov/about/ ry a Adult System Cost System Adult $54.89 Cost System Juvenile $4.04 $1.63 . 2.. Dutton by 1205 HB Re: in Session Regular Legislative Operating Budget Fiscal Year 2016 Submitted to the Governor’s Governor’s to the Submitted 2016 Year Fiscal Budget Operating th umm S Fiscal Note, 84 Note, Fiscal A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation nd Funding Funding nd a Figure 131 shows the difference in cost between the adult and juvenile justice justice juvenile the adult and between cost the difference in Figure 131 shows 62 ost ost Placement Adult prison or juvenile detention facility detention juvenile or prison Adult supervision Parole supervision probation or Community LBB estimated that youth in these residential facilities cost $437.11 per day. $437.11 cost residential facilities youth in these that LBB estimated contrast, youth on parole cost $31.93 per day, and youth on probation cost $5.40 per $5.40 cost youth on probation and per day, $31.93 parole cost youth on contrast, day. capitol.state.tx.us/tlodocs/84R/fiscalnotes/pdf/HB01205I.pdf#navpanes=0 Source: Texas Juvenile Justice Department. (2015, December 1). 1). December (2015, Department. Justice Juvenile Texas Source: from Retrieved 8. . Board Budget Legislative the and Policy and Planning ofOffice Budget, grants justice criminal as such contracts, interagency following: the includes Funds” “Other category The Note: . operating_budget.pdf proceeds. bond obligation general and receipts; appropriated 193; No. Fund School Foundation the from transfers and Figure 132. TJJD FY 2016 Operating Budget by Funding Source Budget by Funding 2016 Operating FY TJJD 132. Figure TJJD FUNDING TJJD TJJD’s Figure 132 breaks down $324,782,192. was in FY 2016 operating budget TJJD’s agency the budget by goal. funding source, and Figure 133 breaks down In FYbudget by Goal 2 (Maintaining care services were incorporated within TJJD’s mental health 2016, in green within Figure 133. shown and Oversight) Facilities, State Services, Source: Legislative Budget Board. (2015, April 1). 1). April (2015, Board. Budget Legislative Source: On May 31, 2016 there were 1,086 youth committed to TJJD’s state secure facilities, facilities, secure state to TJJD’s youth committed 1,086 there were 31, 2016 On May care facilities. youth in contract and 114 houses, in halfway 126 youth C systems in Texas. systems Justice Juvenile Adult and the Day Between Per Cost in Differences 131. Figure Systems TJJD 340 juvenile probationdepartmentsinFY2015. services withinTJJD. $84.7 millioninFY2017 fortheprovision ofbehavioral healthandsubstance use The 84thTexas Legislature appropriatedabout$84.2millioninFY2016 and operating_budget.pdf. Budget,Office of Planning and Policy and the Legislative Budget Board. 4. Retrieved from Source: Texas Juvenile Justice Department. (2015, December 1). Figure 133. TJJD FY 2016Operating Budgetby Agency Goal Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas and thejustice system. Title IV-E funding isakey resourceforyouthwhoareinvolved inboth foster care may alsousefederalfundingtosupporttheiractivities. For example,federal services forjuveniles withbehavioral healthneeds. Countyprobationdepartments departments inordertounderwritevariousprobationactivities, includingspecial TJJD distributes aportionofitsstate fundingtolocaljuvenile probation LOCAL JUVENILE PROBATION DEPARTMENT FUNDING expenditure proposal sectionofthisguide. for2017 canbefoundintheHHSC effectively acrossthe state. For moreinformationonthe strategic planandthe leaders determine how behavioral healthfundscanbespentmost efficientlyand a five-year strategic planandexpenditure.Theproposal willhelpagency Coordinating Councilcomprisedof18state agencies, includingTJJD, todevelop prevention andintervention. services, includingcounseling,intensive in-homefamily services, andsubstance use county probationdepartmentsofferawidearray ofmentalhealthandsubstance use community-based probationservices. Usingamixoflocal,state, andfederalfunds, 64 65 LegislatorsalsocreatedtheStatewideBehavioral Health Counties, however, provide themajorityoffundingfor 66 Figure134shows thefundingbreakdown forlocal Operating Budget Fiscal Year 2016 Submitted to the Governor’s https://www.tjjd.texas.gov/about/ TJJD 341 http://www.tjjd.texas.gov/ el facility (e.g., a D JJ T

h e; Figure 135 shows the top five most most the top five Figure 135 shows 68 roug

Annual Report to the Governor and Legislative Budget Board: Board: Budget Legislative and Governor the to Annual Report h ove t ove w enforcement; M JD. JJD Release Review Panel (for youth committed to a (for youth committed Release Review Panel JJD Larceny-theft, running away from home, drug abuse violations, home, drug abuse violations, from running away Larceny-theft, 67 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Appraisal by the T by Appraisal facility); secure state-level of parole supervision; and Completion Discharge from TJ An arrest by local la by An arrest court judg a county juvenile Sentencing by state-lev of a disposition (i.e., sentence) in a Fulfillment detention center or halfway house), county-level facility, and/or in the and/or facility, house), county-level center or halfway detention offense and judicial committing depending upon the juvenile’s community, discretion;

3. 5. 6. 1. 4. 2. common crimes for which Texas youth were arrested in 2014. In contrast, juveniles juveniles In contrast, in 2014. youth were arrested common crimes for which Texas murders in 2014. and 30 759 robberies, assaults, for 1,567 aggravated were arrested 7. Retrieved from from Retrieved 7. Programs. Diversion Special and Riders Appropriations, Justice Juvenile Community How Juveniles typically encounter six major steps, system through TJJD’s youth who move Texas including: Source: Texas Juvenile Justice Department. (2015, December). December). (2015, Department. Justice Juvenile Texas Source: publications/reports/AnnualReportFundingandRiders2015.pdf Figure 134. Funding Breakdown for Local Juvenile Probation Departments in in Departments Probation Juvenile Local for Breakdown Funding 134. Figure 2015 FY and violations of curfew and loitering laws (all of which are nonviolent offenses) (all of which are nonviolent and violations of curfew and loitering laws accounted for nearly 50% of those arrests. The following section will describe each of these steps in greater detail. describe each of these steps section will The following JUVENILE ARRESTS system contact with the justice who come into majority of juveniles The vast 57,447 enforcement officers made Texas law In 2014, offenses. commit low-level arrests. juvenile TJJD 342 residential facilitiestodecreaseby about76%. based interventions foryouth,causingtheaverage dailypopulationwithin mental healthconditions. disruptivereceive treatmentortomanage behaviors thatresultfromunidentified theyareroutedtothejusticewithout receivingaformalcharge; system inorderto those listed inFigure135. individuals aremorelikely thanothers forminoroffenses, tofacecharges suchas their disposition. youth arereleasedtoaparentorguardianastheyawait more information about throughtheintake andassessmentprocess.where theygo At thisstage,most Following an arrest, juveniles aretaken toacountyjuvenile probationdepartment, JUVENILE COURTS, SENTENCES, AND PLACEMENTS before finishinggradeschool. Youth withmentalillnessarethreetimesmorelikely thantheirpeerstobe arrested crimereports/14/citCh9.pdf Source: Texas Public Department of Safety. (2015). 2014 Crime in Texas Report: Texas Arrest Data. 73. Figure 135. Top Five Arrest Categories for Texas Juveniles in2014 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas get senttoadult criminalcourt.Inpractice, datashow thattheprimarydifference In theory, juveniles whocommitthemost serious offenses, suchasmurder, may over of13asadultsand transferthemtotheadultcriminaljustice theage system. juvenile inTexas. However, Texas law alsoallows courtstocertifyyouthwhoare intoaTJJDAdmission securefacility isoneofthemost seriousplacements fora communities. commit misdemeanorsmust bekept incounty-level facilitiesorintheirhome felonies areeligibleforplacementinstate securefacilities, whileyouthwho are inneedofintensive intervention. Since2007, onlyjuveniles whocommit a detention determine facilityarereserved forhigh-riskyouthwhomjudges sentence theyouthtodetention inacountyorstate facility. Placementswithin may community onadeferredprosecutionorprobation sentence, orthejudge For canallow example,ajuvenile courtjudge theyouthtoremaininhisorher can behandledinformallyoriftheyouthmust beplacedunder TJJD custody. A Juvenile typically makes adetermination courtjudge onwhether ayouth’s case within 48hoursofintake. are not diverted orreleasedtoacaretaker must appearbeforeajuvenile courtjudge community-based programs, ortheircasesmay bedismissedentirely. Youth who Curfew and loitering law violation Marijuana possession Runaway Non-aggravated assault property Depends on value of Larceny-theft (excluding motor vehicle) Offense Type 74 Between 2007and2015, TJJD reliedmoreheavily oncommunity-

72 Othersmay bediverted away fromthejustice system andinto 70 73 71

Someyouthalsobecomeinvolved inthejustice system

69 Oncetheyhave madecontactwiththepolice,these Misdemeanor possession Depends on amount in Misdemeanor Misdemeanor taken Classification 75 2,866 5,466 7,472 9,020 10,807 Total Arrests by Offense in 2014 http://dps.texas.gov/ TJJD 343 http://www.tjjd.texas.gov/ FY 2015 FY 62,535 44,060 63,965 825 115 The panel may choose to release The panel may 78

Annual Report to the Governor and Legislative Budget Board: Board: Budget Legislative and Governor the to Annual Report In a 2011 study, researchers found that court that court found researchers study, 2011 In a 76 Within those extension decisions, about 19% of the decisions, Within those extension 79

80 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation In FY 2015, the Release Review Panel extended juveniles’ stays within secure stays juveniles’ extended the Release Review Panel In FY 2015,

Referrals and Dispositions and Referrals Formal Referrals to Juvenile Probation Departments Probation Juvenile to Referrals Formal Referred Juveniles Dispositions Total Dispositions Commitment TJJD Dispositions Certification Adult officials in six counties (Harris, Jefferson, Hidalgo, Nueces, Lubbock, and Potter) Potter) and Lubbock, Nueces, Jefferson, Hidalgo, (Harris, in six counties officials of giving juveniles instead as adults, to certify youth chose disproportionately sentences. determinate facilities 66% of the time. DISCHARGE FROM TJJD discharge may them TJDD their dispositions, successfully complete When juveniles are typically discharged because 1) they finish their treatment Juveniles from custody. jurisdiction, or 3) they receive program, 2) they turn 19 and are no longer under TJJD’s in order to system sentence and are transferred to the adult justice a determinate youth with mental illness justice-involved adults, like their sentence. Just complete and discontinuity of care. including stigma often face challenges upon reentry, RELEASE REVIEW PANEL AND PAROLE PANEL RELEASE REVIEW their minimum length of stay sentences complete with indeterminate After juveniles assess each youth’s Panel Release Review TJJD’s on officials facility, within a TJJD educational behavior, The three-member panel examines the youth’s progress. if health treatments to determine and response to behavioral accomplishments, in the community. safely the youth can be served Source: Texas Juvenile Justice Department. (2015, December). December). (2015, Department. Justice Juvenile Texas Source: from Retrieved 13. Programs. Diversion Special and Riders Appropriations, Justice Juvenile Community The departments. ofnumber total the include probation data juvenile to referrals” “formal referred The were youth times Note: to referred be can juvenile one Because ofnumber total the includes data probation. to referred” “juveniles referred were who youth point. data referred” “juveniles the than greater is point data referrals” “formal the once, than more department the publications/reports/AnnualReportFundingandRiders2015.pdf between assignment to the juvenile or the adult system is the county of conviction, of conviction, the county is system adult or the to the juvenile assignment between history. offense the youth’s not the youth into the community on parole or extend his or her stay within a TJJD within a TJJD his or her stay the youth into the community on parole or extend facility. Figure 136 shows the number of referrals and dispositions for youth involved in the youth involved of referrals and dispositions for the number Figure 136 shows placements and more information about secure For FY 2015. in system justice juvenile see the to youth within these placements, available health treatments the behavioral section of this chapter. System” Justice Services in the Juvenile Health “Behavioral in 2015 Youth TJJD of and Dispositions Referrals 136. Figure juveniles had moderate mental health needs and about 40% had high substance use 40% had high substance had moderate mental health needs and about juveniles treatment needs. TJJD 344 in FY 2013 Figure 137. Texas RatesJuvenile of Justice InvolvementbyRace andEthnicity delinquent. arrest, youthofcolorweremorelikely tobereferredcourt,detained, andfound the juvenile justice system inFY2013. Thoughwhitejuveniles hadhigherratesof white, AfricanAmerican,andHispanicyouthinTexas experiencedvariousstagesof do so). remove astudent fromtheclassroomenvironment, thoughtheyarenot required to (e.g., abehavioral violationforwhichschooladministrators have thediscretion to white andHispanicpeerstoreceive adisciplinaryactionfor adiscretionary violation for 83differentvariables, AfricanAmericanyouthare31%morelikely thantheir becoming involved inthejuvenile justice system inthefuture. expelled fromschool. races misbehave atsimilar rates, minorityyouthare morelikely tobesuspended and 2014, theU.S. DepartmentofEducationreportedthat, thoughyouthofdifferent Youth ofcolorarealsomorelikely tobecaughtintheschool-to-prisonpipeline.In point (e.g., 16 white youth referred to court per 100 white youth arrested). arrest to population areNote: Comparisons rates per 1,000 youth. of All other categories are rates per 100 youth at the prior decision odc=0&dmp=1&dmp-comparison=2&dmp-decisions=2,3,5,7&dmp-county=-1&dmp-races=1,2,3,4,7,5,6&dmp-year=2013. http://data.burnsinstitute.org/decision-points/44/texas#comparison=2&placement=1&races=2,3,4,5,6&offenses=5,2,8,1,9,11,10& Source: The W. Haywood Burns Institute for Juvenile Justice Fairness & Equity. (2013). the justice process. Black andHispanicyouthtendtofareworsethantheir whitepeersatmost stagesof D Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Justice confinement facilities, andcertifiedasadults. more likely thanwhiteyouthtobearrested, referredtojuvenile court, senttosecure isproportion 84 Suchdisparitiesinschooldisciplineplaceyouthof coloratgreaterriskfor S ystem 81 For example,acrossthecountry, African Americanjuveniles are 83 InTexas specifically, researchersfoundthat,aftercontrolling a lity int h e 82 Figure137 shows theratesatwhich T ex a Unbalanced Juvenile Justice. Retrieved from s Juvenile 85 TJJD 345 92 . 90 n a The coalition operates 88 mbudsm O The independent ombudsman investigates a variety The independent ombudsman investigates 91 In December 2016, CEDD will release a report for CEDD In December 2016, ndependent t principles, as well as an understanding of an understanding as well as t principles, 89 I 86 e h workforce; 87 t f , West/Dukes) created the Interagency Council on Addressing , West/Dukes) nd collaborations; and collaborations; trategies; A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation ice o Off e Providing information to legislators and the public regarding facility grievance Providing procedures; facilities; and Regularly visiting and inspecting secure TJJD Exploitation (ANE) incidents in all county facilities Neglect, and Tracking Abuse, the history of institutional racism and its impact on poor communities and on poor its impact racism and of institutional the history color of communities Data-driven s Data-driven development; Leadership competent A culturally engagement;Community Cross-systems by anti-racis defined Training

within HHSC’s Center for Elimination of Disproportionality and Disparities (CEDD) Center for Elimination of Disproportionality within HHSC’s main the coalition’s In 2016, to those of the IC. and holds responsibilities similar and workforce issues health, infant mortality, mental priorities included children’s for individuals with disabilities. of complaints, including medical and mental health concerns, abuse allegations, and abuse allegations, medical and mental health concerns, including of complaints, major duties include: Three of the IO’s suicidal ideation and attempts. · · · the Texas Legislature outlining the coalition’s formal recommendations, including formal recommendations, Legislature outlining the coalition’s the Texas does not however, CEDD, collection on disparity issues. data means to strengthen mandated is legislatively Only DFPS to enforce its recommendations. hold the power agencies, while other to address disproportionality within its service delivery, suggestions. to implement the coalition’s choose whether may including TJJD, · · · · · Disproportionality (the IC) to complete two tasks: 1) examine best practices for practices for best two tasks: 1) examine (the IC) to complete Disproportionality including and services agencies, in the human health addressing disproportionality means of on the best recommendations and 2) develop settings, justice juvenile the agency 2012, in the long-run. In eliminating disproportionality a developed The full tasks. summarizing their progress on these Legislature report for the Texas here: http://www.hhsc.state.tx.us/hhsc_projects/cedd/11-29- report can be found 2012-Report-to-the-83rd-Legislaturel.pdf model” as a means to address disproportionality. the “Texas The report highlighted components: The model includes the following · In 2007, the 80th Texas Legislature created the Office of the Independent Ombudsman Legislature the 80th Texas In 2007, evaluating, and securing the agency (IO) as a separate state responsible for investigating, to TJJD. rights of youth committed Th In 2013, the IC expired, and the Legislature replaced it with the Statewide Advisorywith the expired, and the Legislature replaced it the IC In 2013, Coalition for Addressing Disproportionality and Disparities. In 2011, SB 501 (82 SB 501 In 2011, In 2015, the Council of State Governments (CSG) Justice Center analyzed the racial the racial analyzed Center (CSG) Governments of State Council the Justice In 2015, place since taken that have reforms justice juvenile Texas of impacts ethnic and equally; the of all races impacted youth that the reforms Researchers found 2007. in the involvement minority disproportionate or improve exacerbate not policies did system. justice juvenile Texas TJJD 346 reduced re-arrest rates, off-sitehospitalizations, andself-harmamong TJJD youth. advances inearlydetection andtreatmentforyouthwith mentalhealthconditions secure facilitiesandcountypost-adjudication facilities. IO receives themajorityof complaintsdirectlyfromyouthwhileinspectorsvisitstate below summarizestheIO’s activitiesduringFY2015, andthefirst halfofFY2016. The completing both typesofprogramsfellfrom61%in 2012 to42% in2014. use treatmentshasincreased since2012, ofyouthsuccessfully thepercentage However, ofyouthinneedboth whilethepercentage mentalhealthandsubstance by 32%tomeet juveniles’ behavioral healthneeds. youth toTJJD requiredatleast oneareaofspecializedtreatment. and received behavioral health servicesinTexas. In2015, 99%ofthenewly-admitted Between 2009and2015, agrowing proportion ofjustice-involved youth required services foryouthwhoareunderprobationorparolesupervisioninthecommunity. residential treatmentcenters, andcountysecurefacilities. alsoprovide Theagencies conditions inavariety ofjuvenile justice settings, includingstate securefacilities, secure (TCOOMMI) provide servicesforyouthwithmentalhealthandsubstance use the Texas CorrectionalOfficeforOffenderswith Medicaland MentalImpairments The Texas Juvenile Justice Department,localjuvenile probationdepartments, and SystemJuvenile Justice Behavioral Health Services in the to February 29, 2016. 1. Retrieved from Source: Independent Ombudsman for the Texas Juvenile Justice Department. (2016). Second Quarter Report FY 16: December 1, 2015 Figure 138. Site Visits, Accountof Youth Contact, andCases ClosedbytheIO During the84thlegislative session,lawmakers passedSB1630(84 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas involved youth.Servicesaredivided intothefollowing fourcategories: The following sectiondescribesthebehavioral healthservicesavailable tojustice- provider. new youthalsorequiredmentalhealthtreatment by alicensedorspeciallytrained and contractfacilitieswherecountypost-adjudicated youthareplaced. Following SB1630, theIOmust alsoinspectcounty-level post-adjudication facilities secure TJJD facilities, halfway houses, state contractcarefacilities, andparoleoffices. the IO’s oversight duties. Priorto2015, theIOwas responsibleforinspecting state-level to implementbroadreformsthejuvenile justice system, includinganexpansionof Closed cases youth interviews conducted Number of youth interviewed Number of Site Visits Activity 96 Between 2009and2015, TJJD increaseditsuseofspecialized treatment http://www.tjjd.texas.gov/ombudsman/reports/IO_Second_Quarter_2016.pdf 106 3,004 1,305 207 FY 2015 97 Duringthatsame timeperiod, 94 41 1,974 1,329 85 FY of 2016 First Half th , Whitmire/Turner) , Whitmire/Turner) 95 Halfofthe 93 Figure 138 Figure138 99

TJJD 347

100 101 In 106 All girls who are ecure 105 S y juvenile probation probation y juvenile te http://www.tjjd.texas.gov/aboutus/ a t S In FY 2015, the Ron Jackson the Ron Jackson In FY 2015, 107 Location Edinburg Gainesville Giddings Mart Brownwood el secure facilities el secure

102 ervices in ervices in S

h lt a 108 104 l He a A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation These services last approximately 28 to 35 days during which time youth 28 to 35 days approximately These services last 103 vior Behavioral health services in county-lev in services health Behavioral on parole services for youth health Behavioral b services offered health behavioral Community-based Behavioral health services in state secure facilities secure state in services health Behavioral departments

ha cilities 4. 1. 2. 3. e a TJJD Facility TJJD Evins Regional Juvenile Center Juvenile Regional Evins School State Gainesville School State Giddings McLennan & Facility Correctional Juvenile State County McLennan Center Treatment Residential Complex Correctional Juvenile State Jackson Ron facility served 188 girls and 887 boys (including boys who solely received orientation who solely received (including boys 188 girls and 887 boys facility served services at the facility). receive psychiatric and health evaluations, as well as an introduction to TJJD’s as well as an introduction to TJJD’s and health evaluations, psychiatric receive treatment programs. After orientation, youth are dispersed to various state secure facilities depending After orientation, youth are dispersed to various state 15% of youth are Approximately specific treatment needs. upon the juvenile’s in state juveniles other orientation, while many following house placed in a halfway facilities. fulfill their dispositions within secure detention custody facilities.aspx AND PLACEMENT ORIENTATION, INTAKE, Jackson first go to the Ron facility must to a TJJD who are committed All juveniles and assessment orientation Complex to receive Correctional State Juvenile services. Source: Texas Juvenile Justice Department. (n.d.). TJJD Facilities Address List. Retrieved from from Retrieved List. Address Facilities TJJD (n.d.). Department. Justice Juvenile Texas Source: F offenses. adjudicated for felony state secure facilities for youth five operates Texas B Figure 139 below shows the name and location of the state secure facilities. In FY secure facilities. name and location of the state the shows Figure 139 below youth were adjudicated for high- about one-quarter of newly-committed 2015, such as capital offenses. crimes, severity November 2013, the Ron Jackson facility transitioned from an all-girls complex the Ron Jackson 2013, November bed existing more efficient use of the facility’s to a co-ed complex in order to make different they attend facility, are housed in the same space. Though girls and boys in separate units. programs and live rehabilitative Figure 139. TJJD Secure Facilities Secure TJJD 139. Figure committed to a detention facility must remain at the Ron Jackson complex because remain at the Ron Jackson facility must to a detention committed Programming and services at Ron females. it is the only secure facility that serves McLennan County Residential Treatment are similar to those offered at the Jackson but they are modified to reflect the unique needs of female youth. Center, On May 31, 2016, there were 1,086 youth housed at the state’s five secure facilities. five at the state’s youth housed there were 1,086 31, 2016, On May TJJD 348 development servicesto allcommitted youth. CoNEXTions, whichprovides lifeskillstraining,education,andworkforce All five state securefacilitiesuseamulti-faceted rehabilitationprogramcalled REHABILITATION AND SPECIALIZED TREATMENT PROGRAMS are kept attheRonJackson facilityuntiltheyareabout14 yearsold. secure TJJD facility. Equipped witheightbeds, theCSUprovides hospital-level psychiatric carewithin a such asschizophrenia,may beserved withinMRTC’s CrisisStabilizationUnit(CSU). Center (MRTC) inMart, Texas. Youth withthemost severe formsofmentalillness, primary mentalhealthtreatmentfacility, theMcLennan ResidentialTreatment Youth whoareidentifiedashaving aseriousmentalhealthneedaretaken to TJJD’s Psychiatric andpsychological servicesarealsoavailable withinallsecurefacilities. recidivism amongjustice-involved youth. riskfactors,aims toreducecriminogenic increaseprotective factors, anddecrease depending upontheindividualchild’s treatmentneeds: TJJD andjuvenile courtstakeholders may choosebetween threecoursesofaction highlights thespecializedtreatmentprogramsthat exist acrossthestate. use conditions, mentalhealthconditions, orintellectualdisabilities. Figure140 have committed seriousviolentorsexualoffensesand/or youthwithsubstance within TJJD. Thesespecializedtreatmentprogramsaredesignedforyouthwho at highriskforviolentrecidivismareassignedtospecialized treatmentprograms Youth whoareidentifiedashaving ahighneedforspecializedservicesorwhoare 35 boys. under 15yearsold.Between October2014 andMarch2016, theintake unitserved In October2014, theRonJackson complexalsocreatedamaleintake unitforboys Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas intervention thatisavailable toandappropriatefortheyouth. to deterioration ifleftuntreated,andplacementinthe CSU istheleast restrictive crisis presentsariskofseriousharmtothemselves orothers, thecrisiscouldlead behavioral change andconnectsyouthwithsocialsupportsystems.behavioral change instead usesanevidence-basedtherapeuticframework thatincentivizespositive traditionally focusonestablishing controlover program youth.TheCoNEXTions 3. 2. 1.

staff membersdetermine thatreleaseisboth safe andclinicallyappropriate. treatment needs;or The childmay betransferred toahalfwa The childmay besentto another securefacilitythatcanmee The childmay bekep 109 Childrenunder15whohave beencommitted toastate securefacility 113 Juveniles may beadmitted totheCSUonlyiftheirpsychiatric t atRonJackson tofinishhisorherassignedsentence; 111 Juvenile justice programs y houseortothecommunityifTJJD 114 112 110 t hisorher Theprogram At thistime, TJJD 349 118 addressed by linking the use the linking by addressed use cognitive behavioral concepts behavioral cognitive use - likeli the reduces the program not utilize the same role play activi- play role same the not utilize in two months ofmonths two in six and orientation e required to reenact their crimes their reenact to required e uses a support group structure to structure group support a uses 120 116 119 goal is to reintegrate the young person young the reintegrate to is goal 85% of85% ofneed in juveniles were MHTP 99% of juveniles in need of AODTP were of99% were ofneed in juveniles AODTP treatment, and 91% of91% and need in those treatment, for the program is to treat the underlying the treat to is program the for T program offers treatment in 30 group group 30 in treatment offers program T ogram is similar to CSVOTP, though partici- though CSVOTP, to similar is ogram TP helps young people understand feelings understand people young helps TP am components include evidence-based include components am 117 enrolled, and 55% of55% and completed need in those enrolled, treatment. Participation in Participation pr The as such crimes, serious less committed have pants robbery. aggravated engage Youth ofmonths programs. do Counselors - they focus on self-reg Instead, ties used in CSVOTP. value-changing and management, anger ulation, activities. Circle Girls’ gen- in youth female engage resilience, promote self-esteem. increase and discussions, der-specific goal The regain to allow youth and problem health mental behavior. their over control final The program a in community and family her or his with - correc and health mental her or his addresses that needs. tional therapy 2014, In The AR The weeks. ten over sessions managers Case partici- help to strategies reasoning moral and them that help values pro-social develop pants relationships. their in safely more function CSVO identify and behavior violent their with associated risky with faced when respond to ways alternative situations. ar Participants of role the play and and perpetrator the both victim. hood of being re-incarcerated for any offense by ofhood offense any for re-incarcerated being 55%. Progr is behavior Criminal 2014, In of92% and completed need in those enrolled, treatment. treatment curricula, substance use education, education, use substance curricula, treatment relapse and counseling, training, social skills prevention. offense. and story life ofyouth’s the to drugs In 2014, 98% of juveniles in need of CSVOTP of98% ofneed in juveniles 2014, In CSVOTP received treatment. completed

· · · · · · · · · · · · Treatment Services and Outcomes and Services Treatment · · · · Female youth Female Youth with a with Youth need moderate to treatment for - aggres address behavior. sive who Youths committed have crime violent a whose but not are offenses enough serious for qualify to CSVOTP with Youth mental health conditions. Youths who who Youths committed are murder, for murder, capital offenses and the involving ofuse weapon a force. deadly or Youth with Youth use substance chem- or issues - dependen ical cies. Participants - - - 115 at Ron Jackson at Jackson Ron Juvenile State Cor Complex. rectional Services available Services State Giddings at Jack Ron School, Correctional son and Complex, County McLennan Correctional Facility. available Services - Resi McLennan at Treatment dential Ron and Center Juve- State Jackson nile Correctional Complex. Services available Services state five all at facilities. secure available Services State Giddings at Jack Ron School, Correctional son and Complex, County McLennan Correctional Facility. Location Services available available Services the institu- all at and facilities tional halfway several - Residen houses. programs tial all at offered are secure state five facilities. A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Girls’ CircleGirls’ available Services - Mental Treat Health (MHTP) Program ment inten- Less Note: health mental sive youth for programs needs with moderate all at available are campuses. Violent Offender Offender Violent Program This Note: program in youth serving began 2015. July - Replace Aggression Therapy ment (ART) Program Serious and Capital Offender Violent Program Treatment (CSVOTP) Program Alcohol or Other or Alcohol Drug Treatment Use (AODTP) Programs Specialized Treatment Programs Texas in Programs Treatment Specialized 140. Figure TJJD 350 Specific Servicesin Texas Figure 141. Number(andPercentage) Post-Adjudication of Facilities with http://www.tjjd.texas.gov/publications/other/searchfacilityregistry.aspx. of allcounty-level juvenile justice facilitiesandtheservicesoffered by each,visit: mental health,substance use,sexoffense,andfemale-specificservices. Forafulllisting displays thenumberofpre-andpost-adjudication facilitiesthatofferspecialized the availability oftreatmentandsupportservicesvariesacrossthestate. Figure141 Because localjuvenile justice systems relyheavily oncountyandlocalfundingsources, these individualswereformallyreferredforanon-felony offense. pre-adjudication facilitiesatthecountylevel inFY2015. severe enoughtowarrant placementinastate securefacility. These facilitiesdetain adjudicatedyouthwhohave committed offensesthatarenot Texas alsohas36post-adjudication securefacilitiesoperatedat the countylevel. each youth’s offense. These juveniles aredetained provides before ajudge a“true”or“not true”findingfor deemed unsafe forreleasebackintothecommunitywhileawaiting adjudication. has 49pre-adjudicationfacilitiesoperatedby countiestodetain youthwhoare offer variousbehavioral healthservices:pre-andpost-adjudication facilities. Texas At thecountylevel, juveniles may beplacedintwodifferenttypesoffacilitiesthat S B www.tjjd.texas.gov/Docs/TreatmentEffectivenessReview_2015.pdf Source: Texas Juvenile Justice Department. (2015, December). Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas texas.gov/publications/other/searchfacilityregistry.aspx Source: Texas Juvenile Justice Department. (n.d.). Registered Juvenile Facilities in Texas (CY2015). Retrieved from Female-Specific e fes 7 (14%) Sex Offense usac s 15 (31%) Substance Use etlHat 19 (39%) Mental Health Treatment Program Sexual Behavior yeo evc Pre-Adjudication Facilities Type Service of Management for Anger Strategies Program ecure F e ha vior a a cilities School. Gainesville State State School, and Facility, Giddings County Correctional Center, McLennan dential Treatment at McLennan Resi- Services available all halfway houses. secure facilities and at all five state Services available Location 8 (16%) l He 122 Approximately 500Texas juveniles spent100days ormorein 115 a lt h offenses. TJJD for sex committed to Youth who are Participants treatment. violent offender low need for Youth with a

S ervices in The Annual Review of Treatment Effectiveness. Retrieved from · · · Treatment Services and Outcomes · ·

pleted treatment. were enrolled, those in need com- and 85% of In 2014, and arousal patterns. apies that focus on each youth’s deviant sexuality counseling, education, andtrauma resolution ther Juveniles receive and a relapse prevention component. The pr substitutes for responding to those triggers. Participants ar The 12-ses anger. therapy to help youth identify their triggers for 17 (47%) 20 (56%) 31 (86%) 27 (75%) Post-Adjudication Facilities ogram uses cognitive behavioral strategies C 98% of juveniles in need of the program juveniles in need of 98% of sion program uses cognitive behavioral ounty- 123 e taught to develop more effective About 36%(180youth)of 121 125 additional individual and group

124 L evel http://www.tjjd. https:// - TJJD 351 However, However, 126 130 ervices on S h

rtments h a lt out ep a Y D Second, regions may apply Second, regions may or 129 l He f a 133 tion a First, regions can receive start-up funds start-up regions can receive First, vior 128 In November 2015, the TJJD Regionalization the TJJD 2015, In November Further, TCOOMMI provides continuity of TCOOMMI provides Further, rob 127 assistance. ha 131 P ervices e S

B h Figure 142 shows the type of offenses that precipitated shows Figure 142 ther treatment programs; and programs; ther treatment lt 135 a sed The majority (51%) of referrals were for youth who , Whitmire/Turner), at least 180 juveniles will be diverted will juveniles 180 least at , Whitmire/Turner), th 134 Ba l He a A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation y services in the community; y services in the vior The state may also place paroled youth with a mental illness in therapeutic also place paroled youth with a mental illness in therapeutic may The state 132 ered by Juvenile ered by ha role Benefits eligibility and application eligibility Benefits Individualized assessments; Individualized coordination; Service monitoring; Medication Advocac o to services Transitional ommunity- e

for additional funding that must be directed specifically to the programming and directed specifically to the programming be that must for additional funding facilities. from state-run for diversion of youth targeted placement needs away from state secure facilities and into county juvenile justice systems. justice juvenile into county and facilities secure from state away as shown in Figure 140, counties differ in their capacity to provide services for services to provide in their capacity counties differ in Figure 140, as shown lack of that the reported stakeholders county-level youth. In 2015, justice-involved the barrier to a potential their regions was within providers mental health professional of SB 1630. implementation successful each year between FY 2016 and FY 2019 that can be used to benefit juveniles targeted juveniles that can be used to benefit and FY 2019 FY 2016 each year between youth. justice-involved as well as other for diversion, C Off 62,535 formal referrals probation departments received juvenile In FY 2015, throughout the state. In Texas, parole officers must receive extensive training on working with youth with extensive receive parole officers must In Texas, health issues. mental and behavioral are released on parole health diagnosis who care services to youth with a mental (TCOOMMI also or county secure facility. their placement in a state following will be described in the next services to youth on probation; those services provides 420 was on parole in Texas daily population the average 2016, subsection.) In May youth. B Pa Following SB 1630 (84 SB 1630 Following · · · · · foster homes, group living arrangements, or residential treatment facilities. Services facilities. or residential treatment arrangements, group living homes, foster a serious mental illness and who who have targeted for youth released on parole treatment include: require post-release · referrals to juvenile probation departments. probation departments. referrals to juvenile committed misdemeanors. committed Task Force began developing funding protocols to ensure that county-level juvenile to ensure that county-level funding protocols developing began Force Task servicesto provide financial support the necessary departments would have justice allocate the $11.3 million may that TJJD state youth. These protocols to diverted in two ways. for SB 1630 reforms available TJJD 352 probation hadanidentifiedmentalhealthneed. adjudication andordertreatmentasa conditionofdismissing each juvenile’s health servicesintheirhome communities. Judges couldalsoofferyouthdeferred children may bediverted fromtheprobationsystem toreceive mandatedbehavioral departments, TCOOMMI,LMHAs, foravariety andCRCGs ofreasons. Some Youth with mentalhealthneedsmay receive servicesfromjuvenile probation (MAYSI-2). post-adjudication facilityusingtheMassachusetts Youth ScreeningInstrument mental healthneedswithin48hoursofthejuvenile’s admissiontoapre-or By law, localjuvenile probationdepartmentsmust screenallTexas youthfor publications/reports/AnnualReportFundingandRiders2015.pdf Community Juvenile Justice Appropriations, Riders, and Special Diversion Programs. 12. Retrieved from Source: Texas Juvenile Justice Department. (2015, December). Figure 142. Offense Type for Juveniles Referred to Juvenile Probation Departments Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas based services for juveniles with cross-agency needs.based servicesforjuveniles with cross-agency in 1987aftertheTexas Legislaturedirectedstate toimprove agencies community- delivery forjuveniles across thestate. Communitiesinitiallycreatedthesegroups groupscomprisedofpublicandprivateentitiesthatcoordinateservice interagency to provide justice-involved youthwithbehavioral healthservices. arelocal CRCGs health authorities(LMHAs),CommunityResource Coordination Groups(CRCGs) County juvenile probationdepartmentsmay partnerwithTCOOMMI,localmental community treatmentprograms. the first timeaftertheyhave beenarrested, adjudicated,ordiverted tomandated the justice system. Instead, many juveniles experiencementalhealthtreatmentfor justice-involved youth,fewjuveniles accessmentalhealthservicespriortoentering health needs. Thoughthere isahighprevalenceofmentalhealthneedamong Texas countiesvaryintheircapacitytoidentifyandaddress youthwithmental see http://www.tjjd.texas.gov/publications/forms/2010/TJPCFS0410.pdf. day. refer youthtoaqualifiedmentalhealthprofessional by theendofnext working the youthtoalicensedphysician within48hours, asecondscreeningand or2)forgo juvenile probationdepartmentsmust either:1)conducta secondscreeningandrefer health assessment. referred juveniles screenedinFY2015 wererecommended forasubsequentmental 137 In2015, TJJD reportedthat35%ofjuveniles whowerereferredtojuvenile 136 Ifascreeningindicatesthatfurtherassessmentisappropriate,local 139 For adetailed flowchart ofthescreeningandreferralprocess, 140

Annual Report to the Governor and Legislative Budget Board: 138 Approximately 20%offormally 141 http://www.tjjd.texas.gov/ TJJD 353

143 Number ofNumber Programs 2,571 5,210 2,006 1,059 1,370

142 Number Served Number 382 146 as youth well as parole, TJJD on released youth (includes house) (hallway facility residential non-secure a to released 98 Figure 144 indicates the number of programs in which youth Figure 144 144 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Type of Service Type Mental health programs and mental health court programs court health mental and programs Mental health one-time (including problem health mental a for services health Behavioral services) evaluation and assessment health mental programs services Counseling programs intervention and prevention abuse Substance programs court drug and treatment abuse Substance Type of Discharge Type services CRCG or TCOOMMI to Referred the in services aftercare health mental Received community aftercare health mental receiving parole on youth TJJD community the services in Source: The Texas Juvenile Justice Department. (2016, June). Data Request: Community-based behavioral health programs health behavioral Community-based Request: Data June). (2016, Department. Justice Juvenile Texas The Source: with mental health needs participated during FY 2015, including mental health and during FY 2015, with mental health needs participated and abuse prevention substance counseling services, mental health court programs, abuse treatment and drug court programs. and substance programs, intervention with Youth Which in Number of Programs Community-Based 144. Figure Needs Participated Health Behavioral Source: Texas Juvenile Justice Department. (2016, July). Data Request: Services for discharged youth. discharged for Services Request: Data July). (2016, Department. Justice Juvenile Texas Source: programs. in community-based unique youth were served 33,926 In FY 2015, charges. Finally, youth who are adjudicated and placed on probation may be be may on probation and placed are adjudicated who youth Finally, charges. such as programs, community-based or residential in either to participate required on deferred juveniles 39% of Approximately use treatment. or substance counseling need a mental health having identified as supervision were or probation prosecution in FY 2013. from 44% a decrease in FY 2015, Figure 143 indicates the number of youth discharged from detention and supervision and supervision the number of youth discharged indicates from detention Figure 143 health such as behavioral to community services, who were linked in FY 2015 through TCOOMMI or CRCGs. treatment, care management, and support services, release into the community; youth’s coincide with a always Discharge does not and/or supervision, custody, discharge the ending of all TJJD refers to instead, released into the community but been have on parole, for example, Youth services. under correctional control remain because they must discharged from TJJD not their parole disposition. until they complete including Services, to Community and Linked Discharged Youth 143. Figure 2015 in FY Services and Support Management, Care Treatment, Health Behavioral About 39% of those youth (or approximately 13,200 individuals) had an identified 13,200 39% of those youth (or approximately About programs in 32,504 community-based mental health need; these youth participated throughout FY 2015. TJJD 354 and intervention programsfinishedtheirprogram’s requirementssuccessfully. departments focusedonthreetypesofinterventions: participation inprevention andintervention programsinFY2015. Figure 145 shows thenumberofyouthwhobegan,finished,orsuccessfully completed chances ofbecominginvolved inthejuvenile andadultjustice systems inthefuture. Service providers predictthat participationinsuchprogramscanreduceeachyouth’s investment of$1.4 millionfor24 prevention andearlyintervention programs. supervision servicesbutwhoareathighriskforreferraltothe justice system. 6to17whoarenotprograms aredesignedtoserve youthages currentlyreceiving In FY2015, 3,355 youth received prevention andintervention services. · intervention services, and23departmentswereawarded funding. In FY2015, almost $3.1 millionwas appropriatedforprevention andearly or referraltothejuvenile justice system.” to stop “at-riskbehaviors that canleadtodelinquency, truancy, schooldropout, In 2011, the82ndTexas Legislaturefundedprevention andintervention programs Prevention andIntervention Programs to localjuvenile probationdepartments. describes avariety ofprogramswithbehavioral healthcomponentsthatareavailable facilities andinstead serve themintheirlocalcommunities. Thefollowing section initiatives andgrants. Theprogramsaimtokeep youthoutofstate-operated secure TJJD fundsprogramsinlocaljuvenile probationdepartmentsthroughdiverse DEPARTMENTS WITH BEHAVIORAL HEALTH SERVICE COMPONENTS STATE-FUNDED PROGRAMS AVAILABLE TO LOCAL JUVENILE PROBATION andtheSpecialNeedsDiversionary Program. management, counseling, anger goals andcurricula.Theseprogramsmayor interventions include withspecific substance usetreatmentprogramslisted inFigure144, areplannedactivities an assessment,orpsychological testing. “Programs,” suchasthecounselingand designed tomeet ajuvenile’s immediateneed,suchasamedicalappointment, Definitional Note: “Behavioral healthservices”aretypicallyone-timeevents Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · were eitherHispanicorAfricanAmerican. oftheparticipantswas 11yearsold,andaboutthree-quarters oftheyouthserved age

environments. by ensuring that at-risk students intheireducational remain actively engaged Collaborations with local elementary theirchild’smanage behaviors; and Programs for parents and guardiansof school and during the summer; assistance, Partnerships with out-of-schoolservice providers who can provide educational skills building, character development, and mentoringservicesafter , middle, and high schools to prevent truancy , middle, and highschoolstoprevent truancy at-risk youth to helpcaregivers better 145 151 In2015, 91%ofyouthexitingprevention In2012, TJJD approved theinitial 149 148 The 150 The average Theaverage 152 147 146

The TJJD 355 These 156 154 http://www.tjjd.texas.gov/ 158 The agencies created a 153 Number ofYouth 2,221 2,185 1,999 91% Annual Report to the Governor and Legislative Budget Board: Board: Budget Legislative and Governor the to Annual Report To manage information about these programs, TJJD created TJJD manage information about these programs, To 155 Almost half (47%) of all youth on deferred prosecution or under Almost 157 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Participation Status Participation Youth Beginning a Program a Beginning Youth Program a Exiting Youth Program a Completing Youth - Com Successfully Who Program a Exiting Youth of Percent Program that pleted probation supervision participated in at least one community-based program in one community-based probation supervision participated in at least and 27% participated in three or more programs. 2015, Community-based programs are not dispersed evenly across the state’s 166 across the state’s dispersed evenly programs are not Community-based programs of community-based The availability probation departments. juvenile of youth in a particular depends upon local county resources and the unique needs its online Program and Services Registry in 2010. The registry catalogues all active all active catalogues registry The in 2010. its online Program and Services Registry departments probation juvenile by various programs offered community-based probation departments and contracted agencies juvenile must Both across the state. including programs, of active information regarding the service components provide visit access the registry, To their duration, funding, and eligibility requirements. . https://www.tjjd.texas.gov/programregistryexternal/members/searchprograms.aspx community- active probation departments offered 2,245 local juvenile 2016, In May youth, and their families. based programs to at-risk youth, justice-involved Community-Based Programs and Services Programs Community-Based probation departments continue to programs within juvenile Community-based each fiscal year. grow The 2015-2016 General Appropriations Act required TJJD to partner with the General Appropriations Act required TJJD The 2015-2016 Education Services (DFPS), the Texas and Protective Department of Family Texas of juvenile in the provision Military Department Agency and the Texas (TEA), programs. delinquency and intervention prevention Source: Texas Juvenile Justice Department. (2015, December). December). (2015, Department. Justice Juvenile Texas Source: publications/reports/AnnualReportFundingandRiders2015.pdf Figure 145. Youth Beginning and Exiting Prevention and Intervention Intervention and Prevention Exiting and Beginning Youth 145. Figure 2015 in FY Programs from Retrieved 19. Programs. Diversion Special and Riders Appropriations, Justice Juvenile Community programs involved a wide array of services, including counseling services, gang including counseling services, of services, a wide array programs involved training. In FY 2015, and employment parenting classes, programs, intervention program, 48% were 29% of youth participants were enrolled in a treatment-based enrolled in a skills-building program, and 23% were enrolled in a surveillance- based program. workgroup to minimize redundancy and optimize services for at-risk Texas youth. services for at-risk Texas to minimize redundancy and optimize workgroup they will how that the agencies determine the Legislature requested In particular, the services following manage and intervention prevention the consolidation of on the HHSC more information see Transformation, HHSC (For Transformation. submit a must the workgroup 2016, September the HHSC By of this guide). chapter the By October of each fiscal year, Texas Legislature. to the strategic plan five-year data to the LBB. also submit utilization and effectiveness agencies must TJJD 356 declined toparticipatein2015. All probationdepartmentsareeligibleforthegrant program, but11departments in partby theCommunity Corrections Diversion Program. In FY2015, 6,528 juveniles received aprogram,placement,orservicefundedatleast facilities. community-based rehabilitative servicesanddivert youthaway fromTJJD state provides fundstolocal juvenile probationdepartmentsinordertodevelop appropriationsbill.Throughthisprogram,the C) throughRider21inthegeneral In 2009, the81st LegislaturecreatedtheCommitmentDiversion Program(Grant Community CorrectionsDiversion Program(GrantC) Juvenile Probation Programs. 4. Retrieved from Source: Texas Juvenile Justice Department. (2013, June). Community-Based Program Community-Based Evaluation Series:Overviewof Figure 146. Average Stay ExpectedLengthin of Various Community Programs behavioral healthcomponents. Figure 146 lists theaverage durationofserviceforcommunity-based programswith last oneafternoonwhileothers canlast theentirety ofajuvenile’s supervision. The durationofcommunity-based programsalsovarieswidely. Someprograms community. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas evaluations for juveniles withinlocalprobation departments. N) inordertoexpandtheavailability ofmentalhealth screenings, assessments, and In 2014, TJJD beganallocating fundsfortheMental Health ServicesGrant (Grant Mental Health Grant(GrantN) Services juveniles, not onlythosewithmorespecificbehavioral healthneeds. counseling andeducationalprogramsdesignedtoserve theneedsofawidearray of counties.are typicallyavailable inlarger Instead, smallerdepartmentsprovided not offertargeted programs, suchasmentalhealthcourtsorrunaway programs, that departments offeredan offiveaverage programsperdepartment,buttheyoftendid departments offeredan of11and18programs,average respectively. completed theirsupervision successfully. the supervisiondispositionassociatedwithaGrant Cprogram,andofthose,78% on deferredprosecutionarealsoeligibleforservices. Intotal, 3,533 juveniles exited juveniles served by GrantCfundswereunderprobationsupervision,though youth to keep youthoutofstate-operated facilitieswhilemaintainingpublicsafety. programs, lifeskillscourses, andelectronicmonitoring–allofwhicharedesigned programs, withanaverage of42perdepartment. Substance Abuse TreatmentSubstance Mental Health Programming Mental Health Court Behavioral TherapyCognitive Counseling Program Type 163 The funds support a range ofservices, Thefundssupportarange suchascounseling,educational 159 In2013, thetenurbanjuvenile probationdepartments hadthemost http://www.tjjd.texas.gov/statistics/CommunityBasedJuvenileProbationPrograms.pdf 165 167 109 161 170 70 109 Days in Program 160 Mediumprobation andlarge 168 166 Juvenile probation Themajority(72%)of 161 162 Small 164

TJJD 357 175 FEDI links youth 178 Funding was provided provided was Funding 171 Tier II funding may be used Tier II funding may Diverting youth with mental Diverting tive 174 176 170 a niti I and contracted service providers; and contracted a diagnosed mental illness; and/or a diagnosed mental and services. For about three to six months, SJPOs meet meet SJPOs about three to six months, For 179 iversion , assessments, and evaluations to identify youth with identify youth with evaluations to and , assessments, D nd This section will describe several of those programs in the order of those programs in the order This section will describe several E 177 Departments without a pre- or post-adjudication facility can also Departments without a pre- or post-adjudication Instead, the Mental Health Services Grant must be used to fund: be used must Grant Services Health Mental the Instead, A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 173 Tier I funding may be used to establish new mental health services new to establish be used Tier I funding may 169 172

180 e Front- Community mental health programs mental Community Mental health screenings Mental health services; mental Residential professionals for mental health Salaries treating associated with Medications mental illness; mental

health conditions from incarceration and further involvement in the juvenile justice justice in the juvenile and further involvement health conditions from incarceration Texas operates a number of has significant health and economic benefits. system as possible” in as shallow to help youth “stay around the state initiatives diversion system. the justice Th diversion justice front-end juvenile targeted the MacArthur Foundation In 2008, among the original eight was for Change Texas grant initiative. through its Models grant funding. In partnership with local probation departments, that received states youth away (FEDI) to divert Initiative Diversion the Front-End developed TJJD before they are formally adjudicated. system from the justice Diversion Programs for Youth with Youth for Programs Diversion Conditions Health Behavioral is to forward that its top goal moving stated TJJD plan, strategic In its 2017-2021 system. immersion in the justice minimize juveniles’ TJJD allocated $12.8 million in both FY 2016 and FY 2017 to fund mental health and FY 2017 FY 2016 allocated $12.8 million in both TJJD probation departments. juvenile local by services provided departments cannot use Grant N funds to cover administrative expenses or to supplant expenses administrative to cover N funds Grant use cannot departments funding. local receive Tier I funding to secure mental health services. Tier I funding to secure mental health receive on a per-referral basis. Higher rates of funding are provided to smaller probation of funding are provided Higher rates basis. on a per-referral departments Probation facilities. operate pre- or post-adjudication departments that Tier I fundingthat manage receive or fewer may one or more facilities with 80 beds departments that managefor one full-time mental health professional; facilities two full-time mental health Tier I funds for receive with more than 80 beds may professionals. in two tiers. · · · · · with mental health needs to specialized juvenile probation officers (SJPO) who probation officers with mental health needs to specialized juvenile family engagement, de-escalation, training on mental illness, comprehensive receive and problem-solving techniques. in which juveniles experience the justice system. experience the justice in which juveniles with enrolled juveniles and their families on a weekly basis to fulfill each youth’s their families on a weekly basis to fulfill each youth’s and with enrolled juveniles After this to community resources. plan and connect juveniles crisis stabilization create an aftercare plan and their SJPOs their families, supervision period, juveniles, use once they formally exit that youth may that outlines ongoing support systems FEDI. to fund and/or expand existing services for youth with mental health conditions. expand existing to fund and/or TJJD 358 Institute ofJustice designatedFEDIasa“PromisingProgram” Supervision Who Accessed Community Services Figure 147. Percentage of Youth intheFEDIProgram andUnder Traditional · recruited toreplicateFEDIinMaryland.SomeofFEDI’s successesinclude: with pre-adjudicatedyouth,andin2016, FEDIprogramresearchersinTexas were teams effectively address criminogenic risk factors,teams effectively addresscriminogenic suchas family poverty. in psychiatric hospitals anddetention facilitiesbecausetreatment-orientedcourt found thatmentalhealthcourtsinTexas areaneffective alternative toplacement arrests andre-convictions thantheirpeerswithsimilarcriminalhistories. health courtsexperience improved psychiatric outcomes andsignificantlyfewerre- researchers alsodemonstrated thatindividualswhoparticipateinjuvenile mental Dallas, Harris, ElPaso, andTravis counties. In April2016, Texas operatedspecializedmentalhealthcourtsforyouthinBexar, supervision tolinkyouthtreatmentservicesin the community. types ofcourtsutilizeindividualtreatmentplans, andjudicial casemanagement, used specialtycourtsforjuveniles arementalhealthcourtsanddrugcourts. Both diversion servicesforyouthwithbehavioral healthconditions. Themost frequently continuumof inappropriate. Specialtycourtsoftenoperateasonepiece ofalarger treatment butforwhomcommitmenttoasecurefacility may beclinically involvement. Thecourts serve individualswhocouldbenefitfromsupervised Specialty courtsaimtoaddresstheunderlyingcausesofjuvenile justice S Diversion Initiative. 6. Retrieved from Source: National Center for Mental Health and Juvenile Justice. (2015, April). · · Antonio. In 2008, FEDIwas launchedinfourTexas counties:Austin, Dallas, Lubbock,andSan Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Although the courtsproducepositive outcomes, recentdataalsoshow racialand

Other Community Resources Family Counseling Individual Therapy Service Type peci youth receiving traditional supervision services. the use of community services among youth enrolled in the FEDIprogramand adjudicated than their peers receiving traditional supervision services. Within 90 days ofsupervision, services than other justice-involved youth. than traditionalprobation officers do, leadingparticipantsto usemorecommunity in FEDI officers engage turnov Four FEDIsites (Austin, Dallas, Lubbock, and SanAntonio)reporta0%percent 35% turnover rateover fouryears. 181 a er rate among SJPOs, while most juvenile probation departments reporta Theprogramwas laterexpanded toincludeHouston. In2014, theNational lty Juvenile http://cfc.ncmhjj.com/wp-content/uploads/2015/04/FEDI-508.pdf over 10timesmore collateral contacts in thecommunity 69.2% 35.4% Youth Under Traditional Supervision 82% Youth in the FEDI Program C FEDI participants are 11 timeslesslikely tobe ourts 184 186 185 A2011 evaluationofspecialtycourts Figure147 shows thedifferencein Diverting Youth at Probation Intake: The Front-End 20.3% 4.7% 9.4% 182 for its successes foritssuccesses

183 188 187 In2015, TJJD 359

199 192 Each 191 190 In April m 195 a rogr P Further, the authors’ the authors’ Further, 189 ry a 196 and family therapy; and family 200 Every three to six weeks, juveniles also juveniles three to six weeks, Every 193 iversion D 194 Once enrolled in SNDP, juveniles and their families have and their families have juveniles Once enrolled in SNDP, The agencies used this funding to establish the Special The agencies used this funding to establish education services. 198 197 eeds such as life skills training, angersuch as life skills management,mentoring; and N l a A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation peci S e Mental health services, such as individual health services, Mental services, Probation support and Parental and

· In 2015, 20 local juvenile probation departments utilized SNDP services. Specialized probation departments utilized SNDP services. 20 local juvenile In 2015, from LMHAs to probation officers partnered with mental health professionals including: services, diverse provide · · attend family meetings during which the COPE team can monitor each juvenile’s during which the COPE team can monitor each juvenile’s family meetings attend Enrollment perspective. a strengths-based progress and address problems using are released from the program about six to 12 months before juveniles typically lasts and their charges are dismissed. multi-disciplinary COPE team consists of a court judge, a legal representative COPE team consists multi-disciplinary a casework three probation officers, attorney, district assistant for the youth, the with expertise in child mental health. and mental health professionals manager, 24/7 access to at least one SNDP core team member for crisis resolution services. at least access to 24/7 Th appropriated specialized funding to Texas Legislature the 77th Texas In 2001, and TCOOMMI in order Probation Commission (since changed to TJJD) Juvenile youth to Texas supervision and intensive mental health treatment to provide crimes. who committed Juvenile drug courts use a similar model of diversion. Juveniles who have been who have Juveniles drug courts use a similar model of diversion. Juvenile charged of judicial supervision and a combination crimes receive with drug-related with the justice treatment management future involvement in order to prevent nationwide. drug courts 400 juvenile there were over In 2015, system. Collaborative Opportunities for Positive Experiences (COPE) is a Travis County is a Travis Experiences (COPE) Opportunities for Positive Collaborative Assistance. of Justice funded through the Bureau court project initially juvenile or brain youth with mental illness Texas to divert program in the first COPE was before adjudication. prosecution and system the justice from injuries away gender strategy. this diversion to in access disparities To participate in COPE, juveniles must be eligible for deferred adjudication and be eligible for deferred adjudication must in COPE, juveniles participate To youth must in the program. Enrolled commit to involvement their families must probation supervision, engagecooperate under intensive in therapeutic mental individualized program requirements in meet health treatment, and successfully their charges dismissed. order to have 2016, 24 of those courts were located in Texas. of those courts were located 24 2016, attempts to gather data on the number of youth who are served within these within served who are of youth number on the data to gather attempts from benefit potentially those who could compared to programs resource-intensive analysis among collection and data for improved the need demonstrate such services number of data on the centralized 2016, As of July specialty court programs. existing exist. not outcomes did and their overall in specialty courts youth served Needs Diversionary Program (SNDP), which seeks to rehabilitate and prevent Program (SNDP), which seeks to rehabilitate and prevent Needs Diversionary among youth with diagnosed mental health conditions involvement future justice autism, and pervasive intellectual disabilities, use conditions, substance (excluding disorder). development TJJD 360 disorder, andbipolardisorder. SNDP participantsareattention deficit hyperactivity disorder, oppositionaldefiant publications/reports/AnnualReportFundingandRiders2015.pdf Community Juvenile Justice Appropriations, Riders and Special Diversion Programs. 18. Retrieved from Source: Texas Juvenile Justice Department. (2015, December). Annual Report to the Governor and Legislative Budget Board: new ClassBmisdemeanoroffenseoranofgreater severity withinoneyear. program effectiveness. Oftheyouth starting SNDPin FY2014, 58%committed a Referrals tosecurestate facilitiesandre-offenseratesareusedasmeasuresof the programserved 1,309juveniles. In FY2015, theTexas Legislatureappropriatedabout$2million toSNDP, and Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas placement facility. in theirhistory, andninepercentwerepreviouslyspenttimeinaresidential had atleast threepreviousjuvenile probationreferrals, 52%hadafelony offense in FY 2015 Figure 148. JuvenilesEntering, Exiting, andSuccessfullyCompleting theSNDP exited, andsuccessfullycompleted SNDPinFY2014 andFY2015. facility withinoneyear. Further, about2%ofyouthwhobeganSNDPin2014 werecommitted toaTJJD Percent Completing Program Successfully Juveniles Completing SNDP Successfully Juveniles Ending SNDP Juveniles Beginning SNDP Program Status 202 Traditionally, threeofthemost commondiagnosesamong 206 Figure148 shows thenumberofjuveniles whoentered, 203,204 201 Ofthoseserved inFY2015, 37% ofyouth 64% 552 864 853 Youthof Number http://www.tjjd.texas.gov/ 205

TJJD 361 . (2016, April). Data request: April). Data request: . (2016, 7. Retrieved from http://www.texaspolicy.com/ Retrieved 7. Trends in Juvenile Justice State Legislation 2011- in Juvenile Trends , September). uvenile Justice & the Technical Assistance Collaborative. (2015). (2015). Collaborative. Assistance & the Technical Justice uvenile (2015). Collaborative. Assistance & the Technical Justice uvenile uvenile Justice & the Technical Assistance Collaborative. (2015). (2015). Collaborative. Assistance the Technical & Justice uvenile ustice Center and the Public Policy Research Institute. (2015, January). January). (2015, Research Institute. Center and the Public Policy ustice . Pg. 73. Retrieved from Retrieved 73. Data. Pg. Arrest Texas Report: in Texas 2014 Crime . (2015). ., Schmeidler, J., Briones-Robinson, R., Winters, K.C. (2014, August). Differential Effects August). (2014, K.C. Briones-Robinson, R., Winters, J., ., Schmeidler, right, C.P., Delisi, M., and Perron, B. (2014). Correlates of Traumatic Brain Injury Among Correlates of Traumatic (2014). B. Delisi, M., and Perron, right, C.P., ustice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Justice Prevention. Juvenile of Office Programs, Justice Office of ustice, . Pg. 4. . Pg. Evaluation Initiative of Care a Culture Creating September). (2015, outh Services. from . Retrieved Centers Probation Juvenile County Bexar Visits TNOYS (2014). outh Services. 25. . Pg. Evaluation Initiative of Care a Culture Creating September). (2015, outh Services. Pg. 2. Retrieved from https:// 2. Retrieved Pg. Sheet 2015: HB 2684. Fact tice Coalition. (2015). A Critical Look at Juvenile Offenders with Mental Illnesses: Illnesses: with Mental Offenders A Critical Look at Juvenile January). (2012, y Foundation. Monthly Tracking of Juvenile Correctional Population Indicators (June Indicators Population Correctional of Juvenile Monthly Tracking June). t Board. (2016, . 2. Re- In RE: HB 1205 Regular Session, Legislature Note, 84th April 1). Fiscal t Board. (2015, A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 14). Tracking the School-to-Prison Pipeline from Zero-Tolerance Polices to Juvenile Justice Justice to Juvenile Polices from Zero-Tolerance Tracking the School-to-Prison Pipeline 14). enile Justice Department. (2016, March 4). Personal communication: Identifying youth with brain Identifying communication: March 4). Personal Department. (2016, enile Justice Annual Report to the Governor and Legislative Budget and Legislative December). Annual Report to the Governor Department. (2015, enile Justice http://www.tjjd.texas. from List . Retrieved Address Facilities Department. (n.d.). TJJD enile Justice Annual Report to the Governor and Legislative Budget Budget and Legislative Annual Report to the Governor December). Department. (2015, enile Justice Retrieved from Retrieved (CY2015). in Texas Facilities Juvenile Department. (n.d.). Registered enile Justice , A., Corrigan, J., Horwood, L.J., and Fergusson, D.M. (2014). Substance Abuse and Criminal Activities Abuse Substance (2014). D.M. and Fergusson, L.J., Horwood, , A., Corrigan, J., Ibid, pg. 72. (20 A.J. Curtis, 102, pg. 1256. Law Journal, Georgetown Dispositions. J R., Wareham, Dembo, 20. . Pg. Health Services and Research of Behavioral Journal Problems Among Truant Youths. Health of Mental Criminal Jus Texas Identifying youth with brain injuries. Identifying of Y Network Texas J The Council of State Governments 2. Retrieved Justice Reforms Juvenile . Pg. of the State and Local Impact of the Texas Closer to Home: An Analysis from https://csgjusticecenter.org/wp-content/uploads/2015/01/texas-JJ-reform-closer-to-home.pdf Ibid, pg. 30. Ibid, pg. 53. Ibid. Ibid. Juv Texas injuries. of Y Network Texas from http://tnoys.org/wp-content/uploads/CCC-Evaluation-Report-FINAL.pdf Retrieved of Y Network Texas http://tnoys.org/tnoys-visits-bexar-county-juvenile-probation-centers/ from http://tnoys.org/wp-content/uploads/CCC-Evaluation-Report-FINAL.pdf Retrieved . Pg. 2. Retrieved from http:// 2. Retrieved . Pg. in Detained Youth Disorders Psychiatric and Comorbid Trauma, PTSD, June). (2013, www.ojjdp.gov/pubs/239603.pdf M.G., Salas-W Vaughn, McKinlay Brain Injury in Childhood, Adolescence, Traumatic and Early Adulthood. of Head Trauma Journal Following pg. 498. Rehabilitation, 29(6), Commission, Office of and Human Services Health Acquired Brain Injury National Center for Mental Health and J Health National Center for Mental Department of J U.S. Criminal Behaviour and Mental Health, 24, pg. 189. Offenders: A Multi-SiteJuvenile Study. center/effective-justice/reports/critical-look-juvenile-offenders-mental-illnesses Program Diversion Justice Juvenile a Trauma-Informed Elements to Developing Key Our Future: Strengthening from http://www.ncmhjj.com/wp-content/up- 1. Retrieved . Pg. Health Conditions with Behavioral for Youth loads/2016/01/traumadoc012216-reduced-003.pdf (2015 National Conference of State Legislatures. from http://www.ncsl.org/documents/cj/Juvenile_Justice_Trends.pdf 11. Retrieved 2015. Pg. Juv Texas 12. Retrieved . Pg. Programs and Special Diversion Riders, Justice Appropriations, Juvenile Community Board: from http://www.tjjd.texas.gov/publications/reports/AnnualReportFundingandRiders2015.pdf Program Diversion Justice Juvenile a Trauma-Informed Elements to Developing Key Our Future: Strengthening from http://www.ncmhjj.com/wp-content/up- 1. Retrieved . Pg. Health Conditions with Behavioral for Youth loads/2016/01/traumadoc012216-reduced-003.pdf Texas Public Polic Texas Juv Texas gov/programs/facilities_list.aspx and J Health National Center for Mental Legislative BudgeLegislative Juv Texas Ibid. Juv Texas from Retrieved 7. Pg. Programs. and Special Diversion Riders Appropriations, Justice Juvenile Community Board: http://www.tjjd.texas.gov/publications/reports/AnnualReportFundingandRiders2015.pdf . Pg. Here Go from We Don’t, and Where We What Know, What We Texas Department of Public Safety Department Texas BudgeLegislative http://www.tjjd.texas.gov/publications/other/searchfacilityregistry.aspx National Center for Mental Health and J Health Mental Center for National Program Justice Diversion Juvenile a Trauma-Informed Developing Elements to Key Our Future: Strengthening from http://www.ncmhjj.com/wp-content/up- 1. Retrieved . Pg. Health Conditions with Behavioral for Youth loads/2016/01/traumadoc012216-reduced-003.pdf http://dps.texas.gov/crimereports/14/citCh9.pdf http://www.lbb.state.tx.us/Documents/Publications/Info_Graphic/812_Month- from Retrieved 3. 2016). Pg. ly_Report_June_2016.pdf http://www.capitol.state.tx.us/tlodocs/84R/fiscalnotes/pdf/HB01205I.pdf from trieved

28 29 30 18 25 26 27 19 20 21 22 23 24 15 17 16 9 11 12 13 14 10 7 8 6 Endnotes 1 2 3 4 5 TJJD 362 56 55 54 53 51 50 43 42 41 40 39 38 37 36 35 34 33 32 31 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 63 62 61 60 59 58 57 52 49 48 47 46 45 44

Legislative Budge Texas Juv Texas Juv Texas Juv Texas Juv Ibid. Ibid. Ibid. Focused Cognitive Beha University ofTexas CenterforSocialW Texas Juv pdf#page=1&view=Introduction bySexual AbuseorTrauma.Affected Pg. 2.Retrieved fromhttps://www.childwelfare.gov/pubPDFs/trauma. Child Welfare InformationGatewa Focused Cognitive Behavioral Treatment Pilot. University ofTexas CenterforSocialW Texas Juv Texas Juv Texas Juv Texas Juv Texas Juv Texas Juv from http://www.texastribune.org/2014/05/15/lawmakers-working-repurpose-corsicana-juvenile-fac/ Langford, T. (201 Retrieved from http://www.texastribune.org/2014/02/12/corsicana-closure-lessons-juvenile-lock-/ Chammah, M.(2014, F DeitchUnderstandingandAddressingYouthViolenceinTJJDMay%202013FINAL.pdf School ofPublicAffairs. PG.23. Retrieved fromhttp://www.utexas.edu/lbj/sites/default/files/file/faculty/ Violence intheTexas Juvenile JusticeDepartment.Austin, TX:TheUniversity ofTexas atAustin, LBJ Deitch, M.,Madore,A.,Vickery, K.,andW Retrieved fromhttps://www.tjjd.texas.gov/Docs/TreatmentEffectivenessReview_2011.pdf Texas Juv us1012ForUpload.pdf in SolitaryConfinement in Jails andPrisons.Pg. 24. https://www.hrw.org/sites/default/files/reports/ Human RightsWatch andTheAmericanCivilLibertiesUnion.(2012). prearesourcecenter.org/faq/youthful-inmates National PREAResourceCenter. (2013 Report. Pg. 18. https://www.ncjrs.gov/pdffiles1/226680.pdf National PrisonRapeEliminationCommission.(2009, June). Regionalization/meetings/2015/RTF-MeetingHandouts-Nov1819.pdf Force Handoutsfrom November 18and19, 2015.Pg. 1.Retrieved fromhttps://www.tjjd.texas.gov/Docs/ Texas Juv https://www.tjjd.texas.gov/aboutus/regionalization.aspx. Texas Juv Ibid, pg.53-60. https://csgjusticecenter.org/wp-content/uploads/2015/01/texas-JJ-reform-closer-to-home.pdf Closer toHome:AnAnalysis oftheStateandLocalImpactTexas. Retrieved Juvenile from JusticeReforms The CouncilofStateGovernments J texasappleseed.org/sites/default/files/HB%202684%20Explanation%20FINAL.pdf Texas Appleseed.(2015). publicpolicycenter.texascjc.org/download/fact-sheet-hb-2684-school-law-enforcement-training www.tjjd.texas.gov/about/operating_budget.pdf Governor’s OfficeofBudget,Planning and PolicyandtheLegislative BudgetBoard. Pg. 1.Retrieved from https:// Texas Juv Ibid. Retrieved onJune 21,2016 fromhttp://www.capitol.state.tx.us/tlodocs/84R/fiscalnotes/pdf/HB01205I.pdf Legislative Budge Report_June_2016.pdf 2016). Pg. 3. Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Info_Graphic/812_Monthly_ http://www.tjjd.texas.gov/about/overview.aspx http://www.tjjd.texas.gov/about/overview.aspx gov/programs/facilities_list.aspx agency_mission.aspx Behavioral TreatmentPilot Retrieved from https://www.tjjd.texas.gov/Docs/TreatmentEffectivenessReview_2015.pdf http://www.tjjd.texas.gov/about/glossary.aspx Treatment Center. enile Justice Department.(2011, December).AnnualReviewofTreatment Pg. Effectiveness. 14. enile Justice DepartmentRegionalizationTask Force. (2015, November). Regionalization Task enile Justice Department.(n.d.).TJJD Regionalization Task Force. Retrieved onJuly 29, 2016 from enile Justice Department.(2015, December1).Operating BudgetFiscal Year 2016Submitted tothe enile Justice Department.(n.d.).Overview oftheJuvenile JusticeSystem inTexas . Retrieved from enile Justice Department.(n.d.).Overview oftheJuvenile JusticeSystem inTexas . Retrieved from enile Justice Department.(n.d.).TJJD Facilities Address List.Retrieved fromhttp://www.tjjd.texas. enile Justice Department.(n.d.).AboutTJJD. Retrieved fromhttp://www.tjjd.texas.gov/aboutus/ enile Justice Department.(2016, March4).Personal communication:Trauma-Focused Cognitive enile Justice Department.(2016, March31).Personal communication:TurmanandBeto Houses. enile Justice Department.(2016, July 19). Datarequest: Halfway houseaverage dailypopulations. enile Justice Department.(2015, December).TheAnnualReviewofTreatment. Pg. Effectiveness 18. enile Justicefor Department.(n.d.).Definitions Common TJJD Terms &Acronyms . Retrieved from enile Justice Department.(2016, March31).Personal communication:TurmanandBeto Houses. enile Justice Department.(2016, March4).Personal communication:CorsicanaResidential 4, May 15).Vacant Juvenile Facility Costing $100,000 Monthly . TheTexas Retrieved Tribune. t Board.(2015, April1).Fiscal Note,84th Legislature RegularSession, InRE:HB1205.Pg. 2. t Board.(2016, June). MonthlyTracking ofJuvenile Correctional Population Indicators (June ebruary 12).ClosingCorsicana:LessonsfromaJuvenile Lock-Up. TheTexas Tribune. vioral TreatmentPilot. HB 2684: Training Police inTexas for Public Schools. Pg. 1.Retrieved fromhttps://www. y. (2012). Trauma-Focused Cognitive Behavioral Therapy Children for ustice CenterandthePublicPolicy ResearchInstitute. (2015, January). , February). Youthful. Retrieved Inmates fromhttp://www. ork Research.(2016, March28).Personal communication:Trauma- ork Research.(2016, March28).Personal communication:Trauma- elch, A.(2013, May). Understanding andAddressing Youth . National PrisonRapeEliminationCommission Growing UpLocked Down: Youth

TJJD 363 Legislature, Regular Session Session Regular Legislature, rd Texas Model: A Framework for from Equity. Retrieved Model: A Framework Texas . Pg. 1. March). Data Snapshot: School Discipline. Pg. . (2014, 16, April 26). Personal communication: Statewide Advisory communication: April 26). Personal 16, 83 Senate Bill 1, Rider 87, 14). enile Justice Department. (n.d.). Independent Ombudsman. enile Justice Responding to Youth with Mental Health Needs: A CIT for Youth Health Needs: A CIT for with Mental Youth Responding to Youth 11, July). Health Needs: A CIT for with Mental Youth Responding to Youth 11, July). ustice Center and the Public Policy Research Institute. (2015, January). January). (2015, Research Institute. Center and the Public Policy ustice ustice Center and the Public Policy Research Institute. (2011, July). July). (2011, Research Institute. Center and the Public Policy ustice ustice Center and the Public Policy Research Institute. (2015, January). January). (2015, Research Institute. Center and the Public Policy ustice . Pg. 73. http://dps. 73. Data. Pg. Arrest Texas Report: in Texas 2014 Crime . (2015). . Pg. 7. 7. . Pg. Justice System in the Juvenile Minority Contact y). Disproportionate The Center for Elimination of 1). The Center June (2015, y Research & Analysis. olice Decision-Making in the Gray Zone: The Dynamics of Police-Citizen Encounters Encounters of Police-Citizen Zone: The Dynamics in the Gray olice Decision-Making . Pg. 1. Retrieved Retrieved 1. . Pg. Justice System in the Juvenile for Youth Title IV-E , August). . Pg. 2. . Pg. Reform in Texas Corrections Juvenile Bending the Curve: . (2013). . Austin, TX: The University of Texas at of Texas TX: The University . Austin, in Texas eniles in the Adult Criminal Justice System A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation e daily population in state-operated secure facilities was 4,815 in FY 2007, while the average daily while the average 4,815 in FY 2007, secure facilities was e daily population in state-operated . Retrieved from http://www.tjjd. . Retrieved TJJD Through Offenders Move Department. (n.d.). How enile Justice 2015. Retrieved Year Fiscal by Type: Reviews March 23). Review Panel Department. (2016, enile Justice Annual Report to the Governor and Legislative Budget and Legislative to the Governor December). Annual Report (2015, Department. enile Justice . Pg. 3. Retrieved from http:// from Retrieved 3. . Pg. 2017-2021 Years Fiscal Plan Strategic Health Behavioral Statewide Texas Coalition for Addressing Disproportionality and Disparities. Texas Health and Human Services Commission. (20 Health Texas and Human Services Commission. (20 Health Texas . Pg. 33. Retrieved Retrieved 33. Justice Reforms Juvenile . Pg. of the State and Local Impact of the Texas Closer to Home: An Analysis from https://csgjusticecenter.org/wp-content/uploads/2015/01/texas-JJ-reform-closer-to-home.pdf and Human Services Commission. (n.d.). Health Texas https://www.hhsc.state.tx.us/hhsc_projects/cedd/texas-model.shtml for Urban Polic The Institute from https://www.utexas.edu/cola/iupra/_files/pdf/ Retrieved 6. and Disparities. Pg. Disproportionality CEDD%20Final%203-June%201%202015.pdf U.S. Department of Education, Office for Civil Rights U.S. J The Council of State Governments 61. Ibid, Pg. J The Council of State Governments Texas Juv Texas Ibid. Ma The Sentencing Project. (2014, from http://sentencingproject.org/doc/publications/jj_Disproportionate%20Minority%20Contact. Retrieved pdf Ibid, 1-2. from http://www2.ed.gov/about/offices/list/ocr/docs/crdc-discipline-snapshot.pdf Retrieved and Juvenile School Discipline Relates to Students’ Success Schools’ Rules: A Statewide Study of How Breaking from https://csgjusticecenter.org/wp-content/uploads/2012/08/ Retrieved 45. . Pg. Justice Involvement Breaking_Schools_Rules_Report_Final.pdf. Deitch, M. (2011). Juv Deitch, M. (2011). Ibid, 12. Juv Texas texas.gov/about/how_movethru.aspx from http://www.tjjd.texas.gov/research/RRPSummaryReportFY15.pdf The averag The Council of State Governments J The Council of State Governments Ibid, pg. 12. Charitable Trusts Pew from http://www.pewtrusts.org/~/media/legacy/uploadedfiles/pcs_assets/2013/ Retrieved psppbendingthecurvejuvenilecorrectionsreformintexaspdf.pdf the 2007 data, see The Council of State For 1,150 in FY 2015. secure facilities was population in state-operated Closer to Home: An January). (2015, Research Institute. Center and the Public Policy Justice Governments https:// from Retrieved 27. Justice Reforms Juvenile . Pg. of the State and Local Impact of the Texas Analysis data, the the 2015 . For csgjusticecenter.org/wp-content/uploads/2015/01/texas-JJ-reform-closer-to-home.pdf Average July 7). Data request: Department. (2016, Justice Juvenile Texas filed a data request. Foundation Hogg . FY 2015 daily population in secure facilities, from https://www.utexas.edu/lbj/sites/default/files/file/ Retrieved Pg. 13. LBJ School of Public Affairs. Austin, news/juvenilestexas--final.pdf texas.gov/crimereports/14/citCh9.pdf Ibid, pg. 73. (20 Illness. National Alliance on Mental fromhttps://www.nami.org/getattachment/Law-Enforcement-and- 41. Retrieved . Pg. Implementation Manual Mental-Health/What-Is-CIT/CIT-for-Youth/Responding-to-Youth-with-Mental-Health-Needs_NAMI.pdf P (2015). Schulenberg, J.L. 43 (4), pg. 459. Criminal Justice and Behavior, Ill Persons. with Mentally (20 Illness. National Alliance on Mental from https://www.nami.org/getattachment/Law-Enforcement-and- Retrieved 40. . Pg. Implementation Manual Mental-Health/What-Is-CIT/CIT-for-Youth/Responding-to-Youth-with-Mental-Health-Needs_NAMI.pdf 12. Retrieved Justice Reforms Juvenile . Pg. of the State and Local Impact of the Texas Closer to Home: An Analysis from https://csgjusticecenter.org/wp-content/uploads/2015/01/texas-JJ-reform-closer-to-home.pdf Youth Law Center (2006 Law Youth Juv Texas Retrieved 15. Pg. Programs. Diversion and Special Riders Justice Appropriations, Juvenile Community Board: from http://www.tjjd.texas.gov/publications/reports/AnnualReportFundingandRiders2015.pdf of Public Safety Department Texas Texas Health and Human Services Commission, Statewide Behavioral Health Coordinating Council. (2016, (2016, Council. Coordinating Health Behavioral Statewide Commission, Human Services and Health Texas May). www.hhsc.state.tx.us/reports/2016/050216-statewide-behavioral-health-strategic-plan.pdf from http://www.njjn.org/uploads/digital-library/resource_425.pdf . Pg. 4. Retrieved from http://www.hhsc.state.tx.us/reports/2015/cedd.pdf 4. Retrieved Report. Pg. Legislative from http://www.tjjd.texas.gov/ombudsman/index.aspx Retrieved Independent Ombudsman for the Texas Juv Independent Ombudsman for the Texas

90 87 88 89 86 81 82 83 84 85 78 79 80 74 75 76 77 68 69 70 71 72 73 67 64 65 66 91 TJJD 364 125 122 118 113 111 110 109 108 107 106 105 104 103 102 101 100 99 98 97 96 95 94 93 92 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 131 130 129 128 127 126 124 123 121 120 119 117 116 115 114 112

Texas Juv Texans CareforChildren. (2016 Texas Juv Ibid. Texas Juv Texas Juv Ibid, pg.26. Texas Juv Texas Juv Texas Juv Publishing Group. Hubner, J. (2008).Las Texas Juv Texas Juv Texas Juv Texas Juv Ibid. Texas Juv Complex assessmentandorientationprocess. Ron Jackson CorrectionalComplex.(2016 Ibid. Complex. Texas Juv Ibid. Ibid. meetings/2015/RTF-MeetingNotes-03Sept15.pdf Meeting Notes,September3,2015.Pg. 5. Retrieved fromhttps://www.tjjd.texas.gov/Docs/Regionalization/ Texas Juv Ibid. Complex assessmentandorientationprocess. Ron Jackson CorrectionalComplex.(2016 from https://www.tjjd.texas.gov/Docs/TreatmentEffectivenessReview_2015.pdf Texas Juv Report_June_2016.pdf 2016). Pg. 1.Retrieved fromhttp://www.lbb.state.tx.us/Documents/Publications/Info_Graphic/812_Monthly_ Legislative Budge gov/aboutus/facilities.aspx Texas Juv Ibid, pg.33. Ibid, pg.3&31. Ibid, pg.18. Ibid, pg.7. Retrieved fromhttps://www.tjjd.texas.gov/Docs/TreatmentEffectivenessReview_2015.pdf Texas Juv Ibid, pg.4. IO_Second_Quarter_2016.pdf December 1,2015toFebruary 29, 2016.Pg. 1.Retrievedhttp://www.tjjd.texas.gov/ombudsman/reports/ from Independent OmbudsmanfortheTexas Juv Ibid. Texas Juv Ibid, 1. Ibid, 1. RTFHandouts.pdf. Protocols. Pg. 1.Retrieved from https://www.tjjd.texas.gov/Docs/Regionalization/meetings/2016/2016_March_ Texas Juv ings/2015/091715/MeetingNotes091715.pdf Task Force MeetingNotes.1.Retrieved fromhttps://www.tjjd.texas.gov/Docs/Regionalization/meet- JSWp2E=&SelectedSortBy=laExhobORj5ZHimppFKN0Q==&IncludeInactive=bZL7qeN3IjY= http://www.tjjd.texas.gov/publications/other/searchfacilityregistryresults.aspx?SelectedFacilityType=o5Mkh- GCMUWM=&SelectedSortBy=laExhobORj5ZHimppFKN0Q==&IncludeInactive=bZL7qeN3IjY= http://www.tjjd.texas.gov/publications/other/searchfacilityregistryresults.aspx?SelectedFacilityType=YKSBb- Retrieved from https://www.tjjd.texas.gov/Docs/TreatmentEffectivenessReview_2015.pdf Retrieved from https://www.tjjd.texas.gov/Docs/TreatmentEffectivenessReview_2015.pdf from https://www.tjjd.texas.gov/Docs/TreatmentEffectivenessReview_2015.pdf programs. Retrieved from https://www.tjjd.texas.gov/policies/gap/380/87/gap3808767.pdf programs/conextions.aspx enile Justice Department.(2016, Datarequest: April7). Juveniles served atRonJackson Correctional enile Justice DepartmentRegionalizationTask Force. (2015). Regionalization Task Force enile Justice Department.(December).TheAnnualReviewofTreatment Pg. Effectiveness. 8. Retrieved enile Justice Department.(n.d.).TJJD Facilities Address List.Retrieved fromhttp://www.tjjd.texas. enile Justice Department.(2015, December).AnnualReviewofTreatment Pg. Effectiveness. 7. enile Justice Department. (2016). 2017-2018 TJJD Strategic Retrieved Plan.Pg. fromhttps:// D-14. enile Justice DepartmentRegionalizationTask Force. (2015). Preliminary Regionalization Funding enile Justice DepartmentRegionalizationTask Force. (2015, September Regionalization 17). enile Justice Department.(n.d.).Registered Juvenile Facilities inTexas (CY2015). Retrieved from enile Justice Department.(2016, May). Datarequest: juveniles inpre-adjudicationfacilities enile Justice Department.(n.d.).Registered Juvenile Facilities inTexas (CY2015). Retrieved from enile Justice Department.(2015, December).TheAnnualReview ofTreatmentEffectiveness. Pg. 29. enile Justice Department.(2016, March31).Personal communication:ViolentOffenderProgram. enile Justice Department.(2015, December).TheAnnualReview ofTreatmentEffectiveness. Pg. 24. enile Justice Department.(2015). TheAnnualReviewofTreatmentEffectiveness. Pg. 19. Retrieved enile Justice Department.(2016, April20).Personal communication:TJJD specializedtreatment enile Justice Department.(2014, December).General Policy Manual:CrisisStabilization Unit . Pg. 1. enile Justice Department.(2016, March4).Personal communication:Crisisstabilization unit. enile Justice Department.(n.d.).WhatisCoNEXTions? Retrieved fromhttp://www.tjjd.texas.gov/ t Board.(2016, June) MonthlyTracking ofJuvenile Correctional Population Indicators (June t ChanceinTexas: TheRedemption ofCriminalYouth. NewYork: RandomHouse , May 10).Personal communication:SB1630reforms. , March30).Personal communication:RonJackson Correctional , March30).Personal communication:RonJackson Correctional enile Justice Department.(2016). SecondQuarterReportFY16: TJJD 365 . Pg. 4. . Pg. Legislature Texas nd 12. Retrieved from http:// from 12. Retrieved . Retrieved from https://www.hhsc. . Retrieved 12). CRCG Overview tective Services, Texas Education Agency, Texas Juvenile Justice Depart- Justice Juvenile Texas Education Agency, Texas Services, tective tective Services, Texas Education Agency, Texas Juvenile Justice Depart- Justice Juvenile Texas Education Agency, Texas Services, tective tee on Corrections. (2010, December). Interim Report to the 82 (2010, tee on Corrections. (June 2016). Indicators Population Correctional of Juvenile Tracking Monthly (2016) t Board. A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation trative Code. §343.404. Retrieved from http://texreg.sos.state.tx.us/public/readtac$ext. Retrieved §343.404. Code. trative . Retrieved from http://jsahealthmd.com/2015/06/19/ from TCOOMMI Activities. Retrieved (2015). elepsychiatry. enile Justice Department. (2016, May). Data request: Active programs within the TJJD Programs and Active programs within the TJJD Data request: May). Department. (2016, enile Justice Com- Budget Board: and Legislative Annual Report to the Governor Department. (2015). enile Justice of Commu- Series: Overview Evaluation Program Community-Based Department. (2013). enile Justice Community-Based Program Evaluation Series: Overview of Commu- Series: Overview Evaluation Program Community-Based Department. (2013). enile Justice Annual Report to the Governor and Legislative Budget Board: Com- Budget Board: and Legislative Annual Report to the Governor Department. (2015). enile Justice enile Justice Department. (2016, March 4). Personal communication: Mental health needs among health needs among communication: Mental Personal March 4). Department. (2016, enile Justice need with identified mental health Juveniles Data request: May). Department. (2016, enile Justice health programs behavioral Community-based Data request: June). Department. (2016, enile Justice Com- Budget Board: and Legislative Annual Report to the Governor Department. (2015). enile Justice . Retrieved from http://www.tjjd. . Retrieved Flowchart Mental Health Screening Department. (2010). enile Justice mental health assessments. juvenile Data request: May). Department. (2016, enile Justice Annual Report to the Governor and Legislative Budget Board: Com- Budget Board: and Legislative to the Governor Annual Report (2015). Department. enile Justice Annual Report to the Governor and Legislative Budget Board: Com- Budget Board: and Legislative Annual Report to the Governor Department. (2015). enile Justice Ibid, pg. 2. Ibid, pg. 2. Ibid, pg. 2. Commit House Texas Texas Juv Texas Services Registry Juv Texas http:// from Retrieved 14. Pg. Programs. and Special Diversion Riders Justice Appropriations, munity Juvenile www.tjjd.texas.gov/publications/reports/AnnualReportFundingandRiders2015.pdf Ibid, pg. 14. Juv Texas from http://www.tjjd.texas.gov/statistics/Community- 1. Retrieved Pg. Programs. Probation nity-Based Juvenile BasedJuvenileProbationPrograms.pdf Texas Department of Family and Pro Department of Family Texas 2. Ibid, Pg. Juv Texas from http://www.tjjd.texas.gov/statistics/CommunityBased- Retrieved Programs. Probation nity-Based Juvenile JuvenileProbationPrograms.pdf Texas Juv Texas http:// from Retrieved 18. Pg. Programs. and Special Diversion Riders Justice Appropriations, munity Juvenile www.tjjd.texas.gov/publications/reports/AnnualReportFundingandRiders2015.pdf Ibid, pg. 18. Ibid, pg. 19. & Intervention Prevention for Youth October). Agency Coordination (2015, Military Department. ment, and Texas from https://www.tjjd.texas.gov/services/prevention/docs/Report_Interagency_Coor- 2. Retrieved Services. Pg. dination_Youth_Prevention_Intervention_Services.pdf Texas Juv Texas Ibid, 18. Ibid, 7. Ibid, 7. and Pro Department of Family Texas Texas Juv Texas youth. justice-involved Commission. (20 and Human Services Health Texas Juv Texas Juv Texas Ibid. http:// from Retrieved 18. Pg. Programs. and Special Diversion Riders Justice Appropriations, munity Juvenile www.tjjd.texas.gov/publications/reports/AnnualReportFundingandRiders2015.pdf Services. & Intervention Prevention for Youth Agency Coordination (2015). Military Department. ment, and Texas from https://www.tjjd.texas.gov/services/prevention/docs/Report_Interagency_Coordina- Retrieved 10. Pg. tion_Youth_Prevention_Intervention_Services.pdf www.tjjd.texas.gov/publications/reports/AnnualReportFundingandRiders2015.pdf Ibid, 12. Adminis Texas TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=37&pt=11&ch=343&rl=404 Juv Texas texas.gov/publications/forms/2010/TJPCFS0410.pdf Juv Texas Ibid. state.tx.us/crcg/WhatAreCRCGS/Overview.html JSA Health T JSA Health Juv Texas Pg. Programs. and Special Diversion Riders Appropriations, Justice munity Juvenile www.tjjd.texas.gov/publications/reports/FY17_strategic_plan.pdf BudgeLegislative from http://www.lbb.state.tx.us/Documents/Publications/Info_Graphic/812_Monthly_Re- Retrieved 3. Pg. port_June_2016.pdf new-projects-for-jsa-health-telepsychiatry-assisting-the-texas-correctional-office-on-offenders-with-medical-or-mental-impairments-tcoomi/ Retrieved from http://www.house.state.tx.us/_media/pdf/committees/reports/81interim/House-Commit- Retrieved tee-on-Corrections-Interim-Report-2010.pdf Texas Juv Texas from http:// Retrieved 20. Pg. Programs. and Special Diversion Riders Justice Appropriations, munity Juvenile www.tjjd.texas.gov/publications/reports/AnnualReportFundingandRiders2015.pdf Ibid, pg. 10. Ibid, pg. 19.

161 162 163 157 158 159 160 155 156 151 152 153 154 147 148 149 141 143 144 145 146 150 135 136 137 138 139 140 142 132 133 134 164 165 166 TJJD 366 197 195 194 193 192 191 190 188 185 183 182 181 180 179 178 177 176 175 174 173 172 171 170 169 168 167 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 199 198 196 189 187 186 184

Texas Juv texas.gov/files/cjd/Specialty_Courts_By_County_April_2016.pdf Office ofthe Governor U.S. DepartmentofJ Ibid. Ibid. Opportunities forPositive Experiences(COPE)program Travis CountyJuv Program. 1.Retrieved fromhttp://www.cymhpp-ctx.org/resources/COPE.pdf Experiences Prosecution (COPE):TheDeferred Program oftheTravis County Juvenile MentalHealthCourt Travis CountyJuv Texas. Office ofthe Governor Sociological Quarterly, 54(4),pg.647. Ray, B Ramirez, A.M.,Andret Courts.pdf Retrieved from http://childrenatrisk.org/wp-content/uploads/2013/05/02_Texas-Juvenile-Mental-Health- Children atRisk.(2011). T SAMHSA’s GAINSCenterforBeha National CenterforMental Health andJ Diversion Initiative. University ofTexas CenterforSocialW National CenterforMental Health andJ paign=prg357-diversion tions.gov/ProgramDetails.aspx?ID=357&utm_source=email-govdelivery&utm_medium=eblast&utm_cam- National Institute ofJus forchildren.org/Images/Interior/mh%20forum/probation_intake_diversion.pdf bation Intake Diversion: Texas Front-End Diversion Initiative (FEDI).Pg. 3. Retrievedhttp://texanscare- from Texas Juv 508.pdf End Diversion Initiative. Pg. 4-5. Retrieved fromhttp://cfc.ncmhjj.com/wp-content/uploads/2015/04/FEDI- National CenterforMental Health andJ Ibid. Diversion Initiative. University ofTexas CenterforSocialW Ibid, pg.3. https://www.tjjd.texas.gov/publications/reports/FY17_strategic_plan.pdf Texas Juv Ibid, pg.2. Ibid, pg.2. Ibid, pg.2. www.tjjd.texas.gov/publications/standards/N_Mental_Health_Services.pdf Texas Juv http://www.juvenilelaw.org/Portals/0/Newsletters/2015/201508.pdf State BarSectionReportJuvenile La texas.gov/publications/standards/N_Mental_Health_Services.pdf Texas Juv juvenilelaw.org/Portals/0/Newsletters/2015/201508.pdf State BarSectionReportJuvenile La Ibid, pg.10. Ibid, pg.19. Requirements. Pg. 3. Retrieved fromhttps://www.tjjd.texas.gov/publications/standards/GrantsM/16-17_ Texas Juv http://www.tjjd.texas.gov/publications/reports/AnnualReportFundingandRiders2015.pdf Community Juvenile JusticeAppropriations, Riders andSpecial Diversion Programs. Pg. 18. Retrieved from Texas Juv pdf. Ill Juvenile Offenders. Pg. 1.Retrieved from http://www.tjjd.texas.gov/publications/reports/RPTOTH201102. gov/topics/courts/drug-courts/Pages/welcome.aspx Outcomes inaJuvenile MentalHealthCourt. Juvenile andFamily CourtJournal, 66(1),pg.40. tor/juveniles?field_gains_mhc_state_value=TX ment Court Locator. Retrieved from http://www.samhsa.gov/gains-center/mental-health-treatment-court-loca- pdf End Diversion Initiative. Pg. 11.Retrieved from http://cfc.ncmhjj.com/wp-content/uploads/2015/04/FEDI-508. pdf End Diversion Initiative. Pg. 11.Retrieved from http://cfc.ncmhjj.com/wp-content/uploads/2015/04/FEDI-508. . andDollar, M.B. (2013). Examining MentalHealthCourt Completion: AFocal Concerns Perspective. The enile Probation Commission (since changed totheTexasenile ProbationCommission(sincechanged Juvenile Justice Department).(n.d.).Pro enile Justice Department.(2016, June 24). 2017-2021 TJJD Strategic Plan.Pg. 3. Retrieved from enile Justice Department.(2013, Sept. 1).MentalHealthServicesGrant. Pg. 2.Retrieved fromhttp:// enile Justice Department.(2013). MentalHealthServicesGrant. Pg. 3. Retrieved fromhttp://www.tjjd. enile Justice Department.(2015). SpecialNeedsDiversionary Program (SNDP)2016-2017Summary enile Justice Department.(2015). AnnualReporttotheGovernor andLegislative BudgetBoard: enile ProbationCommission.(2010). Overview oftheSpecialNeedsDiversionary Program Mentally for enile ProbationDepartment.(2016, March4).Personal communication: Collaborative enile Mental Health CourtProject.(2007, May). Collaborative Positive Opportunitiesfor ustice, NationalInstitute ofJustice. (2015). DrugCourts. Retrieved fromhttp://www.nij. , CriminalJustice Division.(2016). Texas SpecialtyCourts. Retrieved fromhttp://gov. , CriminalJustice Division.(2016, July 12).Personal communication:Specialtycourtsin ta, J.R., Barnes, M.E.,andWoodland, M.H.(2015). RecidivismandPsychiatric Symptom tice (2014). Front-End Diversion Initiative. Retrieved from http://www.crimesolu- exas Juvenile MentalHealthCourts: AnEvaluation theFuture. andBlueprintfor 8. vioral Health andJustice Treatment.(n.d.).Juvenile MentalHealthTreat- w. (2016, August). 2015SpecialLegislative Issue. Pg. 18. Retrieved from w. (2016). 2015SpecialLegislative Issue. Pg. 18. Retrieved fromhttp://www. ork Research.(2016, April6).Personal communication:Front-End ork Research.(2016, April 6).Personal communication:Front-End uvenile Justice. (2015). Diverting Youth atProbation Intake: TheFront- uvenile Justice. (2015). Diverting Youth atProbation Intake: TheFront- uvenile Justice. (2015). Diverting Youth atProbation Intake: TheFront- - TJJD 367 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Overview of the Special Needs Diversionary Program for Program Needs Diversionary of the Special Overview Commission. (2010). enile Probation Budget Board: and Legislative Annual Report to the Governor Department. (2015). enile Justice Program. Special Needs Diversionary Data request: May). Department. (2016, enile Justice Annual Report to the Governor and Legislative Budget Board: Board: Budget Legislative and the Governor Report to Annual (2015). Department. enile Justice Texas Juv Texas Juv Texas Ibid. Ibid, pg. 9 & 18. Ibid, pg. 9 & Ibid, pg. 18. Juv Texas http://www.tjjd.texas.gov/publications/reports/ from i & 22. Retrieved . Pg. Offenders Juvenile Mentally Ill . RPTOTH201102.pdf from Retrieved 19. Pg. Programs. Special Diversion and Riders Justice Appropriations, Juvenile Community http://www.tjjd.texas.gov/publications/reports/AnnualReportFundingandRiders2015.pdf SummaryRequirements.pdf Juv Texas from Retrieved 9 & 17. Pg. Programs. Diversion and Special Riders Justice Appropriations, Juvenile Community http://www.tjjd.texas.gov/publications/reports/AnnualReportFundingandRiders2015.pdf

202 203 204 205 206 200 201 TJJD 368 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas TEA 369

398 399 380 381 383 383 384 385 386 387 389 389 390 393 394 396 397 398 370 370 371 372 373 377 378 379 385 387 395 371 372 376

Without Placement

Education Programs (JJAEPs) & Expulsions & (JJAEPs) Programs Education

Alternative Education Programs (DAEPs) Programs Education Alternative

in Texas in unding: Individuals with Disabilities Education Act (IDEA) Act Education Disabilities with Individuals unding: Medicaid unding: (ISS) and Out-of-School Suspensions (OSS) Suspensions Out-of-School and (ISS) in Schools in Learning (SEL) Learning Early Childhood and Youth Transitioning to Adulthood to Transitioning Youth and Childhood Early

Education Services Education

enters (ECSs) enters Care (TIC) Care to Discipline and Student Mental Health Mental Student and Discipline to al Interventions and Supports (PBIS) Supports and Interventions al Schools (CIS) and Dropout Prevention Dropout and (CIS) Schools

First Aid (MHFA) Training in Texas Schools Texas in Training (MHFA) Aid First A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Juvenile Justice Alternative Justice Juvenile School Health Model Health School Special Education Services Education Special Support Systems for Schools for Systems Support Justice Framework eting and Class C Misdemeanors C Class and eting evention and Programs that Promote Healthy Behavior Healthy Promote that Programs and evention Texas Education Agency and Local School Districts School Local and Agency Education Texas

Reduce Bullying Reduce Punishment and the Use of Force in Schools in ofUse the and Force Punishment Mental Health Services in Schools in Services Health Mental acts

Special Education F Education Special F Education Special to Reduce and Decriminalize Truancy Decriminalize and Reduce to Special Education for Education Special C Service Education Suspensions In-School Behavior Positive to Efforts Mental Health Health Mental Special for Eligibility for Funding Coordinated In Communities Disciplinary to Expulsions Expulsions to Tick School Corporal Emotional and Social Trauma-Informed Restorative Policy Concerns Policy Fast F Fast Chart Organizational Pr Suicide Mental Health Mental Health Discipline Exclusionary Approaches Holistic Overview ofOverview Funding ofDelivery Education Services Special Changing Environment Changing Efforts At a Glance and Local School Districts School Local and Districts School Agency and Local Education Texas Texas Agency Education Texas Policy Concerns

· Need for more recovery-oriented educational supports, such as schoolwide positive behavioral interventions and support (SWPBIS) and classroom-based social and emotional learning (SEL) · Disproportionate amount of disciplinary measures for students receiving special education services and racial/ethnic minorities (in-school and out-of-school suspension, district alternative education programs (DAEPs), and juvenile justice alternative education programs (JJAEPs). · Disproportionate use of corporal punishment on students with disabilities or special needs. · Potential impact of budget reductions that could limit access to school counseling services. · Lack of transparency and comprehensive training of school district law enforcement (school resource officers), including a need for Children’s Crisis Intervention Training (CCIT). · Lack of trauma-informed care training. Fast Facts

· A 2011-2012 report found that, compared to the national average of 12.9 percent of students identified as eligible for special education services, Texas only had 8.7 percent of students receiving special education services — the lowest percentage in the country.1,2 · The rate of special education enrollment in Texas remained steady at 8.7 percent for the 2015-2016 school year, with 463,185 of the total student population (5,299,728) enrolled in special education services.3,4 · Roughly 34.4 percent of students eligible for special education services in 2015-2016 had a primary diagnosis of a learning disability, 11.7 percent had a primary diagnosis of Autism, and 5.8 percent had a primary diagnosis of emotional disturbance. 5 · In the 2014-2015 school year, 9.5 percent of students in Texas schools received special education services, but those students represented 18.3 percent of expulsions to Juvenile Justice Alternative Education Programs (JJAEPs), 17.1 percent of expulsions to Disciplinary Alternative Education Programs (DAEPs) and 14.9 percent of expulsions without placement. 6 · Students receiving special education services were also overrepresented in receiving out-of-school suspensions (19.3 percent) and in-school suspensions (15.4 percent) in 2014-2015. 7 · The majority of expulsions to DAEPs and JJAEPs continued to be discretionary in 2014-2015 (i.e. expulsions that were not mandated by state law but instead involve local codes of conduct). 8 · The majority of students in Texas are Hispanic (52.0 percent) and many students in Texas — nearly one million — are still learning English. 9

370 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas TEA 371 The 15,16 15,16 According to TEA, 10,11 10,11 Over an eleven-year an eleven-year Over 12

13,14 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation period, total enrollment in Texas schools increased by roughly 20.4 percent, or roughly 20.4 increased by schools enrollment in Texas period, total students. 899,084 most recently available data from the National Survey of Children’s Health (2011- Health of Children’s data from the National Survey recently available most mental health needs have in Texas children that roughly 500,000 reveals 2012) and the behavioral receive percent) of those children do not half (40.5 but almost services they need. psychological Source: Texas Education Agency. (January 2016). TEA Hierarchy Chart. Retrieved from https://mansfield.tea.state.tx.us/TEA.AskTED.TSD/ from Retrieved Chart. Hierarchy TEA 2016). (January Agency. Education Texas Source: TSDfiles/tsd2016/not_tagged/tea_hierarchy_chart_org_chart.pdf Figure 149. Organizational Structure of TEA (Unaffected by Transformation) by (Unaffected ofTEA Structure Organizational 149. Figure Undiagnosed or poorly managed impact a health conditions can negatively mental and school attendance. performance, classroom behavior, academic child’s Overview of Texas Education Agency Education Texas of Overview Districts School Local and functions and administrative Education Agency oversight (TEA) provides The Texas and 616 school districts schools for the 1,247 for all primary and secondary public of Texas. in the state open-enrollment charter school campuses and Local School Districts School Local and Texas Agency Education Texas

5,299,728 students were enrolled in Texas public schools in the 2015-2016 school public schools in the 2015-2016 were enrolled in Texas students 5,299,728 and early education providers. including charter schools year, TEA 372 there were438students percounselorforthe2014-2015 schoolyear. students perschoolcounselor, theratioinTexas isalmost doublethatamount: recommendsaratioof250 the AmericanSchoolCounselorAssociation(ASCA) bill, HB3793 (83 of publicschool employees authorizedtoreceive mentalhealthfirst aid trainingthat improve campus-wide identificationofmentalhealthissues by expanding thetypes In 2015, the84 Several billspassedduringthe83 · · · · how to: individuals (suchasteachersandother schoolemployees andsupportstaff) Mental Health First Aid(MHFA) isanevidence-basedprogramthatteaches T M Changing Environment develop eachstudent’s academic,career, personal,andsocialabilities.” “the primaryresponsibilityofaschoolcounseloristocounsel students tofully relatedtomentalhealth;accordingTexasduties thatareonlytangentially law, psychologists, andsocialworkers. Despitetheirtitle,schoolcounselorshave many by anumberoftrainedprofessionals, includingschoolcounselors, nurses, school In Texas, mentalhealthsupportsandservicesmay beprovided inschoolsettings Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas the earlyidentificationof mentalhealthneeds by passingtwobills:SB133(84 at riskforsuicideorexperiencingother mentalorbehavioral health needs. personnel tobetrainedintheearlydetection andidentificationof students whoare certified publicschoolteachers, counselors, principals, and other appropriate (LSSPs), butonly1,582LSSPs worked inTexas publicschoolsin2015. Texas alsohasaspecialcredentialforLicensedSpecialists inSchoolPsychology therapists, andother mentalhealthprofessionalssuchasartandmusictherapists. such aslicensedclinicalsocialworkers, licensedschoolpsychologists, occupational health workers whoplay acrucialroleintreatingmentalhealthissuesschools, be noted, however, thattheseratiosdonot take intoaccountnon-counselormental intervention programslike MHFA. SB460(83 MHFA training. Texas. TEAauthorizedcontinuing educationunitsforeducators whocomplete the health first aidtraining available tointerested individuals andeducatorsthroughout Schwertner/Coleman) andSB674 (84

ex issues issues experiencing distress related to a mental health condition or substance use. Increase individuals’ ov Create a 5-step action Identify professional Recognize signs, s ent a s a S l He c h th 24 24 Legislatureprovided furthersupportforMHFA trainingand rd ools As ofJune 2014, 1,829 educatorshadbeentrainedinMHFA. a , Coleman/Hinojosa), createdtwograntprogramsmaking mental lt ymptoms, andriskfactors of mental health and substance use h and self-help resources to treat mentalandbehavioral health plan to assess asituation and offerimmediateassistance First Aid( erall confidence andcomfort inhelping peoplewho are rd Legislative Sessionthatsupportearly th , Campbell/Coleman).SB 133soughtto M rd HFA) , Deuell/Coleman)requiredall T r a ining in 19,20 21 18 Although It should 23 Another th 25 22 , TEA 373 Suicide 34 33 t ha And while females 35 By 2016, over half a million over 2016, By ms t 27 Studies show that MHFA that MHFA Studies show a 32 vioral health conditions. vioral health rogr P and how to listen non-judgmentally to listen and how 26 vior helping a young person in distress person helping a young nd ha 28 a e Legislatures. In 2015 alone, 6,527 educators and educators alone, 6,527 In 2015 Legislatures. th B y h and 84 titudes about mental health conditions health mental titudes about behavior towards individuals experiencing mental health towards behavior rd lt e of mental health and behavioral health conditions health and behavioral of mental e a 31 revention As of April 2016, TEA and the State Board for Educator Certification TEA and As of April 2016, A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation This new training has a mandated emphasis on teaching school staff emphasis on teaching school staff This new training has a mandated 30 P 29 issues Increased supportive supportive Increased associated with beha in stigma Reductions Decreased negative at negative Decreased comfort and confidence Increased knowledg Increased for suicide risk when to assess Clarified romote He romote uicide

(SBEC) were on track to have these new training requirements fully implemented in these new training requirements fully (SBEC) were on track to have 2016. September 4,792 non-educator school staff were trained in MHFA. were trained school staff non-educator 4,792 individuals had been trained in MHFA across the U.S. and Texas is has the third is and Texas the U.S. across trained in MHFA individuals had been compared to California’s (33,468, in MHFA number of individuals trained highest 44,704). and Pennsylvania’s 52,637 rates in the U.S have steadily increased over the last 10 years, with females age 10 years, the last increased over steadily have rates in the U.S group. increases of any experiencing one of the highest 10-14 · · · · one of the four leading causes of death among individuals age suicide was In 2014, that age accounting for roughly 12 percent of all deaths in group. 10-24, · S P trainings provide participants with a number of beneficial outcomes, including: outcomes, participants with a number of beneficial trainings provide · Training teachers to recognize and offer support for students’ mental health needs, students’ mental health needs, offer support for Training teachers to recognize and for students. mental health outcomes results in better especially before a crisis, updated criteria from using SAMHSA’s been re-evaluated has not Although MHFA as an effective is listed “legacy program” in the National Registry MHFA 2015, Programs and Practices (NREPP). of Evidence-based SB 674 strengthened training requirements for public school employees by requiring by school employees training requirements for public strengthened SB 674 as well as disorders of mental or emotional in the detection them to be trained to on how instruction program that provides a best-practice-based complete rangerespond to the wide health issues faced behavioral of suicidal risk factors and students. by Thousands of Texas school employees have received MHFA trainings as a result as a result trainings MHFA received have school employees of Texas Thousands the 83 of bills passed in is paid for by the Department of State Health Services (DSHS). Previously, educators educators Previously, (DSHS). Services Health of State the Department for by is paid to create DSHS 113 allowed SB in MHFA. be trained to group targeted the only were unused with any (LMHAs) authorities mental health grants to local supplemental trainings. for MHFA money appropriated are more likely to experience suicidal thoughts than males, Figure 150 shows that Figure 150 shows to experience suicidal thoughts than males, are more likely the ages of 6 and 24. suicide between to die by males are roughly four times as likely suicide rate for the highest had that 2014 150 shows the data in Figure Furthermore, a decade. in over youth age 6-24 Texas how to use de-escalation techniques and positive behavioral interventions to better to better interventions behavioral to use de-escalation techniques and positive how the regular school in needs of students and emotional support the psychological environment. TEA 374 Márquez) required informationabout available mentalhealthandsuicide passed in2015, HB2186 (84 suicide rate(13.4 per100,000 people). suicide rateinTexas (12.1per100,000 people)was slightlylower thanthatnational suicide prevention on college campusesanduniversities,suicide prevention oncollege SB1624 (84 school employees. based suicideprevention training includedintheannualorientationforallnew SB 460(83 In Texas alone,3,254 individualsdiedby suicidein2014. U.S. in2014— thatisroughlyonesuicideevery 12minutes. On thenationallevel, anestimated diedby 42,773peopleofallages suicideinthe X60-X84, Y87.0,*U03. (Restricted): 2000 - 2014, Texas Suicide Injury Deaths and Rates per 100,000, All Races, Both Sexes, Ages 6 to 24, ICD-10 Codes: Data compiled from: Center for Disease Control. (2016). WISQARS Fatal Injury Reports, 1999-2014, for National, Regional, and State Figure 150. Youth SuicideRates in Texas (Ages6-24):2000-2014 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas with amentalillnessorsubstance usedisorder. for suicide,asmany as90percentofthosewhodie by suicidehave beendiagnosed · · · · nationwide trendsinsuicidalityhighschoolstudents in2015: occurs inallethnicities, ages, races, socioeconomicclassesandgenders. suicide ratesofany specificpopulation,itisimportanttorecognizethatsuicide training inmentalhealth, youthsuicide,andsubstance useissues. prevention trainingrequirementsby requiringpublicschooleducatorstoreceive educators in2013, and thoseeffortscontinuedintothe84 all deathsinthatgroup). 25-35(8.6third leadingcauseofdeathamongyoungadultfemales ages percentof 15-34(17.1adolescents andadultsages percentalldeathsinthatgroup),andisthe shows thatsuicideinTexas isthesecondleadingcauseofdeathamong male

2.8 percent of students 8.6 percent of s 14.6 percent made a 17.7 percent considered poisoning. rd , Deuell/Coleman)improved suicideprevention trainingforTexas 37 Retrieved from

tudents attempted suicideat least once within thepreviousyear 43 SB 674 (84 suicide plan some timeduring the previousyear http://webappa.cdc.gov/cgi-bin/broker.exe 40 made a suicide attempt that resultedinoverdose, injury, or Althoughtherearemany differentcausesandriskfactors attempting suicide some time duringthepreviousyear th , Cook/Campbell)requiredthattherebeanevidence- th , Campbell/Coleman)also strengthened suicide 39 The most recentlyavailable data(2013) 41 While whitemaleshave thehighest 38 th In thesame year, the 36 Legislative Session; Lookingspecificallyat 44 In regardsto th , Rodriguez/ 42 TEA 375 , Price/ th The new 47 While any While any 46 Similarly, HB 197 (84 HB 197 Similarly, 45 techniques ention and psychology vioral health needs of children with disabilities or special with disabilities of children vioral health needs , Giddings/Whitmire) improved suicide prevention efforts by efforts suicide prevention improved , Giddings/Whitmire) th vioral interventions and supports (PBIS) and vioral interventions A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation reduce the use of restraints reduce the use 48 Effective mental health crisis interv mental health Effective beha The overarching Child and adolescent development development adolescent Child and beha Positive de-escalation resolution and Conflict to How needs.

Nelson) required certain public institutions of higher education to create a web page education to create of higher public institutions required certain Nelson) of the local the number including health services, mental available that compiles authority. mental health (84 HB 2684 Finally, · · · training was put into place in February 2016 and must include information on: and must 2016 put into place in February training was · · · school district can request this new training for its officers, HB 2684 only mandated HB 2684 training for its officers, this new can request school district 30,000. enrollment over with a student districts this training for school requiring the school staff most likely to intervene in mental health crises — school in mental health crises to intervene likely most staff requiring the school least 16 at officers — to complete police (SROs)resource officers school district and health. behavioral education and training on hours of youth-focused While all of these bills together provide a better safety net for students that may be that may for students net safety a better provide While all of these bills together continues prevention suicide crisis or suicidal thoughts, experiencing a psychiatric state and local levels. the to be an ongoing effort at both prevention services to be provided to all undergraduate, graduate and professional and professional graduate undergraduate, to all be provided to services prevention in generalinstitutions. teaching academic students TEA 376 The total TEAbudget forFY2016-17 was $54,666,853,847. budget, theExceptional Item Requests wouldaddanadditional$199,442,002. The total requested TEAbudget forFY2018-19 is$52,774,684,055. Ifincluded inthe Figure 152. Finance TEA FY BudgetbyMethodof 2018-19 from Source: Texas Education Agency. (August 2016). Figure 151. Finance TEA FY BudgetbyMethodof 2016-17 Funding Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas from Source: Texas Education Agency. (August 2016). http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 Legislative Appropriations Request for Fiscal Years 2018 and 2019. Page 39. Retrieved Legislative Appropriations Request for Fiscal Years 2018 and 2019. Page 39. Retrieved

TEA 377 and 53 52

50 Students punished through 51 , Whitemire/Thompson) and HB Legislative session, FTAS was often was session, FTAS Legislative th th 54 Before the 84 49 Pg. 39. Retrieved Retrieved 39. Pg. 2019. and 2018 Years Fiscal for Request Appropriations Legislative Legislature passed SB 107 (84 , Villarreal/Van de Putte) established the requirement for a committee the requirement for a committee established de Putte) , Villarreal/Van , West/Lewis) provided funding for juvenile case managers funding for juvenile through provided , West/Lewis) A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation th rd rd resources Legislature passed two bills to improve the approaches and strategies used the approaches and strategies Legislature passed two bills to improve Legislative session. Legislative rd rd http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 HB 1479 (83 HB 1479 SB 1419 (83 SB 1419 in counties of a certain size to recommend uniform truancy policies, court costs, expanded the services they provide, and established a truancy and established provide, the services they expanded court costs, fund. and diversion prevention Goal1Goal Description and guidance, leadership, system education Provide 2Goal support and oversight system Provide

to reduce FTAS: · In 2015, the 84 In 2015, However, the criminalization of truancy through the use of formal courts and However, because it fails to FTAS method to reduce the prevalence of an effective fines is not causes for the absences. address the underlying root the criminalization of truancy further alienated from school while were often ended up with a criminal and some students going formal court system through the impacting on their record, which has the possibility of negatively conviction The burden of fines is employment. future schooling, educational funding, and/or strain. particular tough on families already under financial Efforts to Reduce and Decriminalize Truancy Decriminalize and Reduce to Efforts (SROs) school resources officers to issue tickets allowed to law Texas Prior to 2015, school. These class or missing such as disrupting misbehavior for low-level students and a parent to appear and required the student were citations in lieu of arrest tickets students Texas SROs gave of ticket of the peace court. One type in a municipal or justice Education Code, According to the Texas or truancy. School (FTAS), Attend to is Failure in a six-month period or three or if they miss 10 or more days a youth commits FTAS period. in a four-week more days Source: Texas Education Agency. (August 2016). 2016). (August Agency. Education Texas Source: from Figure 153. TEA Budget by Strategy FY 2016-17 FY Strategy by Budget TEA 153. Figure HB 1479 and SB 1419 attempted to improve policies related to truancy prevention, to improve attempted and SB 1419 HB 1479 following to issue Class C Misdemeanors for FTAS authorized but schools were still the 83 The 83 · treated as a Class C Misdemeanor and processed in an adult criminal court forum wheretreated as a Class C Misdemeanor and court. in a juvenile available of the protections entitled to many were not students of Class C cases) found that 34 percent (roughly 76,000 Appleseed Texas by One study were for FTAS. in 2011 for students Misdemeanor tickets TEA 378 the continuumofmentalhealthservices. Commission onMental Health recognizedthecritical rolethatschoolscanplay in absences fromschool. offinesthatcanbeusedincaseswhichaparent contributedtothechild’srange care from school to school but even though access to services and supports varies care fromschool toschoolbuteven though accesstoservicesand supportsvaries providing mentalhealth servicestostudents. children arehigherinrural areasandthatschoolcounselorsplay acriticalrolein referenced priorresearchthatsaid depression,substance useandsuicideratesamong ones. than20,00015 percenthigherinrural counties(less residents) thaninmetropolitan 25 percentoftheirstudents received adequatecounselingservices. to students; nearlyhalfofthecounselorssurveyed inthestudy said thatlessthan health servicesfoundthatruralschoolsstruggle toprovide mentalhealthservices and approaches. Astudy fromTexas A&MUniversity-Kingsville onaccessto mental School-based mentalhealthservicesencompassawide variety ofdifferentprograms or behavioral healthservices. often serve asthefirst point of intervention whenachildneedspsychiatric testing partoftheirday inacademicsettings,because childrenspendsuchalarge schools Schools have alonghistory ofproviding mentalhealthservicestostudents and Schools Mental Health Services in Delivery of 2398 (84 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas that warrants community supervision. FTAS asacriminaloffenseandremoved schoolabsencesfromthelist ofconduct has beeninvolved incertaintypesofdisciplinarymeasures. student discipline,inadditiontonotifying parentsandguardianswhenastudent schools tohave acampusbehavior coordinatorwhoisresponsibleformaintaining generally dobettergenerally inschool. effective socialskillshave an easiertimedeveloping relationshipswithpeersand and beproductive. fewer contactswithlaw enforcement,andimprove theirabilitytolive independently mentalhealthservicesaremorelikely tocompleteage-appropriate highschool,have mental illnessareapparentby 14, age and75percentareapparentby24. age frequently continueintoadulthood.Asmuchas50 percent ofalllifetime casesof justification exists forthefailuretoattend school”. because: (1)thereisalow likelihood ofrecidivismby thedefendant;or(2)sufficient cases“ifthecourtfindsthatadismissaltruancy wouldbeintheinterest ofjustice significant psychological deterioration. functioning andpeerinteractions, andallows schoolstointervene beforethereis increases healthy stress skills, management improves socialandemotional Early intervention withmentalhealthissuessupportsacademicachievement, traditional mentalhealthsetting. services forchildrenandfamiliesinanenvironment that is lessstigmatizing thana 68 Barrierstodelivering mentalhealthserviceslead to inconsistent mentalhealth th , J. White/Whitemire). 64 Withoutearlyintervention, childandadolescentdisorders 59 63 60 Furthermore, youngchildrenwhoreceive effective, Onthenationallevel, thePresident’s NewFreedom 55 SB107established arequirementforallpublic 57 62 Courtsnow have thediscretion todismiss Childrenwhoenterkindergartenwith 61 Schoolscanprovide convenient accessto 67 InTexas, thesuiciderateisroughly 58 HB2398alsodeveloped aset 56 HB2398repealed 66 Thestudy also 65 TEA 379 74 69 The ARD meeting 73 72

This holistic approach to meeting every student’s needs includes includes needs student’s every meeting to approach holistic This for school; entire an by used frameworks treatment and models (PBIS), supports and interventions behavioral positive example, care. trauma-informed and (SEL), learning emotional social and Description and basic programs prevention health mental includes Typically licensed by on-site provided are that counseling as such treatments workers). social and psychologists counselors, (e.g. personnel school mental community with made contracts and agreements Formal the at or school in services provide to LMHAs) (e.g. agencies health agency. community clinics or units health mental own their operate may districts School staff trainings services, health mental and psychosocial provide to consultation. and prevention-oriented with needs health mental address Schools may curricula These instruction. teacher through provided materials emo- and social the fostering and promoting by learning enhance of growth tional students. all health behavioral activities, multiple together bring can Districts of range full a provide to agencies community and strategies health mental complex with students to services and interventions needs. A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 70, 71 70, Schoolwide Behavioral and Emotional Support Emotional and Behavioral Schoolwide Frameworks School-Based Mental Health Service Delivery Service Health Mental School-Based Financed School Mental Community with Connections Formal Services Health Clinics or Units Health Mental District School Curricula Classroom-Based Integrated and Multi-Faceted Comprehensive, Approaches Special education and related services can include a wide range of supports depending The types of special education specific and individualized needs. on each student’s through an annual Admission, are determined Reviewservices and supports provided caregivers, parents and/or the student’s with the student, (ARD) meeting and Dismissal care, school personnel, and at in the child’s involved mental health professionals any regular and special education instructors. one of the child’s least Special Education Services in Texas in Services Education Special including students, Schools are accountable for the academic performance of all When academic issues or mental health conditions. those with serious behavioral the Individuals with disability, performance is impacted due to a student’s Education Act special education Disabilities (IDEA) requires schools to provide which may and related services based on an Individualized Educational Plan (IEP), include mental health treatment and supports. The different methods of delivering mental health services in schools are described schools are described health services in mental of delivering methods The different 154. in Figure Delivery Methods Service Mental Health 154. Figure based on a school’s region (i.e. urban vs. rural), academic level, and student population, student and level, academic rural), vs. (i.e. urban region on a school’s based or services. referral screening, health of mental level offer some schools most is an essential part of creating, updating, amending and improving the individualizedis an essential part of creating, updating, amending and improving The IEP is the organizing framework and planeducation plan (IEP) on an ongoing basis. the by be provided that must supports and interventions used to specify the behavioral and success in the classroom. experience stability to help the student school district TEA 380 · · · · 2015-2016: education services. are includedinthedevelopmental andeligibletoreceive delay special category physical, cognitive, communication,social,emotional oradaptive development(s)” and childrenbetween ofthreeandfive whohave delays theages intheir “general EarlyChildhood”(NCEC) this development “Non-Categorical delay category category,delay” how toincludeaseligible. todefineit,andwhatages Texas calls However, states have theauthoritytodecidewhatcall“developmental using properinstruments andprocedures. diagnostic called“developmental delay,” category solongasthediagnosisismade ofthreeandninetoqualifyforspecialeducationservicesunderabroader the ages (IDEA)allowsIndividuals withDisabilities forchildrenbetween EducationAct diagnosis andmay not receive servicesbeforeentering schoolinKindergarten,the intervention services. To thegapforyoungchildrenwhodonot bridge have aspecific are alsochildrenwithoutamentalhealthdiagnosiswhomay still benefitfromearly it canbedifficulttodiagnoseayoungchildwith psychological condition.There Because children’s brainsaregrowing andtheirbehaviors areconstantly changing, Y S · · · · · health include: Some examplesofschool-basedandeducationalservicesrelatedtobehavioral Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas special educationneedsinthe2015-2016 schoolyear. An estimated 8.7 childreninTexas percentofschool-aged wereidentifiedashaving services through aprogramcalledPreschool ProgramforChildren with other states. Texas schoolsidentifiedaseligibleforspecialeducationservicesisfarlower thanin · · · · · aredesignatedasdevelopmental delayscategories atthefederallevel:

out peci 34.4 percent were 11.7 percent were classified asha 10.0 percent 5.8 percent were Specialized classes and services fors Skills training Case management Parental and familycounseling Assessments or medical services todiagnose types of disabilities conditions, Intellectual and Developmental Disability (IDD) diagnoses, andother Adaptiv Social oremotional development Communication development Cognitive development Physical dev h a e development

l T 76 r Ofthe463,185 students identifiedashaving special education needsin E elopment were classified ashaving anintellectual disability a duc nsitioning to Adul 80 classified ashaving emotional disturbance Children who fall under the NCEC category areprovided Childrenwhofallunder the NCECcategory classified ashaving alearning disability. a tion 79

f ving autism or tudents with developmental delays, physical Ea 78 The following typesofdiagnostic rly or evaluateastudent’s disability Ch t h 75 The percentage ofchildrenin Thepercentage ood ild 77 h ood a nd TEA 381

th Finally, Finally, 83 85 ervices S HB 617 also requires 82 tion a SB 1259 also required there to be notes SB 1259 also required there to be notes 84 duc , Rodriguez/Zaffirini), which required school , Rodriguez/Zaffirini), E rd l , Zaffirini/Naishtat), which required information , Zaffirini/Naishtat), which required a th peci S or f turbance A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation , Rodríguez/Allen) improved the Admission, Review and Dismissal improved , Rodríguez/Allen) th 81 Legislature passed HB 617 (83 rd Emotional dis Emotional disability learning Specific Autism Intellectual disability disability Intellectual ligibility

school districts to work with DSHS, TEA, and other state agencies transition state to make TEA, and other to work with DSHS, school districts . through a central website: www.transitionintexas.org information available supports for youth transitioning into adulthood, the 84 further strengthen To Legislature also passed SB 1117 (84 SB 1259 (84 districts to assign at least one employee to provide transition and employment transition and employment to provide one employee to assign at least districts receiving special education services. services to students (ARD) process wherein families and school staff develop an Individual Education develop school staff (ARD) process wherein families and with who is involved to include a teacher the ARD meeting requiring by Plan (IEPs) IEP. implementing a portion of the child’s E Special education services encompass a wide range and children can of interventions a diagnosis for a specified condition receiving become eligible for these services by education learning and the child has a need for special that impacts the child’s behavioral the various mental health diagnoses, Figure 155 shows services. in Texas students that made 463,185 disabilities and developmental conditions, school year: eligible for special education services in the 2015-2016 · · with to bridge worked has also for students the gap in services and supports Texas special who receive students assist out of high school. To special needs transitioning school to appropriate post- with a successful transition from education services integrated education or and vocational postsecondary such as school activities, individual transition begin must and independent living, schools employment are required to Schools age 14. and their families by planning with students education and services for postsecondary identify needed courses and related The availability, IEP. through each student’s adult living objectives to develop vary widely in Texas and quality of transition services available comprehensiveness, across the state. The 83 Disabilities (PPCD). PPCD services are provided in a variety of settings such as of settings in a variety provided are PPCD services (PPCD). Disabilities or community classrooms, self-contained classrooms, resource pre-kindergarten, eligible for to becoming In addition Start and pre-school. such as Head settings qualify for also may in Texas children NCEC category, through the PPCD services specific diagnoses: the following PPCD under · · on housing and independent living to be provided in the transition/discharge plans in the transition/discharge to be provided on housing and independent living the age of 16 who are under DFPS conservatorship. to youth over given taken about actions taken and discussions during ARD meetings. actions taken about taken TEA 382 school, orincommunity situations. not theresultofatemporary reactiontoadverse yet normalsituationsathome,in personnel alsoseekevidencethatthestudent’s behavior andneedforservicesis In determining whether specialeducationserviceswillbeprovided, school as eligibleforspecialeducationservices. serious emotional disturbance —roughly5.8 percentofallstudents identified In the2015-2016 school year, over 26,000 Texas students wereidentifiedashaving rptsvr1.tea.texas.gov/adhocrpt/adser.html Charter Schools, Students Receiving Special Education Services by Primary Disability, PEIMS Data 2015-16. Data obtained from: Texas Education Agency. (July 2016). 2015-2016 Special Education Reports: All Texas Public Schools Including Figure 155. Reasons forSpecialEducation Eligibilityin Texas Schools:2015-2016 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · · · · student’s educationalperformance: a marked degreeover an extended periodoftime,inways thatadversely affectthe is basedonthestudent exhibitingoneormoreofthefollowing characteristics to Eligibility forschool-basedmentalhealthservicesserious emotional disturbance traumatic stress disorder, attention deficitdisorder, andmore. disabilities andautism)whoalsohave mentalhealth needs, suchasanxiety, post who receive specialeducationbasedonother primarydisabilities (e.g.intellectual half ofthispopulationdroppingouthighschool. having seriousemotional disturbance have thehighest rateofschoolfailure,with

problems todevelop ph A tendency mood ofunhappiness A general Inappropriate types of beha An inability to relate appropriately impairments An inability to learn that canno 89 ysical symptoms, pains or fearsfrompersonalsocial viors or feelings under normalcircumstances t be explained by intellectual,sensory, orhealth and depression to peers and teachers 86,87 Nationwide, students identifiedas 88 However, there arestudents Retrieved from https:// TEA 383

99 100 ervices S tion tion a As Figure 156 shows, federal funding for As Figure 156 shows, The Individuals with Disabilities Education The Individuals with Disabilities duc 97 102 E Local funding must make up the difference in make Local funding must The proportion of students enrolled in special students The proportion of 101 l 93 a peci S To support schools with increased costs, the federal government costs, support schools with increased To 98 or or f Federal funding accounted for 94.6 percent (2016-17) and 94.8 funding accounted for 94.6 percent (2016-17) Federal A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation In order to comply with the Texas Legislature’s goal reducing of Legislature’s In order to comply with the Texas During the same year, only 8.6 percent of the student population in population the student percent of 8.6 only year, same During the 94 95 90 96 Despite this commitment, the federal government has given less than half of its has given Despite this commitment, the federal government year of funding in 1981. first financial support since IDEA’s committed funding for this increased need in order to meet IDEA’s requirements for funding IDEA’s funding for this increased need in order to meet special education services in schools. education services in Texas has dropped over the last ten years, but the reason for years, ten the last dropped over has in Texas education services the percentage to research on this topic is needed decrease is unclear and further and national special educational Texas discrepancies between understand better enrollment levels. is expected (1.2.3) within TEA strategy with Disabilities” for the “Students Funding with $2,108,308,102 in the upcoming years, consistent to remain relatively for the 2018- requested biennium and $2,153,551,378 for the 2016-17 budgetted 19 biennium. Additionally, the percentage of students identified with emotional disturbance in the in disturbance with emotional identified the percentage of students Additionally, in recent years. in Texas and population has decreased nationally special education From the 2003-2004 to the 2012-2013 school year, the population of Texas students students the population of Texas year, school to the 2012-2013 the 2003-2004 From only was percent while there 3.1 education services decreased by receiving special percent decrease nationally. a 0.3 Overall, spending for special education programs has increased since the inception spending for special education programs has increased since the inception Overall, for special education funding but federal and state of IDEA and its predecessor, increased proportionately. has not SPECIAL EDUCATION FUNDING: INDIVIDUALS WITH DISABILITIES WITH DISABILITIES FUNDING: INDIVIDUALS EDUCATION SPECIAL (IDEA) ACT EDUCATION Act Education Under the Individuals with Disabilities (IDEA), children and a to receive are entitled disabilities the agesand 21 who have adolescents between of 3 free and appropriate public education. In the 2013-2014 school year, roughly 6.5 million public school students received received students public school million roughly 6.5 school year, In the 2013-2014 students 13 percent of all — about across the U.S services special education nationwide. Funding Funding Act passed in 1975 (as the Education for All Handicapped Children (IDEA) first Act, created, the When IDEA was and has been reauthorized multiple times. PL 94-142) projected to be twice with special needs was of educating students expected cost require special who do not as much as the national average of educating students education services. special education through IDEA has remained relatively constant for the past 14 14 for the past constant special education through IDEA has remained relatively an increase in the number of despite years and it is expected to remain constant Texas received special education services — the lowest percentage in the country. — the lowest education services special received Texas percent (2018-19) of the total funding for the “Students with Disabilities” strategy strategy with Disabilities” funding for the “Students of the total percent (2018-19) within TEA. committed to contributing up to 40 percent of this anticipated additional cost. committed government agencygovernment proposed a number of funding four percent, TEA has by budgets of the Academic defunding & Mentoring including completely Innovation cuts, Humanities Texas Buddies program, and the Educator Excellence program, the Best program. TEA 384 special educationallocationsthatalreadyexist. match requirementforSHARSMedicaid fundingismet by usingstate andlocal being fullyfundedinFY2014. education atthefederallevel resultedinIDEAfallingmorethan$10billionshort of to increasedby 2.3percent(to$1,996,823,246) forthe2018-19 biennium. federal IDEAPart Bfundingforthe2016-17 biennium,andthatnumberisexpected Excluding fundingforpreschoolsthroughIDEA,TEAreceived $1,952,599,033 in · The SHARSprogramincludes: (HHSC). through thecoordinationofTEAandHealth andHumanServicesCommission Related Services(SHARS)program.provided by SHARSaremadeavailable can billMedicaid directlyforcertaineligibleservicesthroughtheSchoolHealth and In additiontofundingfromthefederalandstate government throughIDEA,schools SPECIAL EDUCATION FUNDING:MEDICAID Retrieved from Source: Dancy, K. (March 23, 2016). Fully Funding IDEA: A Democratic Dream or Just an Empty Promise?. Figure 156. Federal SpecialEducation Share Funding of Through IDEA:2002-2024 students eligibletoreceive specialeducation. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · · · · · these services. as Medicaid providers andemploy orcontractwithqualifiedprofessionalstoprovide certain health-relatedservicesprovided tostudents inspecialeducation. (SSAs)toobtainand sharedservicesarrangements Medicaid reimbursementfor

Physical therap Occupational therapy Medical services School health services Counseling Audiology Assessment 106 https://www.newamerica.org/education-policy/edcentral/fully-funding-idea/ SHARSisaMedicaid financingprogramthatallows localschooldistricts 108 y 104

103

School districts andSSAsmust enroll Thistrendofunder-funding special New America Foundation.New America 107 105 Thestate TEA 385 110 s) . http://tea.texas.gov/regional_services/esc/ ECS For example, the Region IV Education For 112 enters ( C Retrieved from from Retrieved Map. Centers Service Education 109 . ervice S A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Although schools are not required to provide mental health services required to provide are not Although schools

111 tion a Speech therapy Speech Special transportation care services Personal Psychological services Psychological duc

unless specifically stated in an IEP, there are still students in the students in still general population there are stated in an IEP, unless specifically and services vary health supports Mental mental health services. who receive mental health services but there are certain individual schools and districts, between section describes the mental health services and This next across the state. available statewide. related programs available Source: Texas Education Agency. (2016). (2016). Agency. Education Texas Source: topic areas and services Regional education service centers also specialize in specific and general support, programmatic assistance expertise resources, and then provide statewide. or schools to school districts Created in 1965, 20 regional educational service centers (ESCs) in Texas provide provide 20 regional educational service centers (ESCs) in Texas Created in 1965, in a throughout the state to all school districts support and technical assistance A map of service support. special education and behavioral including of areas, variety in Figure 157. center regions is shown Map of Regions Service Center Education 157. Figure E Mental health services are required by law to be provided for students who receive who receive for students to be provided law by health services are required Mental Education Individual of their services if those services are part special education Plan (IEP). · · Schools for Systems Support Health Mental In order to receive SHARS services, students must be eligible for Medicaid, qualify to qualify to eligible for Medicaid, be must students services, SHARS to receive In order an IEP. services under IDEA, and have special education receive · · TEA 386 · · · · · · · · components: The 8-ComponentModel forCoordinatedSchoolHealth includes thefollowing Coordinated SchoolHealth program. by theschooldistrict toserve andmake recommendationsforthedistrict’s and charterschoolsanestimated $623.5 millionperyear. infrastructure asawholesupportsschoolsincomplyingwithIDEAandsaves public as the School Health Advisory Council(SHAC). as theSchoolHealth Advisory 8-Component Model, andisdirectedby amandatory, multidisciplinaryteam,known student health,modeledaftertheCentersforDiseaseControl andPrevention’s law. TheCoordinatedSchoolHealth Model focusesoneightcorecomponentsof school districts arerequiredtoprovide acoordinatedschoolhealthprogramby workshops, consultations, andtechnicalassistance forbehavioral supports. andspecialeducationspecialistsgeneral whofocusonproviding campuseswith Region XIIIEducationServiceCenterinAustin hasaBehavior Team thatprovides School Health Model. Counseling andmentalhealthservicesareacoreelement ofTEA’s Coordinated C 885,000 individualsperyearthrough thestate’s 20ESCs. trained in2013. For 2017-2019, TEAexpectstocontinuetraininganestimated A total of903,257 in2015, individualsweretrainedthroughESCs upfrom853,573 by twopercentforthe2018-19reduced fundingforESCs biennium. inthe2016-17A total of$25millionwas allocatedforESCs biennium,andTEA by addressingtheneedsofstudents withbehavior challenges. ofenhancingtheeducationexperienceforallstudentsSupports (PBIS)withthegoal Service CenterinHouston specializesinPositive Behavioral Interventions and Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas optimal physical, emotional, socialandeducationaldevelopment.” services designedtoadvancestudent academicperformanceandpromote their systematic set ofplanned,sequential, school-affiliated strategies, activitiesand opportunities (asopposedtoin-persontrainings). and reducedtransportationstaffing costs provided through distance learning (asopposedtotheopenmarket orrunningthoseprogramsinternally) through ESCs mainly aresultofschooldistricts having accesstocheaperproductsandservices

oordin Comprehensive school health education School-site health promotion fors Healthy schoolen Physical education Nutrition services Family and community in Counseling, psychological School health services a ted vironment 120 DSHSdefinescoordinatedschoolhealthas“anintegrated, S c volvement h and social services ool He taff a 123 lt 122 h SHACmembersareappointed 117

M odel 118,119 116 Annualsavings are 113 Additionally, the 121 115 Texas The ESC TheESC 114 TEA 387 CIS is also at 127,128 ropout ropout All but two percent of All but two percent D 125 . 132 In the 2014-2015 school school In the 2014-2015 nd nd 124 a ) 129 CIS legislative session; in an effort to comply with legislative th ools ( ools h This partially restored funding allowed CIS to serve CIS to serve funding allowed This partially restored c 126 S n Schools can even remove or expel special education remove Schools can even I 130,131 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation ommunities ommunities revention more students in 2015 (87,990) than in 2013 (63,527), but state funding for CIS is still funding for CIS is still but state (63,527), than in 2013 (87,990) in 2015 more students which cuts, funding less than appropriations before the 2012-2013 roughly $600,000 who can benefit from CIS services. limits the amount of students Unfortunately, exclusionary discipline has a disproportionate impact on exclusionary Unfortunately, of the is a breakdown The following receiving special education services. students school year: for the 2014-2015 discipline removals exclusionary of all overrepresentation Exclusionary Discipline in Schools in Discipline Exclusionary from students remove discipline in schools refers to practices that Exclusionary from common, daily students from the classroom excludes the classroom. Removal development. to normal childhood and student experiences that are conducive to disciplinary or expel students to remove the option schools have law, Under state education alternative justice or juvenile education programs (DAEPs) alternative programs (JJAEPs). To learn more about CIS services in Texas and see a list of all CIS providers in the of all CIS providers and see a list learn more about CIS services in Texas To visit http://tea.texas.gov/interiorpage.aspx?id=4639 state, P program funded dropout prevention (CIS) is a national in Schools Communities case management, individualized provides local support. CIS and state through services. mental health-related and other counseling, C students after following protective procedures required under federal law. Many Many procedures required under federal law. protective after following students school year; for given children are sent to these programs more than once in a from were removed in Texas students 616,987 year, school in the 2014-2015 instance separate incidents that of 1,840,642 once, adding up to a total the classroom at least from the classroom. of a student resulted in the removal the Legislature’s stated goal four agenciesreducing spending in government of stated by the Legislature’s 14.7 for TEA reduces CIS funding by appropriations request percent, the legislative biennium. percent (or $4,541,545) for the 2018-19 risk of losing more funding in the 85 risk of losing more funding in the the students receiving CIS case management services in grades 7-12 stayed in school stayed receiving CIS case management services in grades 7-12 the students were promoted and 94 percent of CIS participants year, school during the 2014-2015 grade or graduated. to the next delivery, service impacted significantly 2013 in program CIS the to cuts funding State restored mostly was cut from the CIS budget million that was but the roughly $5 CIS to an estimated appropriations for increasing annual state in the years since, and 2017. in 2016 $15,521,815 year, CIS provided case management services for 87,990 students through 27 local students case management services for 87,990 CIS provided year, across Texas. districts school in 145 CIS programs operating TEA 388 mandated by law, butinstead authorizedatthediscretion ofschooldistricts. should bedisciplined.Asignificantportionofdisciplinaryreferralsarenot vague, allowing forwideinterpretation whendetermining whatandhow behaviors Summaries.html Data. Retrieved from from: Texas Education Agency. (2016). 8.5 percent,respectively). (16.3 percent)fordiscretionary reasonscomparedtotheirpeers(22.8percent and Suspension Suspension (34.5percentofISSactions)orOut-of-School to In-School education services;in2015, students inspecialeducationweremorelikely tobesent Discretionary removals alsodisproportionatelyimpactchildrenreceiving special based onpoliciesintheirlocalstudent codeofconduct. district todistrict. Discretionary referralsaremadeby teachersoradministrators Discretionary referrals, determined by schooldistrict policy, varywidelyfrom performs aspecificactthatautomaticallyrequirestheremoval fromtheclassroom. discretionary. Mandatedreferrals, determined by state code,occurwhenastudent Removals fromtheclassroomtothesedisciplinaryprogramscanbemandatoryor using the 3 Note: Total student population and special education population data in this chart is increased because discipline reports are tabulated Discipline Figure 158. Overrepresentation of Youth inSpecialEducation inExclusionary Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Breaking Schools’ Rules,apivotal 2011 study conductedby the Council ofState · · · 2014-2015 schoolyear, discretionary removals accountedfor:

60.8 percent of expulsions 58.8 percent of D 51.9 percent of expulsions to rd submission of PEIMS data while annual enrollment is tabulated using 1 submission of https://rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/DAG_Summaries/Download_State_DAG_ AEP removals Counts of Students and Discipline Counts of Actions by Discipline Action Groupings: PEIMS 2014-2015 136 without placement (i.e. “to the streets”) JJAEPs st submission data from the fall. Data obtained 133 Thesepoliciescanbe 135 134 Inthe TEA 389

141

145 More More 137 - f tive ut-o a Any DAEP that serves that serves DAEP Any O 147 nd a s) ) ) EP In addition to removing children In addition to removing ry Altern ISS A DAEP in smaller rural districts may may districts in smaller rural A DAEP

142 A a D OSS 144 ms ( suspensions (OSS), According the central academic mission to statute, a 146 140 . isciplin D rogr study found that “because study Schools’ Rules The Breaking there uspensions ( P 148 S There has been some increased attention in recent years on the in recent years on the increased attention There has been some 138 uspensions ( of in-school suspensions (ISS), and suspensions of in-school A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation S While only representing 12.7 percent of Texas’ total student population student total 12.7 percent of Texas’ While only representing ool tion ISS and OSS place a strain on families who need to make transportation on families who need to make ISS and OSS place a strain 139 a h 143 c ool S h 34.8 percent of out-of-school of 34.8 percent percent 25.4 of expulsions percent 15.9 duc xpulsions to xpulsions to c n-

of DAEPs “is to enable students to perform at grade level.” “is to enable students of DAEPs be a separate classroom on the school campus, but DAEPs are more frequently are more frequently but DAEPs be a separate classroom on the school campus, housed at a separate campus. in the 2014-2015 school year, African American youth accounted for: American youth accounted African year, school in the 2014-2015 · · · and/or childcare arrangements, and schools lose roughly $45 in funding from the and childcare arrangements, and/or a child is absent. for each day state a student with an Individualized Education Plan (IEP) must provide the services provide with an Individualized Education Plan (IEP) must a student outlined in the IEP. E a Disciplinary Alternative is required to provide in Texas school district Every or can join DAEP operate their own may Districts Education Program (DAEP). program. together to support a cooperative In the 2014-2015 school year, students receiving special education services accounted students school year, In the 2014-2015 percent of in- population but represented 15.4 student percent of the total for 9.5 (OSS). percent of out-of-school suspensions school suspensions (ISS) and 19.3 E I S and assigned one from the regular classroom can be removed student A disruptive or their class assignments, to a separate ISS classroom to complete or more days period of time (OSS). be required to remain off campus for a specified they may Governments Justice Center and the Public Policy Research Institute at Texas A&M A&M Texas at Institute Research Policy Public and the Center Justice Governments for special qualified who students four Texas out of that three found University, diagnosed with once. Students at least or expelled had been suspended education or expelled. to be suspended more likely were even disturbance emotional recent research conducted in 2014 found that students who had been removed from from had been removed who found that students in 2014 conducted recent research feel negatively to likely 10 times more were up to (i.e. suspended) the classroom or drop out of school entirely, held back a grade, fail academically, about school, be be incarcerated. from their regular classroom and from normal interactions with their peers in a from their regular classroom and increases for schools and to significant cost classroom, ISS and OSS can also lead families. According to the Texas Education Code, the principal or other appropriate school appropriate Education Code, the principal or other According to the Texas for engaging in conduct identified as also suspend a student may administrator of conduct. code prohibited in the school’s over-representation of students receiving special education services among the receiving special education students of over-representation for disciplinary reasons. from classrooms removed population of students African American target discipline practices also disproportionately Exclusionary students. TEA 390 · · · · · · The Legislative Budget Boardhasexpressedthefollowing concernsaboutDAEPs: Questions have beenraisedaboutthequalityofeducationservicesprovided inDAEPs. W E E 17.1 percentofreferralstoDAEP. identified aseligibleforspecialeducationservices, butthose students represented In the2014-2015 schoolyear, 9.5 percentofallstudents inTexas public schoolswere education servicesareoverrepresented inremovals fromtheclassroomtoDAEPs. Similar toother methods ofexclusionary discipline,students receivingspecial offenses listed intheir student codeofconduct. Texas schoolsalsohave widediscretion tosendstudents toaDAEP forother by under-resourced programs.” and instruction variesamongdistricts, withsomestudents inDAEPs poorlyserved has beenlittle monitoringandoversight ofDAEPs, thequalityofprogramming Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas students are senttoDAEPs. Juvenile Justice Alternative EducationPrograms into aprogram(i.e.“expelled tothestreets”), andasmallnumberofexpelled Justice Alternative Education Programs(JJAEPs) orexpelledwithoutplacement When childreninTexas areexpelledfromschool,theysenttoeither Juvenile “ removals toDAEPs (or55,192) werediscretionary. drawing containsaweapon.” a prescription orover-the-counter drugtoschool,ordoodlinginclasswhenthe missing another student, misusingaschoolparkingdecal,inadvertently bringing profanity, playing apranksuchasthrowing atennisballinthehallway andnarrowly from“fightingandgangactivitytodisruptingthese offensescanrange class, using · · · · · Education Code: Certain infractionsrequiremandatoryremoval toaDAEP accordingtotheTexas

E duc xpulsions to JuvenileJustice Altern Absence of transitional Insufficient communication be Lack of instructional Inadequate training for D Failure to pro Failure to s retaliation against aschool employee Committing anoffense thatin alcohol Selling, giving, possessing, or being Assaulting ano Committing afelony orengaging Making a terroristic threat it xpulsions to t h out a tion taff the DAEP withcertified teachers P vide alearning environment equivalent to mainstream campuses ther student or school employee l a P rogr cement ( alignment between DAEP and mainstream campuses programming upon astudent’s return fromaDAEP. AEP instructors and staff 151 h or afalse alarm/report. Inthe2014-2015 schoolyear, 58.8 percentofall a 149 e volves volatile chemicals, publiclewdness, or 154 ms (JJA

tween a student’s homecampusandDAEP S in conduct punishable as afelony treets”) a under the influence of a dangerous drug or under the influence ofadangerous lso known EP

Depending ontheschooldistrict, s) & 152

150 E xpulsions a s a tive 153 TEA 391

165

158 160 163 JJAEPs are operated by juvenile boards boards juvenile operated by are JJAEPs (31 percent), which includes Attention Deficit includes Attention which (31 percent), 155 Legislative intent in creating JJAEPs was “to was JJAEPs intent in creating Legislative The primary goals of JJAEPs are to “reduce are to “reduce The primary goals of JJAEPs While students receiving special education are still receiving special education are still While students 156 157 diagnosis of a Learning Disability (45 percent) Disability a Learning diagnosis of 162 Discretionary expulsions for “serious or persistent expulsions for “serious or persistent Discretionary

164 167 166 primary diagnosis of Serious Emotional Disturbance (24 (24 Disturbance of Serious Emotional primary diagnosis School districts without a JJAEP may send expelled students send expelled students may without a JJAEP School districts 159 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Texas school districts placed students into JJAEPs on 2,640 separate into JJAEPs placed students school districts Texas 161 104 students with a 104 students of Other a primary diagnosis 135 had or traumatic brain injuries, disabilities, physical speech problems, Disorder, disabilities. intellectual 199 students had a primary 199 students percent)

to DAEPs or opt to expel them without placement, also known as expulsion “to placement, also known to expel them without or opt to DAEPs and the length of their expulsion unsupervised serve because students the street” expulsion have following referrals to JJAEPS Overall, setting. outside of a school school years. and 2014-2015 the 2010-2011 33 percent between declined by Students younger than 10 cannot be sent to a JJAEP; instead, they are sent to DAEPs are sent to DAEPs they instead, JJAEP; be sent to a Students younger 10 cannot than for children a JJAEP to that would result in expulsion for engaging in conduct years old. 10 over delinquency, increase offender accountability and rehabilitate offenders through and rehabilitate offenders increase offender accountability delinquency, probation system.” juvenile coordinated community-based a comprehensive, provide continuing educational opportunities for students expelled from school for students continuing educational opportunities provide serious offenses.” for the most disproportionately represented in JJAEP referrals, that overrepresentation has that overrepresentation referrals, JJAEP disproportionately represented in school year. fallen from 20 percent in the 2010-2011 Some school districts use JJAEPs at a higher rate than others, and the size of the others, at a higher rate than JJAEPs use Some school districts expulsions. correlate with the number of student necessarily does not school district for mandatory or can be expelled to JJAEPs students to DAEPs, Similar to removal exhibits, uses, a student Mandatory expulsions occur when reasons. discretionary Discretionary or possesses a weapon or engages in serious criminal behavior. within 300 feet expulsions vary widely from serious criminal offenses that occur in a DAEP. or serious misbehavior on a school employee from the school, to assault · · Looking specifically at a report from the Texas Juvenile Justice Department (TJJD) Department (TJJD) Justice Juvenile Texas the Looking specifically at a report from in special education in 2014-2015: for students that cited 438 entries into JJAEPs · In the 2014-2015 school year, JJAEPs served 282 school districts across 26 counties 282 school districts served JJAEPs school year, In the 2014-2015 in Texas. (JJAEPs) were created in 1995 to provide ongoing educational services for students ongoing for students services educational to provide in 1995 created were (JJAEPs) than of more population with a in Texas county Every expelled. been have who a JJAEP. have residents must 125,000 with oversight provided by the Texas Juvenile Justice Department (TJJD) so when Department (TJJD) Justice Juvenile the Texas by provided with oversight in the involvement that referral is considered JJAEP, is expelled to a a student itself. by system justice juvenile In 2014-2015, 51.9 percent of expulsions to JJAEPs were discretionary while 48.1 while 48.1 were discretionary 51.9 percent of expulsions to JJAEPs In 2014-2015, percent were mandatory. misbehavior” and misdemeanor drug charges represent the vast majority (76 misbehavior” (76 majority and misdemeanor drug charges the vast represent occasions in 2014-2015, and 483 of those placements (or 18.3 percent) were for and 483 of those placements (or 18.3 occasions in 2014-2015, in special education. students The vast majority (80 percent) of mandatory referrals to JAEPs in 2014-2015 in 2014-2015 of mandatory referrals to JAEPs majority (80 percent) The vast drug offenses or weapons offenses while reasons for discretionary were for felony disciplinary wide variation in discretionary referrals were more varied, suggesting schools. policies between TEA 392 expulsions toJJAEPs and14.9 percentofexpulsionswithoutplacement. 9.5 percentofthestudent populationinTexas butaccountedfor18.3 percentof In the2014-2015 schoolyear, students receivingspecialeducationmadeuponly years. expulsions and72days fordiscretionary) —aslightreductioncomparedtoprevious of stay forallstudents whofinished JJAEP was 77days (84days formandatory long students spendinJJAEPs atthemacrolevel. In2014-2015, theaverage length Figure 159. Expulsionsin Texas Public Schools:2007-2015 school years. Figure 159shows thetrendofexpulsionsbetween the2007-2008 and2014-2015 a JJAEP. is widevariationacrossschooldistricts regardinghow muchtimestudents spendin standards thatset minimumormaximumamountsoftimeforexpulsions, sothere who areremoved fromthe classroomusingexclusionary disciplinepractices. Many expertsagreethatthereisaschool-to-prison pipeline formany ofthestudents Download_State_DAG_Summaries.html action groupings (PEIMS Data). Retrieved from Texas Education Agency. (2007-2015). Note: Years the school year (i.e. correspond with the beginning of 2007 stands for the 2007-2008 school year. Data obtained from: 38 percentbetween 2002and2007, therewas toaJJAEPWhile total expulsions(both ortothestreet) increasedapproximately percent) ofalldiscretionary expulsionsin2014-2015. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas approximately threetimesmorelikely thenwhitestudents tobeexpelled. suspension rates, a2014 study foundthatAfricanAmericanstudents nationallyare to theoverrepresentation ofAfricanAmericansinin-schoolandout-of-school experienced by childrencomingoutof JJAEPs. ofJJAEPs Although thegoal isto JJAEPs, butitisstill importanttounderstand theshort-and long-termeffects of discipliningchildrenwithout suspendingorexpellingthemtoprograms like Child advocates andschooldistricts inTexas areincreasinglyutilizing methods between 2007and2009expulsionshave continuedtodecreasesince2009. 170

169 However, TJJD publishesdatathatprovides someunderstanding ofhow Discipline data products: 2007-2015 counts of students and discipline actions by discipline Discipline data products: 2007-2015 counts of http://ritter.tea.state.tx.us/adhocrpt/Disciplinary_Data_Products/DAG_Summaries/

a 26percentdecreaseinexpulsions 168 Therearenostatewide 171 172 Similar 174,175 173

TEA 393

180

th nors a In contrast to a ticket, a to a ticket, In contrast , Whitmore/Herrero) , Whitmore/Herrero) isdeme rd M

183,184 C Furthermore, students sent to a DAEP sent to a DAEP students Furthermore, ss ss 185,186 185,186 177 a l C nd a , West/Lewis) and SB 1114 (83 and SB 1114 , West/Lewis) rd Legislature built on the previous session’s significant progress in significant Legislature built on the previous session’s icketing For example, students who have been sent to ISS, OSS, or a DAEP DAEP or a OSS, been sent to ISS, who have students example, For Legislative Session, two bills were passed that addressed the Session, two bills were passed that addressed Legislative A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation th T 176 rd However, data from TJJD suggests that there may be some short-term be some that there may suggests data from TJJD However, 181,182 178 ool h One study conducted by Texas Appleseed concluded that “placing students in students Appleseed concluded that “placing Texas conducted by One study c or a JJAEP are more likely to drop out of school and enter the adult criminal justice justice the adult criminal of school and enter to drop out are more likely or a JJAEP system. are more likely to be expelled and sent to a JJAEP than those who are not referred to referred who are not than those JJAEP and sent to a to be expelled likely are more actions. discipline exclusionary one of these increasing number of students receiving Class C misdemeanors for minor receiving Class C misdemeanors for minor increasing number of students SB 393 (83 misbehavior. While these correlations do not imply a direct causation of exclusionary discipline discipline of exclusionary imply a direct causation do not While these correlations the effectiveness question into incarceration, these findings call resulting in future on a long- rehabilitating students in successfully and JJAEPs DAEPs, OSS, of ISS, educational setting. into a mainstream term basis and integrating them back positive effects from attending a JJAEP; in the short-term, a student’s successful student’s a in the short-term, JJAEP; a effects from attending positive to reduce the rate of school absences, program appears of a JJAEP completion referrals. the number of disciplinary lower and academic achievement, improve complaint may or may not lead to a criminal charge once it has been submitted to lead to a criminal charge once it has been submitted not or may complaint may and the amount of of the behavior the court for evaluation, depending on the context also required SB 393 and SB 1114 supporting documentation and evidence provided. use schools may example, For to issuing tickets. that schools explore alternatives engage offender programs if they to first-time students or refer graduated sanctions or encourage prosecutors to consider non-court sanctions in a Class C misdemeanor, such as tutoring or counseling for an offense. addressing the overuse of ticketing and disciplinary sanctions in public schools. in public schools. and disciplinary sanctions of ticketing addressing the overuse impactful change offense and dealt with repealing truancyThe most as a ticketable programs that can prevent disciplinary intervention strengths-based promoting involved. gets enforcement problems before law In 2015, the 84 In 2015, During the 83 S school resource officers (SROs) could issue tickets law, Texas years under many For class or skipping school. such as disrupting misbehavior for low-level to students Class C misdemeanors and required for were citations in lieu of arrest These tickets court, possibly facing up or county and a parent to appear in a municipal the student students did The proceedings were public criminal proceedings and to $500 in fines. punishable Class C misdemeanors are not because a right to an attorney have not and system criminal justice into the inserted students jail time. These tickets by afford the families could not in special education. Many students unfairly targeted 17 student’s upon the warrant for arrest can result in a fines and failure to pay rehabilitate and integrate students back into a mainstream school environment, school environment, into a mainstream back students integrate and rehabilitate of delinquency levels to increased linked been have programs education alternative and adversity. JJAEPs for ‘serious or persistent misbehavior’ not only fails to correct behaviors, misbehavior’ only fails to correct behaviors, for ‘serious or persistent not JJAEPs system.” justice in the juvenile risk for future involvement but leads to increased 179 worked in conjunction to prohibit school resource officers (SROs)in conjunction to prohibit school resource officers from issuing worked by only allowing traffic violations) (excluding for Class C misdemeanors tickets SROs to issue complaints for Class C misdemeanors. birthday. TEA 394 spray by atthelocal level. SROS Houston ISD, have alreadybannedtheuseofTasers andlimitedtheuseofpepper Texas received corporalpunishment(i.e.spankingorpaddling). the targetsofcorporalpunishment. Texas, students withdisabilities andAfricanAmericanstudents aredisproportionately HB 2684(84 punishment asaviolationofhumanrights. banned allcorporalpunishmentinschoolsandtheU.N. hascondemnedcorporal many districts. punishment, butallowance ofcorporalpunishmentremainsthedefaultoption in now given theoption tosignawaiver thatexcludes theirchildfromreceivingcorporal by SROs. Session andtherearecurrently nostatewide standards regardingtheuseofTasers to banTasers and pepper sprays inschoolsstatewide duringthe83rdLegislative served by IDEArepresented79percentofstudents whowerephysically restrained. as specialeducation(i.e.served by IDEA)inthe2011-2012 schoolyear, thosestudents concern ofchildadvocates. Whileunder9percent ofTexas students wereclassified Use offorce(e.g.physical restraints andTasers) by hasalsosurfacedasa SROs when theymisbehave. approximately 40percentofTexas schooldistricts permitting students tobestruck of thestates withthehighest numberofstudents receivingcorporalpunishment,with permitted ontheircampus. tothemost recentlyavailable According data,Texas isone In Texas, eachschooldistrict isallowed todetermine whether corporalpunishmentis S C Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas for de-escalationspecifictochild-centeredsettings, orrestraint training. discipline foryouthwithcognitive oremotional disabilities, appropriatetechniques school environments have not appropriate hadtrainingintrauma-informedcare, age not sharedwiththepublic. working inschoolshaveonuseofforceschools, aspecificpolicy thosepoliciesare While theTexas Police ChiefsAssociationstates thatmany police departments There aredistricts implementinglessaversive ways toaddressdiscipline matters. should betrueforpublicschools. from beingusedinjuvenile justice facilities, andadvocates arguethatthesame schools. Theseweaponsarecompletely (Tasers) ormostly (pepperspray) prohibited A particularconcernistheuseofTasers andpepperspray by inTexas SROs public isnotSROs mandatedincurrentlaw. certain schoolstaff positionsarerequiredtobeapartofthisteam.Theparticipation school tohave ateamofschoolstaff trainedinrestraints appropriatefor youthand fell intoacomaafterhewas Tasered by andhithisheadontheground. anSRO schools afteronehighschool student inCentralTexas intervened tostop afightand needs ofchildrenwithdisabilities andmentalhealthneeds. de-escalation techniques, positive behavioral interventions, andthebehavioral health school districts, includingHouston ISD. based practiceandhasbeenbannedby themajorityofstates (31)intheU.S andmany psychological italsoisnot harm,trauma,andacademicdisengagement; anevidence- c orpor h ools 201 Therehasbeenarenewed pushagainst theuseoftheseweapons in th a , Giddings/Whitmire)improved toinclude mandatedtrainingforSROs 193,194 l P unis 187 Inthe2011-2012 schoolyearalone,roughly28,569 childrenin 196 h Historically, whoareworkingtoprotect SROs public ment 200 199 Therewas anunsuccessfullegislative attempt 189 Someschooldistricts inTexas, suchasthe Corporalpunishmentcancauseseriousinjury, 190,191 a 192 nd t Internationally, over 100countrieshave Beginningin2012, parentsinTexas are h e U se o 198 TEA also requires each TEAalsorequireseach 188 Nationwide andin f Force in 197 However, 202

195

TEA 395 206 As an 204 207 vironment and minors and emergencyand minors and vironment detention w officers to gain practical experience in active experience in active gain practical to w officers in school campus environments in school campus and developmental disoabilities, and substance abuse in and substance disoabilities, and developmental community resources community tice (also known as restorative discipline) as restorative known tice (also vioral interventions and supports (PBIS) supports and vioral interventions The CCIT includes education on: The CCIT includes A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 205 tening and de-escalation techniques tening and de-escalation Building community partnerships to support youth’s ability to access ability to youth’s to support community partnerships Building tropic medications tropic 203 positive beha positive learning (SEL) emotional social and (TIC) care trauma-informed jus restorative Role-play scenarios that allo scenarios that Role-play experiencing a crisis. students specific to techniques and de-escalation listening Active lis learning illness, Mental Psycho and perspective Family school en to relating Legal issues Officer tactics and safety safety and Officer tactics and youth children

example, Bexar County created the Children’s Crisis Intervention Training (CCIT) Training (CCIT) Crisis Intervention the Children’s Bexar County created example, training is approved 40-hour The in the Greater San Antonio area. for use in schools Standards and provides Enforcement Officer Commission on Law the Texas by any previously received not Units (CEUs) for SROsContinuing Education who have CIT training. · · Public schools in Texas are increasingly moving to proactive, coordinated to proactive, are increasingly moving Public schools in Texas While some needs of all students. and academic the behavioral approaches to meet and trained with mental health needs require tailored interventions students a more holistic models that provide there are also intervention professionals, These initiatives needs of all students. approach to supporting the developmental targeted early intervention activities, prevention generally include campus-wide with complex and individualized services for students with risk factors, for students to approaches positive promoting is among a number of states Texas needs. in children. problems mental and emotional preventing · Holistic Approaches to Discipline andDiscipline to Approaches Holistic Health Mental Student and academic behavioral, developmental, discipline practices have Exclusionary models of intervention The alternative a high financial cost. as well as costs, of development the social and emotional discussed in this section can support than the while remaining more cost-effective behavior student and improve students discipline practices (i.e. suspension and expulsion) exclusionary resource-intensive on four This section will focus public schools. that are currently used in Texas specific interventions: · One example is crisis intervention teams (CIT) for children and youth that are youth that and for children (CIT) teams intervention is crisis example One behavioral to appropriate needs health with mental individuals to divert designed justice juvenile them to the of referring instead and supports health services system. · · · · · · · services and supports is the foundation of a successful CIT program. a successful CIT foundation of and supports is the services TEA 396 · · the following: · communication, andindividualresponsibility. replace apunishment-orientedsystem withacampusculturebasedonrespect,open and reinforceappropriatebehaviors forallstudents. PBISprogramsaredesignedto PBIS isanevidence-basedframeworkthatusesathree-tiered approachtoteach Retrieved from Interventions and Supports. (2010). Source: U. Special Education S. Education & Office of Programs’ Department of Technical Assistance Center on Positive Behavioral is Positive Behavioral Interventions andSupports(PBIS). A well-known exampleofapositive andproactive approachtoschool-basedservices S P Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Figure 160. Hierarchical Positive Modelof Behavioral Interventions&Supports the basicframeworkofPBIS.

upports ( ositive protective factorsfor students and their families. mental health issues. Thistierfocuses on developing skills and increasing of aloved onethatcauses them to have ahigher-than-normal riskofdeveloping who have risk factorssuch as exposure to violence, a history of trauma, ortheloss Tier 2: The secondary Tier 1:Theprimary prev severe, complex orchronic issues. providing comprehensive, individualized interventions forstudents withthemost population who need an in-depth system ofsupports. Thistierisfocused on Tier 3:Thetertiary prev personnel are expected to follow. curriculum to teachsocial skills and expectations that allstudents and school interventions for80 to 90percent of students. Inthis tier, schoolstaff usesa https://www.pbis.org/Common/Cms/files/pbisresources/SWPBS_ImplementationBlueprint_vSep_23_2010.pdf B e PBIS ha Implementation blueprint and self-assessment: Positive behavioral interventions and supports. vior ) prevention level focuses on the10 to 15percentofstudents ention level focuses on the1 to 5percentofthe student ention tier isthelargest ofthethree,focusingon a l I 210 nterventions 209 Theprogram’s threetiersconsist of 208 Figure160illustrates a nd TEA 397

217,218 ) Schools can choose 219 SEL 221 When PBIS initiatives 215 rning ( 224 a e L Technical assistance to implement PBIS is to implement assistance Technical l 211 TBSI was designed to build capacity in Texas in Texas to build capacity designed TBSI was SEL programs can be implemented from SEL programs can be implemented a 212 220 afe, ethical, and responsible. afe, ethical, and effectively well and productively with others with well and productively motion Schools that have implemented PBIS have achieved a wide achieved have implemented PBIS Schools that have 213 E tle conflicts with consideration for others for consideration conflicts with tle 214 e relationships AISD began implementing SEL in the 2013, with 73 of AISD’s 129 with 73 of AISD’s AISD began implementing SEL in the 2013, A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation PBIS also serves as a key organizing framework for other interventions, interventions, framework for other organizing as a key PBIS also serves nd 222 216 a By the 2015-2016 school year, all 86,000 students in AISD’s 129 different in AISD’s students all 86,000 school year, the 2015-2016 By l 223 a Help students work students Help positiv Develop their emotions Cope with set Appropriately efficiently more Work s that are decisions Make oci

include an anti-bullying component, schools have seen a 55-69 percent drop in seen a 55-69 percent drop component, schools have include an anti-bullying misbehavior. While there is currently no outcomes data available for SEL programs in Austin or for SEL programs in Austin While there is currently no outcomes data available of SEL has found: national research on the effectiveness elsewhere in Texas, Austin Independent School District (AISD) in central Texas has committed to has committed (AISD) in central Texas Independent School District Austin this in the country to make districts incorporate SEL in its schools — one of the first commitment. Social and Emotional Learning (SEL) is not a specific program, but a framework to Learning (SEL) is not Social and Emotional approach to working with students. help change the school’s S In 2009, more than 800 schools were actively participating in the PBIS trainings participating in than 800 schools were actively more In 2009, TBSI. facilitated by The Texas Education Agency Education PBIS to utilize districts school that recommends Texas The to required currently are not schools public Texas but behavior, student address related approaches. or other use PBIS available through the network of regional educational service centers and the Texas and the Texas service centers educational of regional the network through available (TBSI). Initiative Support Behavior from a variety of proven, effective SEL programs, but it is not necessary to hire necessary but it is not SEL programs, effective of proven, from a variety of an SEL program are related to implement SEL — the primary costs additional staff student surveys. training and staff such as the Social and Emotional Learning (SEL) approach described below. The below. Learning (SEL) approach described and Emotional such as the Social campuses but PBIS program varies greatly between to implement a school-wide cost training, for staff, including compensation per year, as roughly $10,000 can be as low to implement a PBIS program. and data resources needed and the infrastructure schools for the provision of positive behavioral interventions by assisting schools in assisting by interventions behavioral of positive the provision schools for and prevention- a wide range and implementing strategies developing of behavior based interventions. · · preschool through high school and have the ability to improve student functioning in student the ability to improve have preschool through high school and a number of areas. The main goals are to: of the SEL framework · · · · campuses were involved in the SEL program. campuses were involved However, there are many different variables that affect the cost of implementing PBIS, of implementing PBIS, that affect the cost different variables are many there However, to large urban centers. its proximity including the size of the school and range favorable outcomes, including fewer disciplinary referrals, improved academic improved including fewer disciplinary referrals, outcomes, range favorable restraints. less use of physical overall performance, and schools implementing SEL in the first school year, reaching over half of the students half of the over reaching year, school schools implementing SEL in the first enrolled. TEA 398 information ontrauma-informedcare,refertotheTexas Environment section. the trainingofteachersandschoolpersonnelwhointeract withchildren.For more Trauma-informed careisanoverarching concept thatcanbeimplementedthrough children feelsafe andaccepted by theirpeers, even whentheymake mistakes. organization’s approachtoworking with them.Inatrauma-informedenvironment, this understanding toensurethatstaff donot re-traumatizeindividualswiththe informed understandsoftraumasurvivors anduses thevulnerabilitiesandtriggers an annualcost of$16,000 — costs weremainlyfrom additionalstaff training, but oneschoolinSanAntonio implementedarestorative justice programat Costs associatedwithimplementing restorative justice can varybetween schools, inside andoutsideofthe classroom. managing behavior andpromoting academicandsocial-emotional growth both framework offersschoolsamoreproactive and strengths-based frameworkfor recover fromtheincidentinahealthy way. student behavior onothers, andhow thatstudent andtheirschoolcommunitycan can beappliedtotheentireschoolsetting by focusingontheimpactofharmful people, relationships, andtheschoolcommunity. Arestorative justice framework more thananinfractionoftheschool’s ruleby reframingthebehavior asharming Restorative justice isaprevention-oriented badbehavior frameworkthatviews as R ability tolearnandinteractsociallywiththeirpeers. threatening place,andthiscanleadtoanxiousbehaviors thatinterferewiththechild’s trauma insomeform.Childrenwhohave experiencedtraumaoftenseetheworldasa school employees inTexas, many childreninTexas publicschoolshave experienced While trainingintrauma-informedcareisnot requiredforeducatorsorpublic T · · · · · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas changing individualbehaviors. allowing schoolculturetobeimproved asawholerather thannarrowly focusing on to beusedby theentireschool sothattheoverall schoolcommunityisimproved by for restitution. Whilethecirclestake placeinclassrooms, the frameworkisintended expectations tocollectively address theproblemandmake anindividualizedplan school. Arestorative circleallows thestudents tousecommunityvaluesandgroup honestly aboutstudent misbehavior andtheeffectsithas ontheclassroomorentire by usingrestorative circlesintheclassroom,whereinstudents cantalkopenlyand of how theyeducateandinteractwithstudents. affects anindividualandincorporatesthatunderstanding oftraumaintoevery aspect environment (inthiscaseaschool)requiresthatallstaff understand how trauma

r estor A reduction in reports of depression, Fewer disciplinaryreferrals disruption) Reduced negative classroombeha Greater motivation SEL) Improved academicperformance(11 percent increase in achievement scoresafter a um a a - tive Justice Fr I n f ormed to learnand increased time studying athome 230 Ca SimilartoPBISandSEL,therestorative justice viors (e.g. less noncompliance, aggression,and re ( a anxiety and stress. mework 229 TIC Restorative justice canbeimplemented 228 ) Anorganizationthatistrauma- 227 Creating a trauma-informed Creatingatrauma-informed 225,226 TEA 399 Schoolwide 237 Examples of these side effects 235 234 ullying B This particular school in San Antonio experienced experienced Antonio in San school particular This 231 In 2015, TEA began partnering with the Institute for the Institute partnering with TEA began In 2015, 232 233 educe R Interventions to address bullying show moderate success; the to address bullying show Interventions 236 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation orts to orts to include anxiety, low grades, and social rejection. grades, low include anxiety, The Texas Education Code requires each school district to have an anti-bullying to have Education Code requires each school district The Texas to prevent policy methods and educators enforce appropriate measures that ensures educators, administrators, a webpagebullying. TEA has developed to provide resources about bullying — http://tea.texas.gov/Texas_ with and students parents, Schools/Safe_and_Healthy_Schools/Coordinated_School_Health/Coordinated_ . Research indicates that bullies and School_Health_-_Bullying_and_Cyber-bullying/ risk factors and could benefit from interventions of the same victims share many and interpersonal social interactions their problem-solving skills, to improve communication. Eff and a wide range legislators the acknowledge of advocacy now organizations Texas of 250 In one study and through the Internet. impact of bullying in schools negative experienced who were bullied 90 percent of the students middle school students, side effects as a result of the bullying. negative consultations, and materials. consultations, most effective are intensive programs that avoid peer-based approaches and include approaches peer-based avoid programs that are intensive effective most supervision. playground and better firm discipline, parent meetings, an 84 percent decrease in off-campus suspensions after switching from a “zero from a “zero switching after suspensions in off-campus decrease percent an 84 implementing Prior to framework. justice policytolerance” a restorative to of rates of the highest school had one this conflicts, to handle justice restorative in its district. discipline efforts like PBIS and SEL also have the potential to reduce bullying by creating an to reduce bullying the potential PBIS and SEL also have efforts like the school campus. of open communication and respect across environment Restorative Justice and Restorative Dialogue through the UT Austin School of School UT Austin through the Dialogue Restorative and Justice Restorative across the administrators district offer training for schools and to Social Work implementation discipline. Statewide and restorative justice in restorative state justice but restorative in its early stages, still in schools is justice of restorative 20 regional educational state’s of the being offered through 10 trainings are now service centers (ESCs). TEA 400 27 24 23 19 18 17 16 13 12 11 10 9 8 7 6 5 4 3 2 1 Endnotes Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 26 25 22 21 20 15 14

Text.aspx?LegSess=84R&Bill=SB133 Lakey, D Gaines, S. (20 History.aspx?LegSess=83R&Bill=SB460 Texas LegislatureOnline. (2013). Aid: Research andEvidence Base.Retrieved fromhttp://www.mentalhealthfirstaid.org/cs/about/research/ National CouncilforBehavioral Health andMissouriDepartmentofM Statewide Health CoordinatingCouncil’s H Texas EducationAgenc Texas EducationAgenc www.statutes.legis.state.tx.us/Docs/ED/htm/ED.33.htm#33.000 Texas EducationCode,tit.2,subtitle F months (Indicator4.5). Retrieved fromhttp://www.nschdata.org/browse/survey/results?q=2220&r=45 Health Initiativ Child andAdolescent in children’s mentalhealth.SchoolPsychology Review, 32,153-168. H.,Henderson,Ringeisen, K.,&H achievement. Journal ofHealth andSocialBehavior, 53(4),482-497. McLeod, J. D Texas EducationAgenc Texas EducationAgenc rptsvr1.tea.texas.gov/adhocrpt/adste.html Texas EducationAgenc gov/acctres/enroll_2014-15.pdf 2014-15: StatewideEnrollment, Texas PublicSchools,1987-88 Through 2014-15.Retrieved fromhttp://tea.texas. Texas EducationAgenc aspx Texas EducationAgenc Retrieved from http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 Texas EducationAgenc ries.html rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/DAG_Summaries/Download_State_DAG_Summa- Texas EducationAgenc DAG_Summaries/Download_State_DAG_Summaries.html PEIMS 2014-2015Data.Retrieved from https://rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/ Texas EducationAgenc DAG_Summaries/Download_State_DAG_Summaries.html PEIMS 2014-2015Data.Retrieved from https://rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/ Texas EducationAgenc gov/adhocrpt/adser.html Special EducationServicesbyPrimaryDisability, PEIMSData2015-16.Retrieved fromhttps://rptsvr1.tea.texas. Texas EducationAgenc gov/adhocrpt/adser.html Special EducationServicesbyPrimaryDisability, PEIMSData2015-16.Retrieved from https://rptsvr1.tea.texas. Texas EducationAgenc rptsvr1.tea.texas.gov/adhocrpt/adste.html Texas EducationAgenc gov/acctres/enroll_2014-15.pdf 2014-15: StatewideEnrollment, Texas PublicSchools,1987-88 Through 2014-15.Retrieved fromhttp://tea.texas. Texas EducationAgenc http://nces.ed.gov/programs/digest/d13/tables/dt13_204.70.asp by agegroup andstateorjurisdiction:Selectedyears, 1990–91through 2011–12(Table 204.70). Retrieved from Number andpercentage ofchildren Part served underIndividualswithDisabilitiesEducationAct(IDEA), B, U.S. DepartmentofEducationIns WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590006580 Mental HealthServices.Texas DepartmentofStateHealth Services. Retrieved fromhttp://www.dshs.texas.gov/ Lewis, L.&Jessee, G.(March22,20 Texas LegislatureOnline.(2015). substance abuseservices[PowerPoint slides]. [PowerPoint slides].Retrieved fromhttp://www.hhsc.state.tx.us/news/present83.asp hprc/publications/2015/2015LSSPFactSheet.pdf Demographics: LicensedSpecialistsinSchoolPsychology, 2015.Retrieved fromhttp://www.dshs.texas.gov/chs/ Retrieved fromhttp://ritter.tea.state.tx.us/adhocrpt/adpeb.html Retrieved fromhttp://ritter.tea.state.tx.us/adhocrpt/adpeb.html rptsvr1.tea.texas.gov/adhocrpt/adste.html gov/acctres/enroll_2014-15.pdf 2014-15: StatewideEnrollment, Texas PublicSchools,1987-88 Through 2014-15.Retrieved fromhttp://tea.texas. . (2014). Presentation toSenateHealth andHumanServicesCommittee: Overview mentalhealthand ., Uemura,R.,&Rohrman,S. (2012). Adolescentmentalhealth,behaviorproblems, andacademic 14). Presentation totheSenateHealthandHumanServicesCommittee on mentalhealthcoordination y. (2016). 2015-2016StudentEnrollment, StatewideTotals. Retrieved fromhttps:// y, DivisionofResearchandAnalysis. (April2016). Enrollment inTexas PublicSchools, y. (2016). Overview ofTexas Schools.Retrieved fromhttp://tea.texas.gov/districtinfo. y. (August 2016). Fiscal Legislative Appropriations Requestfor Years 2018and2019. Pg. 9. y. (2016). Counts ofDAEP andJJAEP PlacementReasonTypes. Retrieved from https:// y. (2016). Counts ofStudentsandDisciplineActionsbyActionGroupings: y. (2016). Counts ofStudentsandDisciplineActionsbyActionGroupings: y. (July 13, 2016). AllTexas PublicSchoolsIncludingCharterSchools,StudentsReceiving y. (2016). AllTexas PublicSchoolDistrictsIncludingCharterSchools:StudentsReceiving y. (2016). 2015-2016StudentEnrollment, StatewideTotals. Retrieved fromhttps:// y, DivisionofResearchandAnalysis. (April2016). Enrollment inTexas PublicSchools, y. (2016). StaffFTEcountsandsalary reports: 2015-2016Statewidetotals[Datafile]. y. (2014). StaffFTEcountsandsalary reports: 2013-2014Statewidetotals[Datafile]. y. (2016). 2015-2016StudentEnrollment, StatewideTotals. Retrieved fromhttps:// y, DivisionofResearchandAnalysis. (April2016). Enrollment inTexas PublicSchools, Senate Bill133.Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ Senate Bill460. Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ titute ofEducationSciencesNationalCenterforStatistics. (2013). oagwood K.(2003).Context matters: Schoolsandthe“research topractice” gap e. (2012). Received mentalhealthtreatment orcounselinginthepast12 16). Presentation totheSelectCommittee onMentalHealth:Children’s ., Chapter 33, Subchapter A.§33.006(a). (2013). Retrieved fromhttp:// ealth ProfessionsResourceCenter. (2016). Trends, Distribution,and . ental Health. (2013). MentalHealthFirst TEA 401 Mental Health First Health First Mental (2013). ental Health. Item 21: Update and Report of Legislation Related to the and Report of Legislation Item 21: Update WISQARS Fatal Injury Reports, 1999-2014, for Injury Reports, 1999-2014, National, Fatal WISQARS Reports, 1999-2014, for Injury National, Re- Fatal WISQARS Reports, 1999-2014, for Injury National, Fatal WISQARS Legislative Session (2015) — HB 2684: Training for in Police Training (2015) — HB 2684: Session Legislative Legislative Session (2015) — HB 2684: Training for in Police Training (2015) — HB 2684: Session Legislative th th Youth Risk Behavior Surveillance — United States, Risk Behavior Surveillance Youth 2016). une 10, States, — United Behavior Surveillance Risk Youth 2016). une 10, Table 17: five leading causes of death by sex and age Texas Texas and age of death by sex leading causes five 17: Table . (2015). 13). Suicide fact from http://www.nami.org/factsheets/ sheet. Retrieved 13). Suicide fact from http://www2.nami.org/factsheet. Retrieved ter 25., subchapter A. § 25.094 (2011). Retrieved from http://www.statutes. Retrieved (2011). A. § 25.094 subchapter ter 25., Retrieved from http://www.capitol.state.tx.us/BillLookup/ Retrieved House Bill 1479. from http://www.capitol.state.tx.us/BillLookup/ Retrieved Senate Bill 1419. Retrieved from http://www.capitol.state.tx.us/BillLookup/ House Bill 2186. Retrieved from http://www.capitol.state.tx.us/BillLookup/ Retrieved Senate Bill 674. from http://www.capitol.state.tx.us/BillLookup/ . Retrieved Senate Bill 1624 from http://www.capitol.state.tx.us/BillLookup/ Retrieved House Bill 1684. Senate Bill 674. Retrieved from http://www.capitol.state.tx.us/BillLookup/His- from Retrieved Bill 674. Senate http://www.capitol.state.tx.us/BillLookup/ from Retrieved Senate Bill 674. Update from Texas’ 84 Texas’ Update from Update from Texas’ 84 Texas’ Update from Frequently Asked Questions: What are “leg- Questions: What are Asked Services Administration. (n.d.). Frequently ental Health Retrieved from https://mhfa.com.au/ Retrieved Evaluations. Course MHFA (2016). t Aid Australia. A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation NCHS Data Brief No. 241: Increase in Suicide in the Unit- 241: Increase NCHS Data Brief No. (April 2016). H. & Hedegaard, M., arner, Criminalization of truancy in Texas: Prosecution of “Failure to Attend School” in adult criminal of “Failure Prosecution truancy in Texas: of Criminalization (2013). , D. to Attend School” in adult criminal of “Failure Prosecution truancy in Texas: of Criminalization (2013). , D. Criminalization of truancy in Texas: Prosecution of “Failure to Attend School” in adult criminal of “Failure Prosecution truancy in Texas: of Criminalization (2013). , D. Texas Appleseed. Retrieved from http://youthlaw.org/wp-content/uploads/2015/01/Truancy-Research. from Appleseed. Retrieved courts. Texas pdf http://youthlaw.org/wp-content/uploads/2015/01/Truancy-Research. from Appleseed. Retrieved courts. Texas pdf Texas Appleseed. Retrieved from http://youthlaw.org/wp-content/uploads/2015/01/Truancy-Research. from Appleseed. Retrieved courts. Texas pdf Fowler Legislature Online. (2013). Texas History.aspx?LegSess=83R&Bill=HB1479 Legislature Online. (2013). Texas Retrieved from https://www.texasappleseed.org/sites/default/files/HB%202684%20Ex- Public Schools. Retrieved Texas planation%20FINAL.pdf legis.state.tx.us/Docs/ED/htm/ED.25.htm Fowler Fowler Texas Appleseed. (2015). Appleseed. (2015). Texas E., chap Edu Code titl. 2 subtitle Tex Retrieved from https://www.texasappleseed.org/sites/default/files/HB%202684%20Ex- Public Schools. Retrieved Texas planation%20FINAL.pdf Texas Appleseed. (2015). Appleseed. (2015). Texas suicide_factsheet.pdf Legislature Online. (2015). Texas History.aspx?LegSess=84R&Bill=HB2186 Legislature Online. (2015). Texas History.aspx?LegSess=84R&Bill=SB674 Legislature Online. (2015). Texas History.aspx?LegSess=84R&Bill=SB01624 Legislature Online. (2015). Texas History.aspx?LegSess=84R&Bill=HB2684 Texas Department of State Health Services Department of State Health Texas (20 Illness. National Alliance on Mental (20 Illness. National Alliance on Mental Regional, and State (Restricted): 2014, United State Suicide Injury Deaths and Rates per 100,000, All Races, Both and Rates per 100,000, 2014, United State Suicide Injury Deaths Regional, and State (Restricted): from http://webappa.cdc.gov/cgi-bin/broker.exe Retrieved Y87.0,*U03. X60-X84, Codes: All Ages, ICD-10 Sexes, (2016). Center for Disease Control and Prevention. All All Races, Both Sexes, Suicide Injury Deaths and Rates per 100,000, gional, and State (Restricted): 2014, Texas http:// from http://webappa.cdc.gov/cgi-bin/broker.exe Retrieved Y87.0,*U03. X60-X84, Ages, ICD-10 Codes: webappa.cdc.gov/cgi-bin/broker.exe (2016). Center for Disease Control and Prevention. All Races, Both Suicide Injury Deaths and Rates per 100,000, Regional, and State (Restricted): 2014, United States from http://webappa.cdc.gov/cgi-bin/broker.exe Retrieved Y87.0,*U03. X60-X84, Codes: All Ages, ICD-10 Sexes, http://webappa.cdc.gov/cgi-bin/broker.exe http://www.dshs.texas.gov/chs/vstat/vs13/t17.aspx from [Data file]. Retrieved residents sheets/suicide_factsheet.pdf Curtin, S. C., W C., Curtin, S. (2016). and Prevention. Center for Disease Control (J Centers for Disease Control and Prevention. Retrieved Retrieved Session. Legislative Texas Plan Implementation for 84th for the Certification: Educator State Board from http://tea.texas.gov/WorkArea/DownloadAsset.aspx?id=51539607825 and M Abuse Substance Firs Health Mental research/mhfa-course-evaluations (J and Prevention. Centers for Disease Control http://www.cdc.gov/healthyyouth/data/yrbs/pdf/2015/ from Retrieved 26 and 27. 25, Tables 75-77, 2015. Pages ss6506_updated.pdf http://www.cdc.gov/nchs/products/databriefs/db241.htm from ed State, 1999-2014. Retrieved from http://www.cdc.gov/healthyyouth/data/yrbs/pdf/2015/ Retrieved 26 and 27. 25, Tables 75-77, 2015. Pages ss6506_updated.pdf Texas Legislature Online. (2015). (2015). Online. Legislature Texas Online. (2015). Legislature Texas 2016). (April 15, for Educator Certification. State Board http://www.nrepp. from on NREPP?. Retrieved included do they differ the programs and how from acy” program samhsa.gov/02c_faq.aspx National Council for Behavioral Health and Missouri Department of M Department and Missouri Health for Behavioral Council National from http://www.mentalhealthfirstaid.org/cs/about/ Retrieved Aid: About. tory.aspx?LegSess=84R&Bill=SB674 History.aspx?LegSess=84R&Bill=SB674

52 53 51 54 49 50 48 43 44 45 46 47 37 39 40 41 42 32 34 35 36 38 33 28 29 30 31 TEA 402 77 71 70 69 63 62 61 60 59 58 57 56 55 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 80 79 78 76 75 74 73 72 68 67 66 65 64

Texas EducationAgenc files/TEAComplaint_Release_MAIN-WEBFinal_5-27.pdf Force StudentswithDisabilitiesOut ofSchool.Retrieved fromhttps://www.texasappleseed.org/sites/default/ Disability RightsTexas Texas EducationAgenc Texas EducationAgenc Texas EducationAgenc Texans CareforChildren.(n.d.).Education. Texas EducationAgenc of-Exclusionary-Discipline-in-11-Texas-School-Districts_TxAppleseed.pdf districts. Retrieved fromhttp://www.njjn.org/uploads/digital-library/Breaking-Rules-Breaking-Budgets--Cost- Texas Appleseed.(2009). NAL_10.2.09.pdf ommendations. Retrieved from http://www.mhtransformation.org/documents/pdf/sbbh/SBBH_Report_FI- Texas Mental H trieved fromhttps://www.texastribune.org/2016/05/29/higher-suicide-rates-trouble-small-town-texas/ Walters, E.(Ma Bain, S., Rueda,B., Mata- Bain, S., Rueda,B., Mata- Kessler, R.C Substance Abuse andM Substance Abuse andM PMC4477835/ countries. The Lancet Psychiatry,1 (5),377-387. Retrieved fromhttp://www.ncbi.nlm.nih.gov/pmc/articles/ Fazel, M.,Hoagwood, K.,Stephan,S mental healthcare inAmerica.Retrieved fromhttp://www.samhsa.gov/federalactionagenda/NFC_intro.aspx The President’s NewFreedom CommissiononM GIH%2010_23_13.ashx slides]. Retrieved fromhttp://www.healthinschools.org/~/media/Presentations/2013%20Presentations/ Price, O. A.(2013). History.aspx?LegSess=84R&Bill=HB2398 Texas LegislatureOnline.(2015). tlodocs/84R/billtext/pdf/HB02398F.pdf#navpanes=0 Texas LegislatureOnline.(2015). aspx?LegSess=84R&Bill=HB2398 Texas LegislatureOnline.(2015). History.aspx?LegSess=84R&Bill=SB107 Texas LegislatureOnline.(2015). pus_discipline/ dence/TAA_Letters/Legislation_passed_by_the_84th_Texas_Legislature_relating_to_truancy_and_on-cam- and on-campusdiscipline.Retrieved fromhttp://tea.texas.gov/About_TEA/News_and_Multimedia/Correspon- Texas EducationAgenc History.aspx?LegSess=83R&Bill=SB1419 www.tea.state.tx.us/index4.aspx?id=2147494988 Texas EducationAgenc Retrieved fromhttp://www.gpo.gov/fdsys/pkg/CFR-2007-title34-vol2/pdf/CFR-2007-title34-vol2-part300.pdf Education Assistance toStates fortheEducationofChildrenwithDisabilities Rule,34C www.tea.state.tx.us/index4.aspx?id=2147494988 Texas EducationAgenc 5MHc/view?usp=sharing ment Data2015-2016[Excel file]. Available https://drive.google.com/file/d/0B-CM0KurzX_rR0Y2d1VpZUZ- 5MHc/view?usp=sharing ment Data2015-2016[Excel file]. Available https://drive.google.com/file/d/0B-CM0KurzX_rR0Y2d1VpZUZ- Retrieved fromhttps://framework.esc18.net/Documents/ARD_Guide_ENG.pdf Retrieved fromhttps://framework.esc18.net/Documents/ARD_Guide_ENG.pdf drens-Mental-Health-Forum/Education Retrieved from www.tea.state.tx.us/FosterCareStudentSuccess/resource-guide.pdf and studentsuccess: Texas systems working care. together totransform educationoutcomesofstudentsinfoster Permanent Judicial CommissionforChildren,Youth andFamilies (Children’s Commission).(2013). Foster care Texas: Counselors’ perspectives. ResearchinHigherEducationJournal, 14, 1-11. Texas: Counselors’ perspectives. ResearchinHigherEducationJournal, 14, 1-11. al Psychiatry, 62(6). 593-602. age-of-onset distributionsofDSM-IV disorders intheNationalComorbidity Survey replication. Archives ofGener- gov/shin/content/SMA10-4547/SMA10-4547.pdf (HHSPublicationNo.young children andtheirfamilies (SMA)-10-4547). Retrieved fromhttp://store.samhsa. gov/shin/content/SMA10-4547/SMA10-4547.pdf (HHSPublicationNo.young children andtheirfamilies (SMA)-10-4547). Retrieved fromhttp://store.samhsa. ., Berglund,P., Demler, O., Jin, R.,Merikangas, K.R.,Walters, prevalence E.(2005).Lifetime and y 29, 2016). SuicidePrevention Efforts Focus onSmall Texas Towns. TheTexas Tribune.Re- ealth Transformation.(2009). Texas school-basedbehavioral healthsurvey -results andrec- Sustaining effective behavioralSustaining effective healthapproaches: Research, practices andpolicy[PowerPoint . (May 27, 2015). Complaint Charges Texas SchoolDistrictswithUsing TruancyCourts to y. (August 25, 2015). Legislationpassed bythe84th Texas Legislature relating totruancy y. Texas (2013). Servicesfor studentswith disabilitiesages3-5.Retrieved fromhttp:// y. Texas (2013). Servicesfor studentswith disabilitiesages3-5.Retrieved fromhttp:// y. Request#27332: (2016). PublicInformation DisabilityandSpecialEducationEnroll- y. Request#27332: (2016). PublicInformation DisabilityandSpecialEducationEnroll- y. (April2016). Parent’s Guideto theAdmission, ReviewandDismissal Process. Page 4. y. (April2016). Parent’s Guideto theAdmission, ReviewandDismissal Process. Page 4. y, Texas DepartmentofFamily and Protective Services, &SupremeCourtofTexas ental Health (2010). ServicesAdministration. Addressing thementalhealthneedsof ental Health (2010). ServicesAdministration. Addressing thementalhealthneedsof Villarreal, J., &Mundy, M.(2011). Assessing mentalhealthneedsofrural schools inSouth Villarreal, J., &Mundy, M.(2011). Assessing mentalhealthneedsofrural schools inSouth Breaking rules,breaking budgets:Cost ofexclusionary disciplinein11Texas school House Bill2398.Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ House Bill2398.Pg. 2-3. Retrieved fromhttp://www.capitol.state.tx.us/ House Bill2398.fromhttp://www.capitol.state.tx.us/BillLookup/History. Senate Bill107. Retrievedhttp://www.capitol.state.tx.us/BillLookup/ from ., &Ford, T. (2014). Mentalhealthinterventions inschoolshigh-income Retrieved fromhttp://texanscareforchildren.org/Texas-Chil- ental Health. (2009). Achievingthepromise: Transforming .F.R. §300.8 (2007). TEA 403 Retrieved Retrieved Retrieved Retrieved Retrieved from http:// 2016. Retrieved of Education The Condition Retrieved from 15). School Health and Related Services. Retrieved from 15). School Health and Related Services. Retrieved Retrieved from Retrieved with Disabilities: 2013-14. Children ercent January 14, 2015). School Health and Related Services (SHARS) 2015). 14, January School Health and Related Services (SHARS) 2015). 14, January Retrieved from http://www.edcentral.org/edcy- Retrieved IDEA Funding. Quarterly Agency and Department Activity Reports. Agency and Department Quarterly 2016). tee. (July Individuals with Disabilities Education Act – cost impact on local school Individuals with Disabilities Education Act – cost impact on local school Retrieved from http://www.capitol.state.tx.us/BillLookup/His- Retrieved Bill 617. House Retrieved from http://www.capitol.state.tx.us/BillLookup/ from Retrieved Senate Bill 1117. http://www.capitol.state.tx.us/BillLookup/ from Retrieved Senate Bill 1259. Individuals with Disabilities Education Act-funding distribution. 4). Individuals with Disabilities Education Act-funding distribution. 4). Individuals with Disabilities Education Act-funding Individuals with Disabilities Education Act-funding distribution. 4). Individuals with Disabilities Education Act-funding Retrieved from http://www.edexcellence- in special education. Retrieved 11). Shifting trends Page Page 2018 and 2019. Years Request for Appropriations Legislative Fiscal 2016). (August y. Enrollment in Texas Public Schools, in Texas Enrollment (April 2016). Division of Research and Analysis. y, Pg. 2018 and 2019. Years Request for Appropriations Legislative Fiscal 2016). (August y. Pg. 2018 and 2019. Years Request for Appropriations Legislative Fiscal 2016). (August y. Pg. 2018 and 2019. Years Request for Appropriations Legislative Fiscal 2016). (August y. from http:// 3-5. Retrieved students with disabilities ages Services for (2013). Texas y. 2015-2016 Special Education Reports: All Texas Public Schools Includ- Public Reports: All Texas 2015-2016 Special Education 2016). 13, (July y. https:// from Retrieved Totals. Statewide 2015-2016 Student Enrollment, (2016). y. Outcomes for youth with serious emotional disturbance in secondary school and early adult- in secondary school and early Outcomes for with serious emotional disturbance youth Fully Funding IDEA: New America Funding Just an Empty Promise?. or Dream Fully , 2016). A Democratic A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation tate.tx.us/index4.aspx?id=2147494988 Education Assistance to States for (2007).ernment Publishing Office. with Education Assistance of Children the Education http://www.hhsc.state.tx.us/rad/acute-care/shars/ http://www.hhsc.state.tx.us/rad/acute-care/shars/ 183. Retrieved from http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 Retrieved 183. and Human Services Commission. (20 Health Texas and Human Services Commission. ( Health Texas and Human Services Commission. ( Health Texas New America Foundation’s Ed Central. (n. d.) New America Foundation’s clopedia/individuals-with-disabilities-education-act-funding-distribution/ Education Agenc Texas and Human Services Commission. (20 Health Texas http://www.hhsc.state.tx.us/rad/acute-care/downloads/ from Retrieved 15. Questions. Pg. Asked Frequently shars-cr-faq.pdf New America Foundation. (2013). (2013). New America Foundation. (2013). New America Foundation. K. (March 23 Dancy, from https://www.newamerica.org/education-policy/edcentral/fully-funding-idea/ Retrieved Foundation. from http://febp.newamerica.net/background-analysis/individuals-disabilities-education-act-funding-distribution (201 New America Foundation. from http://febp.newamerica.net/background-analysis/individuals-disabilities-education-act-funding-distribution (201 New America Foundation. from http://febp.newamerica.net/background-analysis/individuals-disabilities-education-act-funding-distribution Pg. X. Retrieved from http://tea. X. Retrieved Pg. 2014-15. Through Public Schools, 1987-88 Texas 2014-15: Statewide Enrollment, texas.gov/acctres/enroll_2014-15.pdf from http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 Retrieved 39. Education Agenc Texas from http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 Retrieved 39. Education Agenc Texas from http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 Retrieved 13. Education Agenc Texas www.tea.state.tx.us/index4.aspx?id=2147494988 (201 New America Foundation. from http://febp.newamerica.net/background-analysis/individuals-disabilities-educa- districts. Retrieved tion-act-cost-impact-local-school-districts from http://febp.newamerica.net/background-analysis/individuals-disabilities-educa- districts. Retrieved tion-act-cost-impact-local-school-districts Scull, J. & Winkler, A. M. (20 & Winkler, Scull, J. Education Agenc Texas Education Agenc Texas U.S Gov U.S from http://www.gpo.gov/fdsys/pkg/CFR-2007-title34-vol2/pdf/ Retrieved § 300.8. Disabilities Rule, 34 C.F.R. CFR-2007-title34-vol2-part300.pdf 2016). of Education. (May United States Department P United States Department of Education. (2015). media.net/publications/2011/20110525_ShiftingTrendsinSpecialEducation/ShiftingTrendsinSpecialEduca- tion.pdf Retrieved from http://www.dads.state.tx.us/providers/pi/piac/7-21-16-reports.pdf Retrieved Education Agenc Texas Education Agenc Texas M. M. (1995). Wagner, Texas Legislature Online. (2013). (2013). Online. Legislature Texas Online. (2015). Legislature Texas Online. (2015). Legislature Texas Independence AdvisoryPromoting Commit PEIMS Data 2015-16. Primary Disability, Receiving Special Education Services by ing Charter Schools, Students from https://rptsvr1.tea.texas.gov/adhocrpt/adser.html Retrieved rptsvr1.tea.texas.gov/adhocrpt/adste.html of Children, (5)2, 90-112. hood. The Future Retrieved from http:// Retrieved ages 3-5. disabilities students with for Services (2013). Texas Agency. Education Texas www.tea.s History.aspx?LegSess=84R&Bill=SB1117 History.aspx?LegSess=84R&Bill=SB1259 nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2016144 http://eddataexpress.ed.gov/data-element-explorer.cfm/tab/data/deid/5/ tory.aspx?LegSess=83R&Bill=HB617

107 108 106 105 109 104 99 100 101 94 95 96 97 98 102 103 90 93 86 87 88 89 81 82 84 85 91 92 83 TEA 404 140 135 127 126 125 124 123 122 121 120 119 118 117 116 115 114 113 112 111 110 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 139 138 137 136 134 133 132 131 130 129 128

hind/460305/ http://www.theatlantic.com/education/archive/2016/02/how-school-suspensions-push-black-students-be- Texas Appleseed.(2016). Justice Center Texas EducationAgenc Texas EducationAgenc net/vimages/shared/vnews/stories/5553607d2a4f8/HB_1952_administrator_training.pdf Region 9EducationServiceCenter. (n.d.)Administr Texas Adminis Texas EducationAgenc Texas Adminis Texas Adminis Texas EducationAgenc Texas EducationAgenc Texas EducationAgenc age.aspx?id=4639 Texas EducationAgenc Communities inSchools. (J about/ Communities InSchools. (n.d.).AboutU texas.gov/schoolhealth/csh.shtm Texas DepartmentofStateHealth Services texas.gov/schoolhealth/csh.shtm Texas DepartmentofStateHealth Services texas.gov/schoolhealth/csh.shtm Texas DepartmentofStateHealth Services Retrieved fromhttp://www.tea.state.tx.us/CounselingMentalHealth.html Texas EducationAgenc bID=25769816356 135. Retrieved fromhttp://tea.texas.gov/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=25769816299&li- Texas EducationAgenc 153. Retrieved fromhttp://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 Texas EducationAgenc loads/2013/08/2014-Rider-38-Report-Final.pdf by SchoolDistrictsandCharterSchools.Pg. 12.Retrieved fromhttp://www.texasresc.net/wp-content/up- Texas System ofEducationServiceCenters Texas EducationServiceCenters. (n.d.) 183. Retrieved fromhttp://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 Texas EducationAgenc Region 13EducationServiceCenter. (2016). net/services/special-education-solutions/behavior-discipline-management Region 4EducationServiceCenter. (n.d.)Behavior Texas EducationServiceCenters. (n.d.) rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=19&pt=2&ch=89&rl=1055 Texas Adminis rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=354&rl=1342 Texas Adminis shars-cr-faq.pdf Frequently Asked Questions.Pg. 1.Retrieved fromhttp://www.hhsc.state.tx.us/rad/acute-care/downloads/ DAG_Summaries/Download_State_DAG_Summaries.html PEIMS 2014-2015Data.Retrieved fromhttps://rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/ Texas EducationAgenc Wong, A.(February 8 www.texasappleseed.org/sites/default/files/TexasAppleseed_Suspensions_Infographic.pdf Report_Final.pdf volvement. Retrieved fromhttps://csgjusticecenter.org/wp-content/uploads/2012/08/Breaking_Schools_Rules_ Breaking schoolrules:Astatewidestudyofhow schooldisciplinerelates tostudentsuccess andjuvenile justicein- Education. Retrieved fromhttp://tea.texas.gov/WorkArea/DownloadAsset.aspx?id=25769823498 ries.html Retrieved fromhttps://rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/Download_State_Summa- ries.html Retrieved from https://rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/Download_State_Summa- rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=37&pt=11&ch=348&rl=104 rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=19&pt=2&ch=103&rl=1201 183. Retrieved fromhttp://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 134. Retrieved fromhttp://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=703&fy=2018 age.aspx?id=4639 , CouncilofStateGovernments, andthePublic Policy Institute atTexas A&MUniversity. (2011). trative Codehttps://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_ trative Codehttp://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_ trative Code:http://www.statutes.legis.state.tx.us/Docs/ED/htm/ED.37.htm trative Code:https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_ trative Code:https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_ , 2016). How SchoolSuspensionsPushBlackStudentsBehind.TheAtlantic. Retrieved from y. (2016). Communities inSchoolsofTexas. Retrieved fromhttp://tea.texas.gov/interiorp- y. (2012). Counseling andmentalhealthservicesoftheCoordinated SchoolHealthModel. y. (August 2014). Fiscal Legislative Appropriations Requestfor Years 2016and2017. Pg. y. (August 2016). Fiscal Legislative Appropriations Requestfor Years 2018and2019. Pg. y. (August 2016). Fiscal Legislative Appropriations Requestfor Years 2018and2019. Pg. y. (2016). Counts ofStudents andDisciplineActionsbyActionGroupings: y. (2016). 2015Performance-Based MonitoringAnalysis System, StateReport:Special y. 2014-2015. (2016) StateLevel AnnualDisciplineSummary: PEIMSDisciplineDatafor y. 2014-2015. (2016). StateLevel AnnualDisciplineSummary:PEIMSDatafor y. (August 2016). Fiscal Legislative Appropriations Requestfor Years 2018and2019. Pg. y. (August 2016). Fiscal Legislative Appropriations Requestfor Years 2018and2019. Pg. y. (2016). Communities inSchoolsofTexas. Retrieved fromhttp://tea.texas.gov/interiorp- Kids Can’tLearnifThey’re PushedOutofSchoolInfographic. Retrieved fromhttps:// uly 29, 2016). Personal Communication:StatewideCoordination. About theESCs. Retrieved fromhttp://www.texasresc.net/about-escs/ About theESCs. Retrieved fromhttp://www.texasresc.net/about-escs/ s: OurStory. Retrieved fromhttps://www.communitiesinschools.org/ . (2016). Coordinated SchoolHealth.Retrieved from http://www.dshs. . (2016). Coordinated SchoolHealth.Retrieved from http://www.dshs. . (2016). Coordinated SchoolHealth.Retrieved from http://www.dshs. . (December2014). Rider38Report:Cost SavingsExperienced Behavior. Retrieved fromhttp://www4.esc13.net/behavior/ /Discipline Management.Retrieved fromhttp://www.esc4. ator Training: HB1952.Retrieved fromhttp://www.esc9. TEA 405 Retrieved from https://www.disability- from Retrieved Retrieved from http://www.capitol.state.tx.us/BillLookup/Histo- Retrieved , National Center for Youth Law, Texas, Appleseed, & Thurgood Appleseed, & Mar- Texas, Law, for Youth , National Center ter 37, subchapter A. § 37.008 (2011). Retrieved from www.statutes.legis. Retrieved (2011). A. § 37.008 subchapter ter 37, ter 37, subchapter A. § 37.005 (2003). Retrieved from www.statutes.legis. from Retrieved (2003). A. § 37.005 subchapter ter 37, ter 37, subchapter A. § 37.008 (2011). Retrieved from www.statutes.legis. Retrieved (2011). A. § 37.008 subchapter ter 37, ter 37, subchapter A. § 37.008 (2011). Retrieved from www.statutes.legis. Retrieved (2011). A. § 37.008 subchapter ter 37, Retrieved from Campaign. Retrieved AISD Attendance Day Counts: Every trict. (2016). Retrieved from https://www. Retrieved to incarceration. school-to-prison pipeline: Dropout Texas’ to dropout. lockout path from –the school-to-prison pipeline: School expulsion Texas’ to dropout. lockout path from –the school-to-prison pipeline: School expulsion Texas’ State Level Annual Discipline Summary: PEIMS Discipline Data for Annual Discipline Summary: State Level (2016). 2014-2015. y. Counts of Students and Discipline Actions by Discipline Action Groupings: by Discipline Action Groupings: of Students and Discipline Actions Counts (2016). y. State Level Annual Discipline Summary: PEIMS Discipline Data for State Level (2016). 2014-2015. y. of Students and Discipline Actions by Discipline Action Groupings: Counts (2016). y. y. (2012). Appendix E: Additional (2012). related to discipline. 2011-2012 PEIMS information y. Counts of Students and Discipline Actions by Discipline Action Groupings: and Discipline Actions by Discipline Action Groupings: of Students Counts (2016). y. 85. . Pg. Public Schools Report on Texas Biennial 2014 Comprehensive 2016). (January y. A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation , Council of State Governments, and the Public Policy Institute at Texas A & M University. (2011). (2011). A & M University. at Texas Institute Public Policy and the , Council of State Governments, , Council of State Governments, and the Public Policy Institute at Texas A & M University. (2011). (2011). M University. A & at Texas Institute and the Public Policy , Council of State Governments, Juvenile Justice Alternative Education Programs Performance Performance Education Programs Justice Alternative Juvenile 2016). Department. (May enile Justice Juvenile Justice Alternative Education Programs Performance Performance Education Programs Justice Alternative Juvenile 2016). Department. (May enile Justice Performance Education Programs Justice Alternative Juvenile 2016). Department. (May enile Justice Performance Education Programs Justice Alternative Juvenile 2016). Department. (May enile Justice . Retrieved from http://www.tjjd.texas.gov/ . Retrieved programming Department. (n.d.). JJAEP enile and Justice /www.texasappleseed.org/when-my-child-disciplined-school-guide-families Tex Edu Code titl. 2, subtitle G., chap Edu Code titl. 2, subtitle Tex state.tx.us/Docs/ED/htm/ED.37.htm Education Agenc Texas from https://rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/Download_State_Summa- Retrieved ries.html Texas Juv Texas Juv Texas from http://www.tjjd.texas.gov/publications/re- Retrieved 17. . Pg. 2014-2015 Report: School Years Assessment ports/JJAEP_2015_Report.pdf state.tx.us/Docs/ED/htm/ED.37.htm Juv Texas from http://www.tjjd.texas.gov/publications/re- i. Retrieved . Pg. 2014-2015 Report: School Years Assessment ports/JJAEP_2015_Report.pdf Juv Texas from http://www.tjjd.texas.gov/publications/reports/ . Retrieved 2014-2015 Report: School Years Assessment JJAEP_2015_Report.pdf Education Agenc Texas from https://rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/ PEIMS 2014-2015 Data. Retrieved DAG_Summaries/Download_State_DAG_Summaries.html from http://www.tjjd.texas.gov/publications/re- Retrieved 16. . Pg. 2014-2015 Report: School Years Assessment ports/JJAEP_2015_Report.pdf Retrieved from http://www.njjn.org/uploads/digital-library/Texas-School-Prison-Pipeline-School-Expulsion_ Retrieved Texas-Appleseed_Apr2010.pdf Appleseed. (2010). Texas from http://www.njjn.org/uploads/digital-library/Texas-School-Prison-Pipeline-School-Expulsion_ Retrieved Texas-Appleseed_Apr2010.pdf Juv Texas services/jjaep.aspx G., chap Edu Code titl. 2, subtitle Tex Retrieved from https://rptsvr1.tea.texas.gov/cgi/sas/broker Retrieved justice in- and juvenile to student success school discipline relates A statewide study of how school rules: Breaking from https://csgjusticecenter.org/wp-content/uploads/2012/08/Breaking_Schools_Rules_ Retrieved volvement. Report_Final.pdf Education Agenc Texas from https://rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/ PEIMS 2014-2015 Data. Retrieved DAG_Summaries/Download_State_DAG_Summaries.html Legislature Online. (1995). Senate Bill 1. Texas Appleseed. (2010). Texas Texas Appleseed. (2007). Texas Education Agenc Texas Center Justice ry.aspx?LegSess=74R&Bill=SB1 Justice Center Justice Education Agenc Texas from http://www.tea.state.tx.us/chapter37_reporting.html Retrieved Data Standard. texasappleseed.org/sites/default/files/01-STPPReport2007.pdf rightstx.org/files/JointOSSReportAug7-2012.pdf Education Agenc Texas Education Agenc Texas Ibid. G., chap Code, titl. 2, subtitle Edu Tex state.tx.us/Docs/ED/htm/ED.37.htm Tex Edu Code, titl. 2, subtitle G., chap G., titl. 2, subtitle Edu Code, Tex Texas Rights Risk, Disability Children at Independent School Dis Austin https://www.austinisd.org/everydaycounts from https://rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/ Retrieved PEIMS 2014-2015 Data. DAG_Summaries/Download_State_DAG_Summaries.html from http://tea.texas.gov/acctres/Comp_Annual_Biennial_2014.pdf Retrieved justice in- and juvenile to student success discipline relates school school rules: A statewide study of how Breaking from https://csgjusticecenter.org/wp-content/uploads/2012/08/Breaking_Schools_Rules_ Retrieved volvement. Report_Final.pdf When my child is disciplined at school: A guide for school: A disciplined at my child is When 2009). families. from Retrieved (January Appleseed. Texas https:/ state.tx.us/Docs/ED/htm/ED.37.htm on out of school reply school districts disproportionately 30 Texas (2012). Institute. Earl Carl of Law’s shall School of school. and pushing students out Leaving money behind suspension:

166 165 160 161 162 163 164 157 158 159 153 154 155 156 151 152 144 148 149 145 146 147 150 141 142 143 TEA 406 190 188 186 185 184 183 181 179 178 177 176 175 174 173 172 171 170 169 168 167 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 193 192 191 189 187 182 180

Greydanus, D.E. e corporal-5893764.php Retrieved fromhttp://www.houstonchronicle.com/news/education/article/Texas-holds-tight-to-tradition-on- Collette, M.(No Nicholson, E.(March4,2016). Texas istheCorporalPunishmentCapitalofAmerica: DeSo corporal-5893764.php Retrieved fromhttp://www.houstonchronicle.com/news/education/article/Texas-holds-tight-to-tradition-on- Collette, M.(No Texas Appleseed.(2013). Know. Retrieved fromhttps://txssc.txstate.edu/topics/legislation/articles/senate-bill-393 Texas StateTexas SchoolSafe aspx?LegSess=83R&Bill=SB1114 Legislature Online.(2013). SenateBill1114. History.aspx?LegSess=83R&Bill=SB393 Texas LegislatureOnline.(2013). from http://www.texasappleseed.net/images/stories/reports/Ticketing_Booklet_web.pdf Texas Appleseed.(2010). Serrano, J. (A Texas-Appleseed_Apr2010.pdf Retrieved from http://www.njjn.org/uploads/digital-library/Texas-School-Prison-Pipeline-School-Expulsion_ Texas Appleseed.(2010). Texas Juv Texas-Appleseed_Apr2010.pdf Retrieved from http://www.njjn.org/uploads/digital-library/Texas-School-Prison-Pipeline-School-Expulsion_ Texas Appleseed.(2010). texasappleseed.net/pdf/Pipeline percent20Report.pdf Texas Appleseed.(2007). Texas-Appleseed_Apr2010.pdf Retrieved from http://www.njjn.org/uploads/digital-library/Texas-School-Prison-Pipeline-School-Expulsion_ Texas Appleseed.(2010). org/fact-sheet/locating-school-prison-pipeline American CivilLibertiesUnion.(n.d.).LocatingtheSchool-to-PrisonPipeline.Re Texas-Appleseed_Apr2010.pdf Retrieved fromhttp://www.njjn.org/uploads/digital-library/Texas-School-Prison-Pipeline-School-Expulsion_ Texas Appleseed.(2010). plinary_Data_Products/DAG_Summaries/Download_State_DAG_Summaries.html actions bydisciplineactiongroupings (PEIMSData).Retrieved fromhttp://ritter.tea.state.tx.us/adhocrpt/Disci- Texas EducationAgenc pline-Snapshot.pdf (School Discipline).Pg. 1,13and15. Retrieved fromhttp://ocrdata.ed.gov/Downloads/CRDC-School-Disci- U.S DepartmentofEducationOfficeforCivilRights. (March 20 DAG_Summaries/Download_State_DAG_Summaries.html PEIMS 2014-2015Data.Retrieved fromhttps://rptsvr1.tea.texas.gov/adhocrpt/Disciplinary_Data_Products/ Texas EducationAgenc JJAEP_2015_Report.pdf Assessment Report:SchoolYears 2014-2015.Retrieved fromhttp://www.tjjd.texas.gov/publications/reports/ Texas Juv Texas-Appleseed_Apr2010.pdf Retrieved fromhttp://www.njjn.org/uploads/digital-library/Texas-School-Prison-Pipeline-School-Expulsion_ Texas Appleseed.(2010). Ibid. ports/JJAEP_2015_Report.pdf Asses Texas Juvenile Justice Department.(May 2016). Juvenile JusticeAlternative EducationPrograms Performance Collette, M.(No desoto-mistakenly-paddles-kindergartener-because-texas-8091506 dles Kindergartener, BecauseTexas. DallasObserver. Retrieved fromhttp://www.dallasobserver.com/news/ Nicholson, E.(March4,2016). Texas istheCorporal PunishmentCapitalofAmerica:DeSo trieved fromhttp://www.theatlantic.com/education/archive/2015/12/corporal-punishment/420420/ Anderson, M.D. (December15, 20 cine. Journal Health, 32(5),385-393. ofAdolescent desoto-mistakenly-paddles-kindergartener-because-texas-8091506 dles Kindergartener, Because Texas. DallasObserver. Retrievedhttp://www.dallasobserver.com/news/ from net/index.php?option=com_docman&task=doc_download&gid=990&Itemid= Retrieved from https://www.texastribune.org/2013/08/29/class-disruption-cases-head-principals-office-not-/ ports/JJAEP_2015_Report.pdf Assessment Report:SchoolYears 2014-2015.Pg. iii.Retrievedhttp://www.tjjd.texas.gov/publications/re- from sment Report:SchoolYears 2014-2015.Pg. ii.Retrieved fromhttp://www.tjjd.texas.gov/publications/re- enile Justice Department.(May 2016). Juvenile JusticeAlternative EducationPrograms Performance enile Justice Department.(May 2016). Juvenile JusticeAlternative EducationPrograms Performance ugust 29, 2013). IssueOn-CampusCitations. SchoolOfficersCanNoLonger TheTexas Tribune. vember 14, 2014). Texas holdstighttotradition oncorporalpunishment. vember 14, 2014). Texas holdstighttotraditiononcorporalpunishment. vember 14, 2014). Texas holdstighttotraditiononcorporalpunishment. t al.(2003).Corporal AdolescentMedi- punishmentinschools:Position paperoftheSocietyfor y. (2007-2015). Disciplinedataproducts: 2007-2015 countsofstudentsanddiscipline y. (2016). Counts ofStudentsandDisciplineActionsbyActionGroupings: School ticketing implementationguide.Retrieved fromhttp://www.texasappleseed. Texas’ school-to-prisonpipeline:Ticketing, arrests, inschools.Retrieved anduseofforce Texas’ school-to-prisonpipeline:Schoolexpulsion –thepathfrom lockout toDropout. Texas’ school-to-prisonpipeline:Schoolexpulsion –thepathfrom lockout todropout. Texas’ school-to-prisonpipeline:Schoolexpulsion –thepathfrom lockout todropout. Texas’ school-to-prisonpipeline:Schoolexpulsion –thepathfrom lockout todropout. Texas’ school-to-prisonpipeline:Schoolexpulsion –thepathfrom lockout todropout. Texas’ school-to-prisonpipeline:Dropout toincarceration. Retrieved fromhttp://www. ty Center. (n.d.)ImplementingSenateBill393: WhatTexas SchoolDistrictsNeedto Senate Bill393. Retrieved fromhttp://www.capitol.state.tx.us/BillLookup/ 15). Where Teachers Are StillAllowed toSpankStudents.TheAtlantic. Re- Retrieved from http://www.capitol.state.tx.us/BillLookup/History. 14). CivilRightsDataCollection: DataSnapshot trieved fromhttps://www.aclu. HoustonChronicle. HoustonChronicle. HoustonChronicle. to Mistakenly Pad- to Mistakenly Pad- TEA 407 . to Mistakenly Pad- to Mistakenly echnical Assistance Center on Positive Center on Positive echnical Assistance ention Teams (CIT): An Invaluable Community Community An Invaluable (CIT): ention Teams Civil Rights Data Collection: Data Snapshot Data Collection: Civil Rights 14). Legislative Session (2015) — HB 2684: Training for in Police Training HB 2684: (2015) — Session Legislative Retrieved from http://txchildren.org/Images/Interior/ ellbeing. Retrieved Retrieved from http://txchildren.org/Images/Interior/ ellbeing. Retrieved th Responding to youth with mental health needs: A CIT for with mental 11). Responding to youth imple- youth Retrieved from http://texanscare- Retrieved Training. Crisis Intervention en’s Houston Public Media. in Schools. Spray Pepper Use of Tasers, wing Over . Retrieved from https://web.archive.org/web/20150924210651/http:// . Retrieved . Retrieved from https://web.archive.org/web/20150924210651/http:// . Retrieved Is School-wide Positive Behavior Support An Evidence-based An Evidence-based Behavior Support Positive School-wide Is (April 2015). , T. ., George, H., Lewis, T., Eber, L., Barrett, S., & Algozzine, B. (July 2012). What 2012). (July B. & Algozzine, S., L., Barrett, Eber, T., ., George, H., Lewis, Retrieved Retrieved and Support Project. Interventions Behavioral Positive twork. (n.d.). Texas from http://www.txbehaviorsupport.org/de- Retrieved twork. (n.d.). About PBIS. Retrieved from http:// and Supports. Retrieved Interventions Behavioral twork. (n.d.). Positive Breaking rules, breaking budgets: Cost of exclusionary discipline in 11 Texas school school discipline in 11 Texas of exclusionary budgets: Cost rules, breaking Breaking school discipline in 11 Texas of exclusionary budgets: Cost rules, breaking Breaking Breaking rules, breaking budgets: Cost of exclusionary discipline in 11 Texas school school discipline in 11 Texas of exclusionary budgets: Cost rules, breaking Breaking Retrieved & use of force in schools. Retrieved arrest Ticketing, pipeline: school-to-prison Texas’ & use of force Retrieved in schools. arrest pipeline: Ticketing, school-to-prison Texas’ Retrieved & use of force in schools. Retrieved arrest school-to-prison pipeline: Ticketing, Texas’ Update from Texas’ 84 Texas’ Update from Re- Observer. The Texas in Schools. Spray Pepper Groups Urge End to Tasers, , 2013). Re- Observer. The Texas in Schools. Spray Pepper Groups Urge End to Tasers, , 2013). Improving access to children’s mental health care: Lessons from a study from Lessons mental health care: to children’s access Improving (2013). & Price, O.A. , J.G. A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Pg. 19. Retrieved from http://ocrdata.ed.gov/Downloads/CRDC-School-Discipline-Snap- Retrieved 19. Pg. (School Discipline). shot.pdf from http://cdm16064.contentdm.oclc.org/cdm/ref/collection/p266901coll4/id/3722 Appleseed. (2010). Texas from http://cdm16064.contentdm.oclc.org/cdm/ref/collection/p266901coll4/id/3722 Appleseed. (2015). Texas Nicholson, E. (March 4, 2016). Texas is the Corporal Punishment Capital of America: DeSo of America: Capital Punishment is the Corporal Texas 4, 2016). E. (March Nicholson, (March 20 for Civil Rights. of Education Office Department U.S (2010). Appleseed. Texas Retrieved from http://www.houstonchronicle.com/news/education/article/Texas-holds-tight-to-tradition-on- Retrieved corporal-5893764.php . Retrieved from fromhttp://www.dallasobserver.com/news/ . Retrieved Dallas Observer Because Texas. dles Kindergartener, desoto-mistakenly-paddles-kindergartener-because-texas-8091506 Implementation blueprint and self-assessment: Positive behav- Positive Implementation blueprint and self-assessment: (2010). and Supports. Interventions Behavioral from https://www.pbis.org/Common/Cms/files/pbisresources/ and supports. Retrieved interventions ioral SWPBS_ImplementationBlueprint_vSep_23_2010.pdf reports/child_mental_wellbeing.pdf txchildren.org/PBIS from http://www.pbis.org/common/cms/files/pbisre- PBIS? Retrieved to Implement School-wide Does it Cost sources/20120802_WhatDoesItCostToImplementSWPBIS.pdf from http://www.njjn.org/uploads/digital-library/Breaking-Rules-Breaking-Budgets--Cost- districts. Retrieved of-Exclusionary-Discipline-in-11-Texas-School-Districts_TxAppleseed.pdf Texas Appleseed. (2009). Appleseed. (2009). Texas Appleseed. (2009). Texas reports/child_mental_wellbeing.pdf from http://www.txbehaviorsupport.org/default.aspx?name=pbs.mission fault.aspx?name=about.history txchildren.org/PBIS Care for Children. (n.d.). PBIS Texans Appleseed. (2009). Texas from http://www.njjn.org/uploads/digital-library/Breaking-Rules-Breaking-Budgets--Cost- districts. Retrieved of-Exclusionary-Discipline-in-11-Texas-School-Districts_TxAppleseed.pdf R., Sugai, G., Kincaid, D Horner, OSEP Technical Assistance Center. Retrieved from https://www.pbis.org/research Retrieved Center. Assistance OSEP Technical Practice? Support Ne Behavior Texas Support Ne Behavior Texas Care for Children. (n.d.). Child mental w Texans Care for Children. (n.d.). PBIS Texans Retrieved from http://www.nami.org/Content/NavigationMenu/Find_Support/Child_and_ mentation manual. Retrieved Teen_Support/CIT_for_Youth/CITYouthWorkbook_Web.pdf forchildren.org/Images/Interior/mh%20forum/childrens%20crisis%20intervention%20training.pdf from http://cdm16064.contentdm.oclc.org/cdm/ref/collection/p266901coll4/id/3722 from http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf404627 states. Retrieved of eleven www.txbehaviorsupport.org/ H., Sugai, G., & Lewis R. Horner, of Special Education Programs’ T Department of Education & Office S. U. Care for Children. (n.d.). Child mental w Texans Texans Care for Children. (n.d.). Childr Texans Appleseed. (2010). Texas Lear D., Behrens, Ne Support Behavior Texas Retrieved from http://www.houstonpublicmedia.org/articles/news/2014/04/21/50525/debate-growing-over- Retrieved use-of-tasers-pepper-spray-in-schools/ from http://www.houstonpublicmedia.org/articles/news/2014/04/21/50525/debate-growing-over- Retrieved use-of-tasers-pepper-spray-in-schools/ Illness (NAMI). (n.d.) Crisis Interv National Alliance on Mental from http://namitexas.org/crisis-intervention-teams-cit-an-invaluable-community-re- Retrieved Resource. source/ (20 Illness. National Alliance on Mental Michels, P. (December 9 P. Michels, from https://www.texasobserver.org/advocacy-groups-urge-end-tasers-pepper-spray-schools/ trieved (December 9 P. Michels, from https://www.texasobserver.org/advocacy-groups-urge-end-tasers-pepper-spray-schools/ trieved Retrieved from https://www.texasappleseed.org/sites/default/files/HB%202684%20Ex- Retrieved Public Schools. Texas planation%20FINAL.pdf Debate Gro Isensee, L. (April 21, 2014).

196 197 198 194 195 211 215 217 219 220 212 213 214 216 218 210 205 206 207 208 209 Houston Public Media. in Schools. Spray Pepper Use of Tasers, Over Debate Growing 2014). 200 Isensee, L. (April 21, 201 204 202 203 199 TEA 408 237 236 235 234 233 232 231 230 228 227 226 225 224 223 222 221 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 229

meta-analytic review. Journal ofExperimentalCriminology, 7, 27-56. Ttofi, M.M.,& Farrington, D childhood andadolescence:Ameta-analyticinvestigation. SchoolPsychology Quarterly, 25(2),65-83. Cook, C.R., Williams, K.R.,Guerra,N among studentsinspecialandgeneral education.Journal ofSchoolPsychology, 50(4),503-520. Swearer, S. M.,W among studentsinspecialandgeneral education.Journal ofSchoolPsychology, 50(4),503-520. Swearer, S. M.,W texas.gov/Home/Commissioner_Blog/Texas_Focusing_on_Restorative_Discipline/ Texas EducationAgenc nio/ student suspensions.Retrieved fromhttp://www.utexas.edu/news/2013/12/17/restorative-discipline-san-anto- Meckel, R.D nio/ student suspensions.Retrieved fromhttp://www.utexas.edu/news/2013/12/17/restorative-discipline-san-anto- Meckel, R.D org/blog/restorative-justice-resources-matt-davis Edutopia. (October29, 2015). org/blog/restorative-justice-resources-matt-davis Edutopia. (October29, 2015). Substance Abuse andM and-anxiety-can-affect-young-childrens-learning-and-development/ dren’s learninganddevelopment. Retrieved fromhttp://developingchild.harvard.edu/resources/persistent-fear- National ScientificCouncilontheDeveloping Child.(2010). www.edutopia.org/sel-research-learning-outcomes Vega, V. (December1,20 tencies. Retrieved fromhttp://www.casel.org/social-and-emotional-learning/outcomes/ Social,andEmo Collaborative forAcademic, austinisd.org/academics/sel Austin IndependentSchoolDis www.austinisd.org/academics/sel Department ofSocialandEmotional Learning.(n.d.)Socialandemotionallearningfir www.austinisd.org/academics/sel Department ofSocialandEmotional Learning.(n.d.)Socialandemotionallearningfir of-Exclusionary-Discipline-in-11-Texas-School-Districts_TxAppleseed.pdf districts. Retrieved fromhttp://www.njjn.org/uploads/digital-library/Breaking-Rules-Breaking-Budgets--Cost- Texas Appleseed.(2009). of-Exclusionary-Discipline-in-11-Texas-School-Districts_TxAppleseed.pdf districts. Retrieved fromhttp://www.njjn.org/uploads/digital-library/Breaking-Rules-Breaking-Budgets--Cost- Retrieved fromhttp://beta.samhsa.gov/nctic/trauma-interventions ., &Campetella, M.A.(2013). Restorative disciplineprogram in SanAntoniomiddleschoolreduces ., &Campetella, M.A.(2013). Restorative disciplineprogram in SanAntoniomiddleschoolreduces ang, C., Maag,J. W., Siebecker, A.B., &Frerichs, L.J. (2012). Understanding thebullyingdynamic ang, C., Maag,J. W., Siebecker, A.B., &Frerichs, L.J. (2012). Understanding thebullyingdynamic y. (June 12,2015). Texas Focusing onRestorative Discipline.Retrieved fromhttp://tea. ental Health (n.d.)Trauma-informed Administration. care andtrauma-informed services. 15). SocialandEmotional LearningResearchReview. Edutopia.Retrieved fromhttp:// Breaking rules,breaking budgets:Cost ofexclusionary disciplinein11Texas school .P. (2011). ofschool-basedprograms Effectiveness to reduce bullying:A systematic and Restorative Schools.Retrieved Justice:Resources fromhttp://www.edutopia. for Restorative Schools.Retrieved Justice:Resources fromhttp://www.edutopia. for trict. (2016). SocialandEmotionalLearningFirst. Retrievedhttps://www. from .G., Kim,T.E. &Sadek,S. (2010). Predictors ofbullyingandvictimization in tional Learning.(2015). OutcomesAssociated withtheFive Compe- Persistent fear and anxiety can affect young chil- Persistent andanxietycanaffect fear st. Retrieved fromhttps:// st. Retrieved fromhttps:// TDHCA 409

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· Lack of affordable housing options for people with disabilities, including individuals living with mental illness · Implementation and distribution of funds from the National Housing Trust Fund · Development of permanent supportive housing · Availability of housing support for veterans · Reducing the Section 8 rental assistance wait list · Housing discrimination against Texans with mental illness and source of payment discrimination against Section 8 voucher-holders · Location of Low Income Housing Tax Credit (LIHTC) developments for persons with disabilities · Reducing housing barriers for individuals with criminal justice history and mental health needs Fast Facts

· In 2015, TDHCA served a total of 562,097 households and individuals through its combined programs, including 155,192 through its homeless services (up from 39,213 in 2014).1 · The most recent Point-in-Time (PIT) count of homelessness in Texas found that nearly 19 percent of individuals who are homeless (over 4,400) have a severe mental illness, and nearly half of those individuals are unsheltered.2 · According to the Office of National Drug Control Policy, approximately 30 percent of people experiencing chronic homelessness across the country have a serious mental illness; around two-thirds have a primary substance use condition or other chronic health condition.3 · Research reveals a housing affordability gap for Supplemental Security Income (SSI) recipients, many of whom are unable to work due to severe mental illness or disability.4 In 2014, recipients of SSI in Texas received only $721 a month from SSI, which constituted 93 percent of the average fair market rent for a one-bedroom housing unit.5 · The 2016-2017 TDHCA budget contains $421 million in federal funding, constituting 87 percent of TDHCA’s total funding for the biennium.6

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Data obtained from: Texas Department of Housing and Community Affairs. (2016). TDHCA organizational chart. Retrieved from https:// www.tdhca.state.tx.us/hrdocs/org-chart.pdf

410 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas TDHCA 411 11 , Nelson/Chavez) to enhance coordination to enhance coordination , Nelson/Chavez) Serious mental illness and substance use Serious mental illness and substance st 7 9 Service-enriched housing is “integrated, affordable 12

8 In 2015, HUD reported that nearly 40 percent of low- In 2015, 10 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation income households with a nonelderly person with a disability experienced “worst experienced “worst income households with a nonelderly person with a disability more than half of income in rent or living in case housing needs” – defined as paying assistance. inadequate conditions without receiving government severely and accessible” housing that “provides residents with the opportunity to receive.... and accessible” housing that “provides [independent living and services and supports that foster health-related and other The Texas Department of Housing and Community Affairs (TDHCA) operates and Community Affairs (TDHCA) Department of Housing The Texas The agency for disperses federal funds major affordable housing programs. several and is responsible for allocating housing tax credits housing and community services Credit (LIHTC) program. TDHCA Tax Income Housing under the federal Low various housing programs governing laws state ensures compliance with federal and to low-income essential services and affordable housing opportunities and provides Agency is also a Public Housing for operating (PHA), responsible TDHCA Texans. rental assistance housing as well as federally-funded multi-family publicly-owned 200 PHAs in the state States and cities can act as PHAs and there are over programs. including TDHCA. of Texas, Despite serving similar populations, most Texas health and human services Texas most Despite serving similar populations, and vice with affordable housing assistance, well-integrated programs are not Services and Health the Housing Legislature established the Texas In 2009, versa. 81 Coordination Council (SB 1878, In addition to supporting the housing needs of low-income Texans, TDHCA has TDHCA Texans, In addition to supporting the housing needs of low-income and those people with disabilities programs and policies that specifically serve face A significant number of people with disabilities experiencing homelessness. housing needs. extreme Community Affairs Community can experience significant mental illness serious and persistent Individuals with barriers to permanent housing. According to the Office of National Drug Control chronic homelessness have 30 percent of people experiencing approximately Policy, use condition a primary substance have a serious mental illness; around two-thirds chronic health condition. or other of and Housing Texas Department Department Texas conditions may create difficulties in accessing and maintaining stable, affordable, stable, maintaining create difficulties in accessing and conditions may and appropriate housing. between housing and health service agencies in order to provide more service- housing and health service agencies in order to provide between enriched housing options. TDHCA 412 and addadditionalstaff whoareconversant inboth housingandhealthservices. inception hasmadeeffortstoprovide newhousingandhealth-relatedresources The executive directorofTDHCA chairsthecoordination council,whichsinceits decision-making] forindividualswithdisabilities andpersonswhoareelderly.”decision-making] Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · with five areasofneed: TDHCA describesitsservicesandactivitiesalonga“Housing SupportContinuum” 15-BiennialPlan.pdf. recent 2014-2015 planisavailable athttp://www.tdhca.state.tx.us/hhscc/docs/14- legislature outliningitseffortstoenhanceservice-enriched housing.Themost . ThecouncilalsosubmitsaBiennialPlantothe tx.us/hhscc/docs/RefGuide.pdf and servicesavailable inTexas. Theguideisavailable athttp://www.tdhca.state. Manual tohelpcross-educatehousingandhealthservices staff ontheprograms In 2011, GuideandTraining theCouncilpublishedStateAgencyReference · · forms ofassistance: Under its“rentalassistance” inFigure161,TDHCA category provides threedifferent housing assistance andservicesthatTDHCA offersineachareaofneed. aretailoredtoindividualswithdisabilities.and ProjectAccess Figure161lists the funds, orenergyassistance, forexample.Inaddition,programssuchasSection811 a housingburdenmay beabletoaccessrentalassistance, housingrehabilitation state. Low-income individualslivingwithdisability ormentalillnesswhoexperience however, by expandingtheoverall stock ofaffordablehousingandservicesinthe The broaderhousingprogramsbenefit Texans withdisabilities andmentalillness, programs seektoexpandhousingopportunityforlow-income Texans broadly. While someprogramsserve individualswithdisabilities specifically, most TDHCA · · · ·

with the housing provider, rather than the tenant. income tenants with disabilities linked tolong-term services. The voucher stays rental subsidytothe housing provider directly to keep aunitaffordable tolow- assistance. In addition, TDHCA utilizesfederalHOME funding to provide timelimitedrental tenant-based assistance because the subsidyis linked toandstays withthetenant. Access and the disabilityvouchers. specific, Project Theseprogramsarecalled HUD Section 8 housing voucher program that serves specific areasofthe state rental voucher from TDHCA. This form of assistance includes the federally funded units themselves in the private market, though landlords must agree to accept the and the state makes up theremainder through the voucher. Tenants selectrental pay up to 30percent of theirincome toward rent for amarket-rate housingunit, of market-rate rental housing for low-income renters. Tenants arerequired to Tenant-based rentalassistance: Disaster assis Rehabilitation and weatherization Homebuyer education, Rental assistance Pov Project-based rentalassistance: ThenewHUD erty and homelessness prevention tance assistance, and singlefamily development Texas provides vouchers tohelpoffset thecost Section 811programprovides a 13 14

TDHCA 413 a Household Income Household Eligibility FPL <125% FPL <150% AMFI <30% homeless) (or ELI <30% homeless) (or AMI <30% AMI <50% AMI <80% AMI <60% AMI <60% AMI <80% Community Services Block Grant (CSBG): Grant Block Services Community programs poverty and services Local (CEA): Assistance Energy Comprehensive assistance utility and education Energy Assistance (ESG): for Program Grants Solutions Emergency ofrisk at or homeless are who persons homelessness Program: Services and Housing Homeless families and individuals assist to 285,500 over cities For homeless are who Program: Voucher Choice Housing 8 Section in individuals for vouchers assistance rental Tenant-based disabilities with individuals for statewide or areas, rural Access through Project (HOME-funded): Assistance Rental Tenant-based vouchers rental tenant-based provide to grants Local credits Tax (LIHTC): Program Credit Tax Income Housing Low of rental rehabilitation or construction for affordable housing Program: Bond Multifamily housing affordable preserve or develop to Loans Develop- Housing Rental RF TCAP and Multifamily HOME ment: housing, affordable preserve or develop to grants or Loans developers qualified for Program Assistance: Rental Project 811 Section persons for very low-income assistance rental Project-based services long-term with linked disabilities, with or rehabilitate affordable multi-family rental housing. This form This form housing. rental multi-family affordable or rehabilitate A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation : Lastly, the state provides subsidies to developers developers to subsidies provides state the : Lastly, assistance Development to construct (LIHTC), Credit Program Tax Housing Income Low the includes of assistance funding TACP and HOME Multifamily - Preven Homelessness and Poverty tion Continuum Activity Continuum Assistance Rental

TDHCA’s non-rental programs focus on single-family homeownership, single-family homeownership, focus on non-rental programs TDHCA’s or homeless low-income as well as services for construction, rehabilitation or individuals and families. Activities Continuum Housing Support TDHCA 161. Figure · TDHCA 414 annual report, Data obtained from: Texas Housing and Community Department of Affairs. (2016). a Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Income; ELI=Extremely Low IncomeLimit Disaster Assistance and WeatherizationRehabilitation and Single Family Development Education,Homebuyer Assistance Continuum Activity FPL =Federal Poverty Level; AMFI=AreaMedian Family Income;AMI=AreaMedian 169. Retrieved from https://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf holds affected by a disaster assistance, and tenant-based rental assistance for house- Home repair, rehabilitation, construction, homebuyer (HOME-funded): Disaster Relief Emergency shelter, food and clothing Community Services Block Grant: Grants to fund minor home repairs to increase efficiency Weatherization Assistance: Grants to fund home repair and replacement assistance Homeowner Rehabilitation Assistance (HOME-funded): people with disabilities Grants to fund accessibility modifications to homes for Fund): Amy Young Barrier Removal (funded through Housing Trust construction to rehabilitate or construct their home through self-help 0% interest loans to owner-builders, through nonprofits, Texas Bootstrap Loan Program: rehabilitation, or acquisition Loans to qualified developer for single-family construction, Single Family Development (HOME-funded): Tax credit for homebuyers based on mortgage interest Mortgage Credit Certificate (MCC): homebuyers Low-interest loans and down payment costs for first-time My First Texas Home: warranty deed Assisting colonia residents to convert contract-for-deed to Housing TrustFund): Contract for Deed Conversion (funded through HOME and modifications family buyers, can include rehabilitation or accessibility Down payment and closing cost assistance for single (HOME-funded): Homebuyer Assistance Training for nonprofits to provide homebuyer education Texas Statewide Homebuyer Education: homebuyer assistance, and housing education in colonias Funding for housing rehabilitation and construction, Colonia Self-help Center (SHC): Program 2016 State of 2016 State of Texas low income housing plan and <80% AMI 125% FPL 150%-200% FPL <80% AMI <80% AMI <60% AMI <80% AMI 115% AMI (targeted) <140% AMI (non-targeted) <115% AMI <60% AMI <80% AMI No income limit <80% AMI Eligibility Household Income a TDHCA 415

15 19 267, 267, SB 16 17 rotections ( rotections TDHCA released the draft for TDHCA P 18 , Perry/Huberty), which prevents which prevents , Perry/Huberty), th ncome ncome rust Fund rust I

T f ource o S A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation l Housing l Housing a erry/Huberty) P , , h tion imiting public comment in July 2016 and a public hearing was held on August 4, 2016. August held on a public hearing was and 2016 public comment in July municipalities from adopting source of income protections for most renters. Source renters. for most protections of income source adopting from municipalities who renters discriminating against from prohibit landlords protections of income vouchers. 8 rental assistance such as Section assistance, federal housing receive also referred vouchers, assistance rental (PHAs) provide Authorities Housing Public renters to help them to low-income Choice” vouchers, 8” or “Housing to as “Section up to 30 percent of their income in Individuals pay housing. rental afford market-rate the tenant’s the difference between subsidizing a voucher and the PHA provides rent dedicates a part of its TDHCA In Texas, housing. of rental and the price income a program called illness through with mental to individuals funds 8 voucher Section Access. Project L 267 (84 passed SB the legislature In 2015, Advocates expect TDHCA to tie funding to the state’s Housing Tax Credit (HTC) Tax Housing to tie funding to the state’s Advocates TDHCA expect Credit Program, or Tax program (known Housing Income federally as the Low the National Low by more information, see the materials provided LIHTC). For . Coalition at http://nlihc.org/issues/nhtf Income Housing In April, 2016 TDHCA held a roundtable meeting to obtain feedback from obtain to held a roundtable meeting TDHCA In April, 2016 on its draft NHTF Allocation Plan. stakeholders TDHCA is responsible for administering and distributing the Texas funds. The funds. the Texas and distributing is responsible for administering TDHCA address persons and to low-income intent of the fund is to support extremely housing that worst-case Data suggest housing needs. individuals with worst-case a disability, households with members who have needs are high among low-income highlighted the fund as an opportunity to create more have and some advocates HUD will require individuals with disabilities. permanently affordable units for for a period of 30 years. NHTF units to remain affordable Changing Environment Changing Na (NHTF) in 2008 Fund Trust Housing the National created government The federal additional Act. to provide The intent was and Economic Recovery under the Housing low-income extremely affordable rental housing for to develop funding for states a percentage of new business The NHTF is funded by individuals and families. a dedicated stream providing Mac, thereby Mae and Freddie Fannie generated by process. the annual federal appropriations subject to to the fund not of revenue 84t Implementation of the fund was initially halted after the federal government’s the federal government’s initially halted after of the fund was Implementation housing during the 2008 and Freddie Fannie conservatorship of decision to take lift its suspension of the fund’s HUD announced that it would In 2014, crisis. HUD granted In 2016, beginning in 2016. and grant funds to states implementation Income Area Median based on the state’s in formula grants to states, million $174 $4.8 million from the fund. received Texas levels. and poverty TDHCA 416 the impositionofadditionalpaperworkandadministrative costs onlandlords. of federalhousingassistance. Opponentsofthecity’s rulesexpressedconcernabout income protection rules, barringlandlordsfromdiscriminatingagainst recipients vouchers. disabilities becauseLIHTCdevelopments arerequiredtoaccept Section8housing housing isanimportantsourceofaffordablerental housing forindividualswith disabilities. housing market andthatthismay disproportionately affectindividualswith concern thatvoucher-holders willcontinuetofacediscriminationintheprivate protection forveterans. Somehousinganddisability advocates have expressed housing assistance. SB267doesnot prevent citiesfrompassingsourceofincome landlords fromrefusingtorentindividualswhoseincome includesfederal source ofincomeprotection andpreventing citiesfrompassinglaws thatprohibit these andother concerns, theTexas LegislaturepassedSB267, overriding Austin’s of color, violatingfairhousingstandards. credits systematically concentratedLIHTCunits inhigh-poverty communities thatTexas’2008 lawsuit alleged annualQualifiedAllocationPlan(QAP)forhousing housing (alsoknown astheHousing Tax Creditprogram,orHTC, inTexas). The allocate federalLow IncomeHousing Tax Credits(LIHTCs)formultifamilyrental Communities ProjectinDallas, TDHCA totherulesthatituses hasmadechanges Since 2012, inresponsetoalawsuit filedagainst the state by theInclusive I inspections andmeet other administrative requirements. housingvouchersAccepting typicallyrequiresthelandlordtoparticipatein payment. units intheAustin Metropolitan Statistical Areaaccepted vouchers asasourceof 2012, anAustin Tenants’ Councilauditshowed thatonlysixpercentofhousing data show thatvoucher-holders oftenexperiencedifficultylocatinghousing.In solely ofSSI(placingthematonly18percentthefederal poverty level). However, mental illness, whoseabilitytoworkmay belimitedandwhoseincomemay consist Vouchers canactasasourceofhousingsupportforindividuals withdisability or Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Housing and economicsegregationintheprogram. summary judgment,Texas committed toalteringitsQAPinorderreduceracial housing (PSH)developments thatserve individualswithspecialneeds. past theQAPhascontainedspecificprovisions toincentivizepermanentsupportive LIHTC isanimportantsourceoffundingforaffordable rental housing,andinthe high-income censustracts. locate LIHTChousinginhigh-opportunityareas, emphasizingschoolqualityand mental illnessinTexas. Project-based RentalAssistance program,whichserves individuals withsevere state addedadditionalpoints fordevelopments thatparticipateintheSection811 points andincentives provided forsupportive housingdevelopments. In2015, the rewrites itsQAPannually, anddisability advocates closelyfollow theamount of individuals withdisabilities whoseprimarysourceofincomeisSSI. nclusive 20 26 Withoutvouchers, however, LIHTCunitsareoftenunaffordablefor In responsetothesedata,in2014 theCityofAustin approved sourceof Ta C ommunities x C 28 redit P rogr 23 a 24 24 In 2012, asaresultoffederalcourt nd t Texas, sincethen,hastaken steps to a m h e L 22 ow In 2015, inresponseto I ncome 27 The agency The agency 25 LIHTC 21 TDHCA 417 29

, h h t nce irini) a ls wit a Zaff 1510, 84 1510, B , Raymond/Zaffirini). TDHCA’s HOME- TDHCA’s , Raymond/Zaffirini). th ndividu I ymond/ Ra or ecord (H ecord , , f h R ) t a rci or Homebuyer Assist bility f a Ga i L 1428, 84 1428, l Justice l Justice B A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation a tion a rimin ompson/ ndlord ndlord C

HB 1510 relieves landlords from legal liability associated with renting to an individualHB 1510 relieves the prevalence of mental illness among individuals record. Given with a criminal justice expressed concern that housing have advocates disability system, in the criminal justice will history individuals with a criminal justice discrimination against and employment Mental health disproportionately affect individuals with mental health conditions. 1510 will help mitigate discrimination against that HB optimism expressed have advocates involvement mental illness and criminal justice experience of both individuals with a lived relieving landlords of legal liability for renting to individuals with a criminal record. by La a Funds (H a contract to purchase were required to have Prior to this legislation, individuals given This created challenges, assistance. a home before applying for homebuyer financial assistance would receive they whether know that individuals did not to purchase the home. This change individuals to apply for allows when attempting commitment, thereby prior to making the home purchase homebuyer assistance them to engage planning and enter into a home financial in more effective allowing assistance Individuals who receive stability. purchase contract with greater financial under the program. to find a suitable home to purchase 90 days at least will have In 2015, the legislature passed HB 1428 (84 passed HB 1428 the legislature In 2015, Applic Texas has added some points and incentives for PSH developments to the QAP in the QAP to PSH developments for incentives and points added some has Texas At credit awards. for tax more competitive developments these making years, past the QAP opportunity concern that expressed have time, some advocates the same judgment in the summary the 2012 the agencyindex, which following adopted located in suburban developments more case, rewards Communities Inclusive in supportive who live and those disabilities, with Individuals neighborhoods. that other amenities and from access to transit, services, can benefit housing units, median higher have typically however, Suburban areas, in urban areas. often exist them an advantage gives which scoring in the QAP schools, incomes and better housing objectives designed to advance fair index was The opportunity system. and stakeholders units, obligation to disperse its LIHTC and address the agency’s with disabilities. Texans affect may standards evolving how continue to monitor projects housing expressed concern that supportive have stakeholders Lastly, opposition from local “NIMBY” Backyard” or in My of “Not levels incur heightened in the QAP that provisions among some stakeholders There is concern residents. for a LIHTC development representatives of support from state requiring letters LIHTC housing, Siting of housing developments. supportive disadvantage may continues to generate annual discussion among fair as directed through the QAP, advocates. and disability developers, housing advocates, funded homebuyer assistance program contains a set-aside for individuals with program contains a set-aside funded homebuyer assistance applying for funds under the an individual this legislation allows and disabilities, a home. to apply prior to entering into a contract to purchase set-aside disability Th TDHCA 418 agency funding. agency appropriated $26.5 million toTDHCA, comprisingapproximately 5percentoftotal TDHCA revenue alsoreceives fromthestate. general For 2016-2017, thelegislature assistance, directfinancialassistance toaddressenergy needs, bonds. andmortgage housing development assistance, disbursingfundstoother agencies, disaster-related uses federalfundsinavariety ofways, includingbutnot limitedto:directrentaland constitutes $39million,orapproximately 8percent,oftheagency’s total funding. of themanufacturedhousingindustry. For 2016-2017, thissourceoffunding TDHCA alsocollectsfees fromseveral ofitshousingprogramsandregulation programs inTexas, butfallsshortofaddressingtheoverall housingneed inTexas. The HTFactsasanimportantrevenue sourcetofundsomeaffordablehousing · · · HTF currentlyfundsthefollowing programs: Services (DADS). Department ofAgriculture(TDA) andtheDepartmentofAgingDisability housing programs. Two holdcontracts withTDHCA: agencies TheTexas contractsprovide anotherInteragency sourceoffundingforTDHCA’s affordable other indirectadministrative costs. Thesefeeshelpfinancetheadministration ofthe Housing Tax Creditprogramand 87 percentofTDHCA’s total fundingforthebiennium. The 2016-2017 TDHCA budget contains$421millioninfederalfunding,constituting 2017 biennium. housing law. Thefollowing isabriefdescription ofTDHCA’s fundingforthe2016- come withspecificationsandrestrictions relatedtotheiruseandaresubjectfair comprisedofTexaspercentage revenue funds. general Federal housingfundsoften Most ofTDHCA’s fundingcomesfromthefederalgovernment, withasmall Funding Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas as securityforrepayment oflow-income housingrevenue bonds. assistance tononprofitorganizationsthatdevelop affordablehousing,andtoserve income individualsandfamilies, provide technicalassistance andcapacity-building affordable housingprogram. (HTF), whichthelegislaturecreatedin1993andisTDHCA’s onlystate-funded electricity, paved roads, andsafe andsanitary housing.” some ofthemost basiclivingnecessities, suchaspotable water andsewersystems, Centers. Acoloniais“aresidentialareaalongthe Texas-Mexico border thatmay lack (CMS). Department ofEnergy(DOE),andtheCentersforMedicare andMedicaid Services Human Services(HHS),DepartmentofHousing andUrbanDevelopment (HUD), funding throughseveral departments, includingtheUSDepartmentofHealth and funds additional housingopportunities forpersonswithdisabilities. Funding from

Texas Boots Contract-for-Deed Conv Amy Young 31 HUDandHHSprovide thelargest financialsupporttoTDHCA. Barrier Removal Program trap Home LoanProgram 33 38 General revenue primarilyfundsthestate Housing Trust Fund The interagency contractwithTDA supports theColoniaService The interagency ersion Program for coloniaresidents 34 The state HTFmay beusedtoassist low- andvery-low 37 30 39 TDHCA receives federal The contractwithDADS 35 In practice,the 32 TDHCA 36 TDHCA 419 40 41 http://docs.lbb.state.tx.us/display.

Legislative Appropriations Request for Fiscal Years 2018 Years Fiscal for Request Appropriations Legislative A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation In terms of its total expenditures, TDHCA is a unique agency. One of TDHCA’s core One of TDHCA’s is a unique agency. TDHCA expenditures, In terms of its total and allocate funds that pass through the agencyfunctions is to administer in the Much of what form of private mortgage funding and federal housing tax credits. the agency in the appear classifies as “expenditures” in its annual report does not indirect (often private or federal) because it is funded by budget biennial state sources for which the agency acts as an allocator or administrator. Total funding requested for TDHCA for FY 2018-19 was $475,399,183. The TDHCA The TDHCA $475,399,183. was for FY 2018-19 for TDHCA funding requested Total Item Requests. Exceptional include any did not Appropriations Request Legislative (2016). Board. Budget Legislative from: obtained Data Retrieved from from Retrieved Affairs. ofDepartment Community and Housing Texas 2019, and aspx?DocType=LAR&agy=332&fy=2018 Figure 163. TDHCA Funding by Method of Finance for FY 2018-19 by Method of for FY Finance Funding TDHCA 163. Figure Legislative Appropriations Request for Fiscal Years 2018 Years for Fiscal Request Appropriations Legislative (2016). Budget Board. Legislative Data obtained from: http://docs.lbb.state.tx.us/display. from Retrieved Affairs. Department of Housing and Community Texas and 2019, aspx?DocType=LAR&agy=332&fy=2018 Total funding for TDHCA for FY 2016-17 was $477,058,359. was for FY 2016-17 for TDHCA funding Total Figure 162 shows TDHCA funding by Method of Finance. Method by funding TDHCA 162 shows Figure 2016-17 of by Method for FY Finance Funding TDHCA 162. Figure interagency contracts accounts for less than 1 percent of TDHCA’s revenue. interagency TDHCA’s of 1 percent for less than accounts contracts TDHCA 420 mortgage productsthatpassthroughbutarenotmortgage directlyfundedby theagency. Homeownership Program, muchofwhichconstitutes privatelyunderwritten Data obtained from: Bill, H.B. 1, Conference Committee Report, 2015 Leg., 84 to administer theseprogramsandexcludes significantindirectfundingsources. appears small,relative tothehomelessservices, becauseitonlyincludesthecost to multi-familyhousingdevelopers. Theallocationforaffordablehousingprograms towardgoes affordablehousingprograms, includingrentalassistance andsubsidies 2016-2017 toward budget goes itshomelessandpoverty services. Only19percent In termsofdirectallocationsoutlinedinthestate budget, 73percentofTDHCA’s Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Figure 164. TDHCA Funding byProgram forFY 2016-17 inFY2015,agency accordingtoitsmost recentannualreport. Figure 165below illustrates thetotal directandindirectfundingexpendedby the rental housing. federal taxcredits, forthenewconstruction orrehabilitationofaffordable includes almost $92 millionforthefederalLIHTCprogram,financedthrough expended atotal ofover $628millioninboth directandindirectfunding. reportsthat,inFY2015,single-family homeownership program.Theagency it distributes througheitherthefederalLIHTCprogramoritsprivatelyfinanced Figure 164,however, doesnot reflecttheamountofindirectfundingthatagency programmatic earmark,asdescribedinthebiennial2016-2017 budget. of Texas’ $209billionbudget. Figure164below illustrates theagency’s budget by budget. For 2016-2017, theagency’s budget is$487million,orlessthan1percent Direct biennialfundingtoTDHCA comprisesonlyasmallportionofTexas’ total 44 Italsoincludesover $311millionfortheagency’s SingleFamily th Reg. Sess., art. VII. (Tex. 2015). 43 This 45 42

TDHCA 421

56 Without In Texas, In Texas, 55 48 This is compared to only Overall, 2008-2012 data 2008-2012 Overall, Data from 2008-2012 show show Data from 2008-2012 50 51 49 2016 State of Texas low income housing plan and plan housing income low Texas of State 2016 Research reveals a housing Research reveals 54 Many SSI recipients are unable SSI recipients are Many However, many Texans face a housing Texans many However, 53 46

52 https://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation A housing cost burden exists when a household pays more than 30 when a household pays burden exists A housing cost 47 169 Retrieved from from Retrieved 169 percent of its total income before taxes and deductions toward housing. toward and deductions income before taxes percent of its total 31 percent of all households face a housing cost burden. housing cost 31 percent of all households face a cost burden. cost show that 2.2 million Texas renter and homeowner households with incomes below incomes below households with and homeowner renter that 2.2 million Texas show burden. 100% AMFI face a housing cost In order to direct resources to the people who are most in need and face the greatest and face the greatest in need In order to direct resources to the people who are most by HUD of the affordable housing programs operated burden, most housing cost Affordable Housing Affordable systems of support and affordable housing is an essential component Safe, stable from mental illness. that facilitate recovery Data obtained from: Texas Department of Housing and Community Affairs. (2016). (2016). Affairs. ofDepartment Community and Housing Texas from: obtained Data annual report, annual report, Figure 165. TDHCA Expenditures, from Direct and Indirect Funding Sources Sources Funding Indirect and Direct from Expenditures, TDHCA 165. Figure (2015) that, of renter households with incomes below 30 percent of Area Median Family Family 30 percent of Area Median below that, of renter households with incomes burden. housing costs Income (AMFI), 66 percent face a 100% AMFI. over 4 percent of households with incomes Barriers to affordable housing can disproportionately affect many Texans living Barriers to affordable housing can disproportionately affect many (SSI) is a federal Supplemental Security Income health conditions. with behavioral income and few income to people with little a monthly program that provides or elderly. resources who are blind, disabled, to work due to severe mental illness or disability. mental to work due to severe affordability gap for Supplemental Security Income (SSI) recipients. In 2014, In 2014, recipients. affordability gap for Supplemental Security Income (SSI) 93 constituted only $721 a month from SSI, which received recipients of SSI in Texas rent for a one-bedroom housing unit. fair market percent of the average affordable housing options, people with serious mental illness are priced out of the affordable housing options, found that 69 percent of people with County study Travis A 2012 housing market. hospitalizations within a certain period were homeless. four or more psychiatric TDHCA 422 people withoutamental illness. periodsoftimethanhomeless homelessness andremaininghomelessforlonger into anintegratedsetting following theirexitfromtransitionalhousing. the development istime-limitedandthereaclearplanfortransitioningresidents homeless intopermanenthousing,isexempt fromthisrule,solongasresidencein which seekstofacilitatethetransitionofpeopleandfamilies whohave been may not solelytopeoplewithdisabilities. limititsoccupancy Transitionalhousing, from choosingtoresideinthesetypesofdevelopments, butanentiredevelopment The above policiesdonot ofpeoplewithdisabilities prevent ahigherpercentage unsheltered. mental illness, andnearlyhalfofhomelessindividualswithsevere mentalillnessare found thatnearly19percentofhomelessindividuals (over 4,400) have asevere condition. Themost recent Point-in-Time (PIT)countofhomelessnessinTexas A significantnumberofpeoplewhoarehomeless also have amentalhealth · · without disabilities. Therulerequiresthat: people withdisabilities canlive inintegratedcommunitiesalongsideindividuals with theIntegrated HousingRule. Therulewas adopted in2003tohelpensurethat In Texas, housingprogramsthatserve individualswithdisabilities must comply finding housing. mental healthconditionwhoalsohave acriminalrecordcanhave adifficulttime participating incommunitylifeandaccessingaffordablehousing. People witha The negative stigma associatedwithmentalillnessalsoprevents many Texans from Texas’ 2016 AMFIis$62,800. nonmetropolitan counties. unique andspecifictoametropolitan area,sub-areasofametropolitan area,and communities throughoutthecountry. TheAMFIcalculationusesdatathatare and resultsfromtheAmericanCommunitySurvey (ACS)todetermine AMFIin receive assistance. HUDusesthemost recentcensusdataonmedianfamilyincome and TDHCA usehouseholdAMFItodetermine whether apersoniseligibleto Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas individuals throughitscombined programs. a mentalhealthcondition. In2015, TDHCA served atotal of562,097 householdsand homelessness prevention are thereforelikely toserve anumberofpeoplewhohave · · · categories: below. For aTexas householdoffourin2015, HUDestablishes thefollowing income does not exceed 80%ofAMFI.HUDbreaks“low-income” down further, as described

percent of unitsfor people with disabilities percent of unitsfor people with disabilities Small housingdevelopments with fewer than housing dev Large Extremely lo Very low Low-income -income (≤50%AMFI): 61 Homeless individualswithmentalillnessareathigherriskofchronic w-income (≤ 30percent AMFI): (≤ 80%AMFI): elopments with 50 unitsor more set asidenomorethan18 57 Low-income householdsarethosewhoseincome

62 Affordablehousingprograms thatfocuson

63 59

50 unitsset aside nomore than 36 ≤ $18,850 ≤ $31,400 ≤ $50,250 58 60 TDHCA 423

community tenants 64 67 For more information on permanent supportive more information on permanent supportive For 65 of housing managementand services staff y under federal and state law and state y under federal A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation The United States Interagency suggests Council on Homelessness 66 Functional separation Functional Affordability surrounding with the Integration of tenanc rights Full Immediacyhousing to of access and supports services Available A high degree of choice offered to of choice A high degree

housing see resources from SAMHSA at http://store.samhsa.gov/product/ housing see resources from SAMHSA Permanent-Supportive-Housing-Evidence-Based-Practices-EBP-KIT/SMA10-4510. For more information on the Housing First model, see the US Interagency First Council more information on the Housing For https://www.usich.gov/resources/uploads/asset_ checklist: on Homelessness . library/Housing_First_Checklist_FINAL.pdf Housing First is an approach to ending chronic homelessness that seeks to connect is an approach to ending chronic homelessness that seeks to First Housing mental health require sobriety, and does not individuals with housing immediately for housing. The service participation as a precondition treatment or supportive is achieved, housing stability is that once First undergirding Housing philosophy address serious mental illness or positioned to effectively clients will be better for individuals First on Housing A 2007 HUD study use. co-occurring substance found that direct access to with mental illness experiencing chronic homelessness for this programs enhanced housing stability First Housing by housing provided population. Housing First Housing No permanent supportive housing project is assumed to be able to offer all of these housing project is assumed to be able No permanent supportive are able to do so tends to predict whether to which they but the extent core elements, the project will be successful. Permanent Supportive Housing Supportive Permanent linked affordable housing is permanent, housing (PSH) supportive Permanent people especially to a range tenants, vulnerable services that enable of support and participate independently to live chronic homelessness, who experience key is a evidence-based practice that PSH is a cost-effective, in community life. health conditions. for people with behavioral recovery component in promoting According housing are: supportive core elements of permanent to SAMHSA, the using Permanent Supportive Housing in combination with a Housing First approach First in combination with a Housing Housing Supportive using Permanent to address chronic homelessness. · · · · · · · TDHCA 424 permanent disability asdefinedinSection 223oftheSocialSecurity Code,orbe moderately-priced dwellingunitinthearea. uptoapredefinedpayment with theremainderpaidbystandard fora theagency for paying 30percentoftheiradjusted monthlyincometoward rentandutilities, owner onbehalfoftheindividual.Families receivingthevoucher areresponsible TDHCA pays thebalanceofapproved rentamountdirectlytotheproperty Once eligible,individualsworkdirectlywithlandlords to obtain housing,and Low Income(i.e.30percentorbelow AMFI). percent ofhouseholdsparticipatinginthevoucher programmust beExtremely Access. 2015, TDHCA spent atotal of$279,657 toserve 68households throughProject institutions intothecommunity by providing accesstoaffordablehousing.InFY designed toassist low-income personswithdisabilities intransitioningfrom ispartofTDHCA’sProject Access Section 8Housing Choice Voucher Program PROJECT ACCESS in theprogram. a householdbeVery Low Income(i.e.50percentorbelow AMFI)toparticipate persons withdisabilities, toobtain safe andsanitary housing.HUDrequires that assistance tolow-income familiesandindividuals, includingolderadults and The Section8Housing ChoiceVoucher Program,fundedby HUD, provides financial S . hud.gov/hudportal/documents/huddoc?id=HUDPrograms2016.pdf htm. Alist ofallfederalaffordablehousingprogramscanbefoundathttp://portal. about theprogramsoperatedby TDHCA athttp://www.tdhca.state.tx.us/overview. are operatedby TDHCA andother localPHAsthroughoutthestate. Findoutmore affordable housingresourcesin Texas. Anumberof other federaland state programs The programsdescribedbelow donot representacomprehensive listing ofallthe aside” funds. disabilities ormentalhealthconditions–thesereserved fundsareknown as“set- programs have policiesthatspecificallyreserve fundingorspaceforpersonswith housing programsspecificallyforpersonswithdisabilities. Avariety ofTDHCA include thestate’s poverty andhomelessprevention programs, aswellaffordable disabilities orseriousmentalillness, orhave componentsthatdoso. Theseprograms Several ofTexas’ housingprogramsarespecificallydesignedtoserve peoplewith Conditions with Disabilities or Mental Health Housing Programs for People Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas expenses, andchildcareexpenses. including sizeandcompositionofthehousehold,citizenship status, assets, medical requirements, several other factorsaretaken intoaccounttodetermine eligibility, ection 8Housing 73 To voucher, beeligible foraProjectAccess anindividualmust have a 68 InFY2016, thestatewide AMFIwas $62,800. Ch 71

oice 72 70 Inadditiontomeeting theseincome V ouc h er 69 P Inaddition,75 rogr a m TDHCA 425 tate tate m

78 a tate psychiatric tate psychiatric 74 rogr P redit C

77 x Ta The goal is for a person to be admitted to the Project Access to the The goal admitted is for a person to be 76 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation

TDHCA is working with DADS and DSHS on a process that allows people DSHS on a process that allows and is working with DADS TDHCA ncome Housing ncome 75 tance (TBRA) from TDHCA’s HOME Investments Partnership Program and Program Partnership HOME Investments TDHCA’s tance (TBRA) from I psychiatric hospital, or board and care facility as defined by the U.S. U.S. by the as defined hospital, or board and care facility psychiatric or and Urban Development, Department of Housing issuance of voucher at the time hospital or board and care facility psychiatric by HUD as defined a previous resident of a nursing facility, intermediate care facility, s care facility, intermediate of a nursing facility, a previous resident s care facility, intermediate of a nursing facility, a current resident

b) within six months of expiration of assistance, and either of expiration of assistance, within six months a) Be an at risk applicant. That is, be a current recipient of Tenant-based Rental recipient of Tenant-based be a current is, risk applicant. That Be an at Assis Be eligible for the DSHS pilot program for residents of Texas s for residents of Texas program DSHS pilot Be eligible for the list waiting of placement on the voucher hospitals at the time

ow program by the time the HOME-funded TBRA assistance expires. While this is not a While this is not the time the HOME-fundedprogram by expires. TBRA assistance sooner than settings for people to transition into community permanent fix, it allows they would be able to otherwise. L Housing Income as the Low Credit (HTC) program, also known Tax The Housing multi-family rental development Credit (LIHTC) program, is federally funded Tax the US Treasury the program, which is funded by administers program. TDHCA largest affordable housing Department through the federal tax code. LIHTC is the the United States and in recent years has produced 100,000 of program in the history units of rental housing nationally per year. TDHCA works in collaboration with the Department of Aging and Disability Services Aging and Disability works in collaboration with the Department of TDHCA Services (DSHS) to implement Project and Department of State Health (DADS) time limited. However, through Project Access is not Assistance vouchers Access. for the Accessthere is a high demand for Project and there is a waitlist vouchers program. 1) determined to have a physical, mental or emotional disability that is expected is expected that disability or emotional mental physical, a to have determined to live ability one’s and impedes duration and indefinite of long-continued to be in either 1 of the criteria the requirements also meet Applicants must independently. or 2 below: The program is important for renters with disabilities or mental health conditions, or mental health conditions, The program is important for renters with disabilities Moreover, limited income and would qualify for LIHTC units. of whom have many Section 8 housing vouchers. are required to accept LIHTC developments award credit tax codifies its requirements for the competitive Texas Additionally, TDHCA provides federal tax credits to investors in multifamily housing who set multifamily housing who set in federal tax credits to investors provides TDHCA for affordable housing. The tax aside a specific number of units of the development residents at below- credits require the units to be leased to qualifying low-income for people who are be reserved minimally, units must, rate. These affordable market to the development. requirements specific other and meet AMFI 60 percent or below rent guidelines that are by at a reduced rate, restricted Rent for these units is set million in housing tax credits to allocated $92 TDHCA In 2015, published annually. 11,500 rental units in Texas. or rehabilitate approximately construct on the Project Access waitlist to relocate from an institution using the HOME- to relocate from an institution on the Project Access waitlist funded TBRA program. 2) TDHCA 426 through theHOMEprogram. 2016-2017 budget allocates approximately $60milliontoprovide affordablehousing both singleandmultifamilyprograms, someofwhicharedescribedbelow. The disabilities, regardlessoftheareasstate inwhichtheylive. programs offereducationalopportunitiestolearn how homeownership. tomanage modifications tosinglefamilyhomes. Inadditiontoproviding financialtools, these to 24 months and are contingent on participation in a self-sufficiency program. to 24 onparticipation inaself-sufficiency months andarecontingent affordable housingintheir community. These HOME rentalsubsidieslast up tenants withthecost ofmoving andprovides rentalsubsidiestotenantsseeking Tenant-BasedThe HOME-funded RentalAssistance (TBRA)programassists TENANT-BASEDRENTAL ASSISTANCE homebuyers. fundingtoprovide down-paymentHBA andclosingcost assistance tosinglefamily Homebuyer program,fundedby Assistance HOME.Organizationscanuse (HBA) Nonprofits, PHAs,government andunitsoflocal are eligibletoparticipateinthe HOMEBUYER ASSISTANCEPROGRAM can applyforset-aside fundswithTDHCA. more details abouttheseprograms. Localgovernments, PHAs, andnonprofitentities Assistance (TBRA),orHomeowner RehabilitationAssistance (HRA).Seebelow for these fundscanbeusedforHomebuyer Tenant-based Assistance (HBA), Rental Five percentofHOMEfundsareset asideforpersonswith disabilities, and PERSONS WITH DISABILITIES(PWD)SET-ASIDE authorities (PHAs),localnonprofits, andprivatehousingactors. and enhancepartnershipsbetween state andlocalgovernments, publichousing of programsthatseektoexpandthesupplydecent,safe, affordablehousing The Texas HOMEInvestments Partnerships Programisafederally-funded set H · · · · including thefollowing: provisions thatprovide scoringincentives forPermanent Supportive Housing, process annuallyinitsQualifiedAllocationPlan(QAP). The 2016 QAPcontains Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · HUD. serve jurisdictions, mostly rural,thatdonot receive HOME fundsdirectlyfrom

OME Housing program Incentives fordevelopments participating low-income set-aside, for tenants with incomes below 30%AMFI Points for if asupportiv Points for offering supportiv Contain at least a5 property is eligible, for entirely supportive housingdevelopments 30 percent Basis Boost, percent) 82 However, thereisa5percentset-aside foractivitiesthatserve personswith

I nvestments 85 Theprogrammay alsohelptofundrehabilitationoraccessibility 79 percent special needs unit set-aside (but nomorethan18 percent special needs unit set-aside (but e housing development contains a20 percent extremely used tocalculate the amount of tax creditsfor which the 81 By state law, 95percentofTexas HOMEfundsmust e services Pa rtners 84 in the Houston Permanent Supportive h ips P rogr 80 83 HOMEfinances a m TDHCA 427 TBRA is a TBRA TDHCA TDHCA 86 93 People with People eople eople 89 P TDHCA and the TDHCA m 90 a or f

94 The number of units created rogr 91 P l a emov R Prior to the changes to the program in 2010, the HUD the HUD Prior to the changes to the program in 2010, rrier 87 upportive Housing Housing upportive S Ba bilities Accessibility modifications may include the installation of ramps, of ramps, Accessibility include the installation modifications may A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation a 92 is Subsequently in 2014, HUD awarded a second round of funds to TDHCA a second round of funds to TDHCA HUD awarded Subsequently in 2014, oung D 88

Y h ection 811 811 ection disburses funds to nonprofit organizations and local governments that process disburses funds to nonprofit organizations and local governments construction. and oversee eligibility, verify applications, Section 811 provided interest-free development funds and operating subsidies funds development interest-free Section 811 provided HUD housing for people with disabilities. of affordable to nonprofit developers With revisions to the nonprofits. capital advances to interest-free continues to offer to be used rental assistance provides HUD now however, years, program in recent Income such as the Low subsidy programs, through other funded in developments Credit and HOME programs. Tax Housing ASSISTANCE RENTAL 811 PROJECT SECTION funds for the Section 811 awarded became one of 13 states Texas 2013, In February program. serious mental illness and people with disabilities exiting institutions are targetexiting institutions disabilities serious mental illness and people with care. as youth exiting foster populations for this program, as well as well. Combined, the awards total received $24 million to provide project-based million to provide $24 received total as well. Combined, the awards income persons with disabilities. low for extremely rental assistance Amy funding for persons provides Program (AYBR) Barrier Removal Young The Amy dangerous conditions in their accessibility and remove to improve with disabilities for accessibility one-time grants of up to $20,000 The program provides homes. whose household incomes are below home modifications to people with a disability 80% of AMFI. wit with disabilities housing programs for people supportive of HUD’s Section 811 is one the Cranston-Gonzales by and is authorized Housing National Affordable Act of reformed in 2010. 1990, S Individuals may receive assistance for up to five years, pending funding. pending years, up to five for assistance receive may Individuals short-term assistance program that also has the possibility to be a bridge to be possibility has the that also program program assistance short-term Project Access Section 8 Housing for the program. on the waitlist for individuals will depend on the prevailing rents at the time the units are placed in services, at the time the units are placed in services, will depend on the prevailing rents anticipates that the program will help TDHCA factors. household incomes and other units per $12 million housing 300 and 400 new integrated, supportive create between more information on this program, For in eight areas throughout the state. award . https://www.tdhca.state.tx.us/section-811-pra/ website please visit the TDHCA handrails, or door widening, for example. Program beneficiaries may be homeowners homeowners be may beneficiaries Program example. for widening, door or handrails, Trust Housing Program come from the state’s for the AYBR Funds or renters. 116 households in FY 2015. spent to serve $2.2 million was About Fund. Texas Health and Human Services Commission (HHSC) inter-agency entered an Health have Texas grant application. This agreement addressesagreement, per a requirement of the this for this program, how of the population that will be targeted the characteristics to the program, and the commitments ofpopulation will be reached and referred service agencies. services from the health and human TDHCA 428 appropriation of$20millionduringthe81 and supportsdesignedtohelppeopleretain housing.HHSPreceived aninitial experiencing homelessness. housingplacement Servicesincludecasemanagement, Fort Worth, Houston andSanAntonio. Theprogramserves individualsandfamilies the eightlargest citiesinTexas –Arlington,Austin, CorpusChristi, Dallas, ElPaso, allocated $10milliontotheprogramfor2016-2017 biennium. in ArticleVIIoftheGeneralAppropriationsBill81 The Homeless Housing and ServicesProgram(HHSP)was established by Rider18 HOMELESS HOUSING AND SERVICES PROGRAM TDHCA dispersed$5milliontoHHSPserve 12,277individuals. who have a disability and/or areelderly, wheretheresidents areunrelatedtothe provides basiccare,such asmealsandtransportation,toatleast threeresidents affordable livingquarters fortheirresidents. Aboardinghomeisabusinessthat mental healthconditions andother disabilities, and some homesprovide safe and Boarding homesserve animportant roleinthecontinuumofcareforpeoplewith MODEL BOARDING HOMESTANDARDS AND HOUSINGREFERRAL NETWORK R individuals intheprogram. In 2015, TDHCA spent$28millioninCSBGfundingtoserve over 324,000 with theaimtopromote stability among andself-sufficiency low incomeindividuals. eligible toreceive thesefundstoprovide essentialservices andpoverty programs funding fromHUD.governments Nonprofitorganizationsandlocalunitsof are TDHCA administers theCommunityServicesBlock Grant(CSBG)Programthrough COMMUNITY SERVICES BLOCK GRANT PROGRAM dispersed $8.4 millionto53,140 program. peoplethroughtheESG of homelessnesstoregainstability inpermanenthousing.InFY2015, TDHCA organizations, cities, andcountiestoassist homelesspersonsandatrisk administered by TDHCA. TDHCA fundstoprivatenonprofit distributes ESG programisfundedby HUDand SolutionsGrants(ESG) The Emergency EMERGENCY SOLUTIONS GRANTSPROGRAM homelessness. TDHCA hasseveral programsthatspecificallyserve peoplewhoareexperiencing P Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Agencies who arehomelessoratriskofhomelessness. families andindividualsfrombecominghomeless. Theprogramtargetsindividuals shelters, rapidlyre-housinghomelessindividualsandfamilies, andpreventing intended toprovide assistance by improving thequalityandnumberofemergency 1, 81 overty el st , Ogden/Pitts), andcodifiedin2011. a ted S a ervices nd Homeless 100 a nd P rogr 97 P TDHCA administers thisprogramin st revention legislative session,andthelegislature 96

a ms - st Legislative Session(SB O t P h rogr 98 99 95 er InFY2015, ESG fundsare ESG S t a a ms te TDHCA 429

104 , Menendez/ st 105 , Burkett/ rd This program is 102 The program was originally established to act as originally established The program was 103 Legislative Session, the Legislature awarded an exceptional an exceptional Session, the Legislature awarded Legislative rd More information on upcoming partnership academies can be More 106 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation The program serves adults with serious mental illness who are adults with serious mental illness The program serves 101 The program today provides longer-term assistance of up to 18 months and a limit assistance longer-term provides The program today (up to three assistance per recipient, and shorter-term $10,300 of approximately for rent and utilities. $2,600 in assistance months) of approximately Shapleigh). Relatedly, in 2013, the legislature passed HB 1191 (83 the legislature passed in 2013, Shapleigh). Relatedly, item to DSHS to provide short-term rental and utility assistance to individuals with short-term rental and utility assistance item to DSHS to provide (LMHAs). In FY 2016, Authorities Health mental illness through the Local Mental million. $5.4 the program received a stop-gap measure while individuals waited to receive Section 8 rental vouchers. to receive measure while individuals waited a stop-gap HOUSING AND SERVICES PARTNERSHIP ACADEMY ACADEMY PARTNERSHIP AND SERVICES HOUSING a Housing to create and implement together worked and DADS TDHCA In 2013, local communities provided The academy (HSP) Academy. and Services Partnership affordable, accessible safe, to create with the tools and education necessary in held meetings TDHCA in their communities. housing for people with disabilities and April, July, in January, Housing partnership with the Corporation for Supportive October of 2016. owner. Securing affordable and safe housing continues to be a major challenge a major to be continues housing safe for and affordable Securing owner. made to been have Efforts conditions. health mental with serious people many safe affordable and of conditions in terms mental health people with support better few years. in the past housing Commission Human Services and Health directed the Legislature the Texas In 2009, with HB 216 (81 (HHSC)standards model boarding home to establish Zaffirini), which added housing resources for people with mental illness to the added housing resources for people Zaffirini), which See the as 2-1-1). also known (TIRN, and Referral Network Information online Texas and HHSC Environment about HB of this guide for more information Sections Texas 216 and HB 1191. HEALTH MENTAL ADULT - BASED SERVICES AND COMMUNITY HOME and the Home Services (DSHS) administers of State Health The Department services (HCB-AMH). Health Community Based-Adult Mental This program is to provide 1915(i) State Plan Amendment, and seeks funded through a Medicaid to individuals with long-term tenure in state home-based services and supports a transition from these facilities into the providing mental health facilities, community. important for individuals with serious mental illness because it provides a number it provides mental illness because important for individuals with serious rather than in housing within the community, them to live of supports that allow Department of State Health more information, see the For setting. an institutional sections. Environment Services and the Texas PROGRAM ASSISTANCE AND UTILITY HOUSING RENT SUPPORTIVE the 83 during In 2013, not otherwise served in a Medicaid waiver program, and provides services such program, and provides waiver in a Medicaid served otherwise not services, home living, peer support, residential as companion care, supportive continuity of care services. and other transportation services, . website http://www.tdhca.state.tx.us/hhscc/ found on the TDHCA TDHCA 430 · · · · · identifies thefollowing goal: state actionitemstoachieve this adopted ofimproving thegoal housingoptions forpeoplewithdisabilities. The report against whentryingtofindhousing. areas, 16percentofpeoplewithdisabilities report thattheyhave feltdiscriminated origin, familialstatus anddisability, includingmentalillness. units intheprivatehousingmarket onthebasisofrace,color, religion,sex,national to astheFair whichprohibitsdiscriminationinthesale Housing orrentalof Act, commonlyreferred In 1968, CongressenactedTitleVIIIoftheCivilRightsAct, Impediments to Fair Housing Choice tx.us/211/clearinghouse/main.do services. Theclearinghousewebsitecanbefoundathttps://211texas.hhsc.state. as localserviceproviders, tofindcommunity-based affordablehousingandhealth clearinghouse provides aninteractive resourceforpeoplewithdisabilities, aswell for housingandservicesresourcesonthe2-1-1 Texas.org website.Theonline In September 2013, DADS andTDHCA finalizedandmade available aclearinghouse CLEARINGHOUSE WEBSITE HOUSING AND SERVICES FORPERSONS WITH DISABILITIES Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas governments: In additiontotheserecommendations, thereportoutlines actionsteps forlocal disproportionately affectspeoplewithdisabilities. concentrationsoflow-incomegeographic housingsaid thatconcentratedhousing conducted forthereport,seventy-four percentofstakeholders reportinghigh and barrierstomobilityfreehousingchoiceforprotected classes. standards, inadequateinformationaboutprograms toassist personswithdisability, conditions. Thesethreeimpedimentsare:lackofaccessiblehousingandvisitability impediments specifictopeoplewithdisabilities, includingpeoplewithmentalhealth In its2013 AnalysisofImpedimentstofairhousing,Texas identifiedthree five years. tofairhousingchoiceintheircommunitiesevery threeto an analysisofchallenges compliance withthisobligation,HUDrequiresfederalfundingrecipientstosubmit segregation andpromote inclusive andintegratedcommunities. Inensuring not just toprohibitdiscrimination, buttotake proactive steps tofighthousing nondiscrimination policies. Thisrequirementobligates recipientsofHUDfunding law, recipientsofHUDfundsareunderanobligationto“affirmatively further”

efforts Governments (COGs)aboutthebenefits ofuniversal designand visitablehousing Educate stakeholders Include informationaboutgrouphomerequirements in educationalandoutreach Promote local approaches Provide findings from persons with disabilities to identify specific needs incommunities Work with s takeholders who areknowledgeable about the housingneeds of , localgovernment officials, planners,of and Councils above processto local governments to meeting these needs 110 In responsetotheseimpediments, TDHCA 109 Moreover, metropolitan in large 107 Aspartofthat 108 In a survey Inasurvey 111 TDHCA 431 for language homes small group that treats ts into planning goals ts into planning local them to and articulate abilities A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 112 as commercial and industrial use and industrial as commercial Review zoning and land use ordinances use ordinances zoning and land Review design concep Build universal Conduct an assessment of the need for affordable, accessible housing serving housing accessible affordable, for of the need assessment an Conduct with dis persons developers

· For more information on these recommendations, see the full report at http://www. information on these recommendations, more For tdhca.state.tx.us/housing-center/fair-housing/docs/DRAFT-FairHousingChoice- AI-Phase2.pdf · · TDHCA 432 6 5 4 3 2 1 Endnotes Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 12 11 8 28 27 26 25 24 23 18 17 16 14 13 10 9 7 22 21 20 19 15

General Appropriations Act, H.B.General AppropriationsAct, 1,ConferenceCommit from http://www.tacinc.org/media/51752/Table%202.pdf Technical Assistance Collaborativ trieved fromhttps://www.ssa.gov/policy/docs/ssb/v75n2/v75n2p19.html Employment, earningsandprimaryimpairmentsamongbeneficiariesofSocialSecuritydisabilityprograms. Re- ssb/v65n2/v65n2p14.html; Mann,D.R., Mamun,A.,&Hemeter, J., (2015). USSocialSecurityAdministration. with multiplerecipients: prevalence andpoverty outcomes.Retrieved fromhttps://www.ssa.gov/policy/docs/ Koenig, M.&Rupp, K.,USSocialSecurityA grate-treatment-for-substance-use-disorders health care recovery. andexpand supportfor Retrieved fromhttps://www.whitehouse.gov/ondcp/chapter-inte- Office ofNationalDrugControl Policy reportmanagement/published/CoC_PopSub_State_TX_2015.pdf programs homelesspopulationsandsubpopulations.Retrieved fromhttps://www.hudexchange.info/resource/ US DepartmentofHousing andUrbanDevelopment. (20 annual report, Page 101. Retrieved fromhttps://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf Texas DepartmentofHousing andCommunityAffairs CaseNeeds_2015.pdf report toCongress, Pages viiand7. Retrieved fromhttps://www.huduser.gov/portal//Publications/pdf/Worst- and UrbanDevelopment. Officeof Development andResearch.(2015). Policy Worst casehousingneeds:2015 annual report, Page 17. Retrievedhttps://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf from grate-treatment-for-substance-use-disorders health care recovery. andexpand supportfor Retrieved fromhttps://www.whitehouse.gov/ondcp/chapter-inte- Corporation forSupportive Housing. (20 Ibid. from http://www.tacinc.org/media/15086/Using%20the%20LIHTC%20Program%2026.pdf people withdisabilities.OpeningDoors:AHousing PublicationfortheDisability Community,Page 8.Retrieved ing Task Force. (April2005).Using theLow IncomeHousingTax Credit programfor tocreate affordable housing Cooper, E.&O’Hara,A.,Technical Assis Retrieved fromhttp://www.csh.org/wp-content/uploads/2016/01/QAP_2015_AbbreviatedStateSummaries.pdf Corporation forSupportive Housing. (20 Ibid. Inclusive Communities Pr Ibid. Lim, A.(2015). Lawmak Austin T Texas DepartmentofHousing andCommunityAffairs Texas DepartmentofHousing andCommunityAffairs hudexchange.info/programs/htf/. US DepartmentofHousing andUrbanDevelopment. (20 org/sites/default/files/NHTF_StateAllocations_2016.pdf National Low IncomeHousing Coalition.(20 questions. Retrieved fromhttp://nlihc.org/sites/default/files/FAQ_2015.pdf National Low IncomeHousing Coalition.(20 Texas DepartmentofHousing andCommunityAffairs TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=10&pt=1&ch=1&rl=11 10 Tex. Code§1.11(20 Admin. tx.us/Docs/GV/htm/GV.2009.htm 10 Tex. Go Steffen, B. L.,Carter, G.R.,Martin,M.,P Texas DepartmentofHousing andCommunityAffairs portal.hud.gov/hudportal/HUD?src=/program_offices/public_indian_housing/pha/contacts/tx US DepartmentofHousing andUrbanDevelopment. (20 from http://www.samhsa.gov/homelessness-housing Substance Abuse andM Office ofNationalDrugControl Policy pdf 2015). Retrieved fromhttp://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017. ment-re/njd8P/. Retrieved fromhttp://www.mystatesman.com/news/news/lawmaker-lawsuit-challenge-new-austin-apart- cfm?id=211114. Retrieved fromhttp://www.austintexas.gov/edims/document.choice vouchers bylandlords intheAustinMSA. Draft-NHTF-Plan.pdf Amended 2016One-Year ActionPlan.Retrieved from https://www.tdhca.state.tx.us/housing-center/docs/16- Draft Housing TrustFund AllocationPlan,Draft Amended 2015-2019StateofTexas Consolidated Plan,andDraft Fund allocationplanroundtable. Retrieved from http://www.tdhca.state.tx.us/events/index.jsp Retrieved from http://www.tdhca.state.tx.us/hhscc/ enants’ Council.(2012). Voucher holders neednotapply:anauditreport ontherefusal ofhousing vernment Code§§2306.1091 -2306.1098 (2009). Retrieved fromhttp://www.statutes.legis.state. er, newAustin lawsuitchallenge apartmentregulation.Austin-AmericanStatesman. ental Health (2016). ServicesAdministration. Homelessness andHousing.Retrieved oject, Inc.v. TheTexas DepartmentofHousing&Community Affairs etal.2012. 10). Retrieved fromhttps://texreg.sos.state.tx.us/public/readtac$ext. e. (2015). State-by-state comparison–2014. InPricedOutin2014.Retrieved . (n.d.)Integrate substanceusedisorders treatment for intomainstream . (n.d.)Integrate substanceusedisorders treatment for intomainstream elletiere, D., Vandenbroucke, D.A., Yao, Y.D., USDepartmentofHousing tance Collaborative &ConsortiumforCitizens withDisabilities Hous- 16). Housingcredit policiesin2015that promote supportive housing. 16). Housingcredit policies in2015thatpromote supportive housing. dministration. (2003).SSIrecipients inhouseholdsandfamilies 16). NHTF: 2016.Retrieved from http://nlihc. StateAllocationsfor 15). NHTF: TheNationalHousing TrustFund, frequently asked . (2016). 2016StateofTexas low incomehousingplanand . (2016). 2016StateofTexas low income housingplanand . (2016). TDHCA Governing Board Approved Draft ofthe . (2016). TDHCA calendar: Texas National HousingTrust . (n.d.)HousingandHealthServicesCoordination Council. tee Report,2015 Leg.,84 15). HUDcontinuumofcarehomelessassistance 14). HousingTrustFund.Retrieved from https://www. . Retrieved16). PHAcontactinformation from http:// th Reg.Sess., art.VII.(Tex. . TDHCA 433 eg. Sess., art. VII. (Tex. 2015 2015 art. VII. (Tex. eg. Sess., Reg. Sess., art. VII. (Tex. VII. (Tex. art. Reg. Sess., th R th tee Report, 2015 Leg., 84th Reg. Sess., art. VII. (Tex. art. VII. (Tex. Sess., Leg., 84th Reg. 2015 tee Report, Leg., 84 tee Report, 2015 tee Report, 2015 Leg., 84 tee Report, 2015 tee Report, 2015 Leg., 84th Reg. Sess., art. VII. (Tex. art. VII. (Tex. Leg., 84th Reg. Sess., tee Report, 2015 Agency strategic plan for the fiscal years 2015-19 plan foryears the fiscal Agency strategic . (2014). Agency strategic plan for the fiscal years 2015-19 plan foryears the fiscal Agency strategic . (2014). 2015-19 plan foryears the fiscal Agency strategic . (2014). . (2016). Personal communication. Personal . (2016). income housing plan and low 2016 State of Texas . (2016). SSI recipients in households and families (2003). SSI recipients dministration. Retrieved from https://www. Supplemental Security Income benefits. Retrieved (2016) (2016) Housing-cost-burdened Dashboard: Community 16). CAN Retrieved from . Retrieved . Priced Out in 2014 State-by-state comparison – 2014 e. (2015). Retrieved from http://www.sos.state.tx.us/border/colonias/ What is a colonia? Retrieved Reg. Sess. (Tex. 2015). Retrieved from http://www.capitol.state.tx.us/tlodocs/84R/bill- Retrieved 2015). (Tex. Reg. Sess. . support #4: recovery initiative Strategic Services Administration. (2013). ental Health th . FY 2016 Income Limits Documentation System: (n.d.). FY 2016 Income Limits Documentation System: ousing and Urban Development. (n.d.). FY 2016 Income Limits Documentation System: ousing and Urban Development. Legislative Appropriations Request for Fiscal Years 2018 and 2019, Texas Texas 2018 and 2019, Years for Request Appropriations Legislative Fiscal t Board. (2016). Frequent utilization of behavioral health services in various service systems: performance im- performance service systems: health services in various of behavioral utilization Frequent A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation ernment Code § 2306.202(b) http://www.statutes.legis.state.tx.us/Docs/ from Retrieved (2009). , 2015 Leg., 84 Leg., , 2015 http://docs.lbb.state.tx.us/display.aspx?Doc- from Retrieved Affairs. and Community Department of Housing Type=LAR&agy=332&fy=2018 Ibid. Commit 1, Conference Act,General Appropriations H.B. text/pdf/HB01428F.pdf#navpanes=0 1, Conference Commit Act,General Appropriations H.B. BudgeLegislative 2015). Retrieved from http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017. Retrieved 2015). pdf H.B. 1428 H.B. ; from http://www.csh.org/wp-content/uploads/2016/01/QAP_2015_AbbreviatedStateSummaries.pdf Retrieved housing. supportive promote in 2014 that policies credit Housing (2014). Housing. for Supportive Corporation http://www.csh.org/wp-content/uploads/2014/12/2014_QAP_Report.pdf from Retrieved 45. Retrieved from https://www.tdhca.state.tx.us/board/docs/books/140605-item2-2015-19-Strat- Retrieved period, 45. Plan-140529.pdf. General Appropriations Act, H.B. 1, Conference Commit General Appropriations Act, H.B. Texas Department of Housing and Community Affairs Department of Housing Texas of State. (n.d.). Secretary Texas 10 Tex. Gov 10 Tex. Commit 1, Conference Act,General Appropriations H.B. and Community Affairs Department of Housing Texas what_colonia.shtml Texas Department of Housing and Community Affairs Department of Housing Texas from https://www.tdhca.state.tx.us/board/docs/books/140605-item2-2015-19-Strat- 44. Retrieved period, Page Plan-140529.pdf GV/htm/GV.2306.htm#2306.202 from https://www.tdhca.state.tx.us/board/docs/books/140605-item2-2015-19-Strat- period. Retrieved Plan-140529.pdf. 2015). Retrieved from http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017. Retrieved 2015). pdf from http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017. Retrieved 2015). pdf http://www.tacinc.org/media/51752/Table%202.pdf (part of the May- Committee Services Stakeholder presented to the Psychiatric update. Paper project provement TX. Austin, Health, Central Initiative), Improvement Indicator Illness, on Mental Force Task Health Mental or’s Department of H U.S. Department of H U.S. Technical Assistance Collaborativ Assistance Technical (2012). Stone, S. from https://www.huduser.gov/portal/data- [online data table]. Retrieved Statewide Income Limits for Texas sets/il/il2016/2016summary.odn?inputname=STTLT*4899999999%2BTexas&selection_type=county&stnam- e=Texas&statefp=48.0&year=2016 from https://www.huduser.gov/portal/data- [online data table]. Retrieved Statewide Income Limits for Texas Retrieved from http://www.cancommunitydashboard.org/drilldowns/hous- data dashboard]. Retrieved [interactive ing-cost-burdened.php Ibid. Ibid. Ibid. US Social Security Administration. (n.d.). ssa.gov/disabilityssi/ssi.html#&a0=0 K., US Social Security A M. & Rupp, Koenig, from https://www.ssa.gov/policy/docs/ outcomes. Retrieved and poverty prevalence with multiple recipients: US Social Security Administration. (2015). J., Mamun, A., & Hemeter, ; Mann, D.R., ssb/v65n2/v65n2p14.html Re- earnings and primary impairments among beneficiaries of Social Security disability programs. Employment, from https://www.ssa.gov/policy/docs/ssb/v75n2/v75n2p19.html trieved Ibid and M Abuse Substance from http://store.samhsa.gov/shin/content/SMA11-4629/06-RecoverySupport.pdf Retrieved Community Advancement (20 Network. Ibid. Ibid. Retrieved from http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017.pdf Retrieved and Community Affairs Department of Housing Texas Ibid. and Community Affairs Department of Housing Texas Ibid. Page 100. Retrieved from https://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf Retrieved 100. Page annual report,

32 33 30 31 29 39 40 35 36 38 34 37 56 57 58 48 51 52 53 54 55 46 47 49 50 41 43 45 42 44 TDHCA 434 81 79 77 76 75 74 73 72 71 70 69 68 67 66 64 63 62 61 60 59 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 80 78 65 85 84 87 86 83 82

General Appropriations Act, H.B.General AppropriationsAct, 1,ConferenceCommit . state.tx.us/home-division/ Texas Departmentof Housing andCommunityAffairs Corporation forSupportive Housing. (20 Annual Report.Page 102.Retrieved fromhttps://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf Texas DepartmentofHousing andCommunityAffairs US DepartmentofHousing andUrbanDevelopment. (20 Ibid. tx.us/section-8/project-access/ Texas DepartmentofHousing andCommunityAffairs tac=&ti=10&pt=1&ch=5&rl=801. state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_ Initiative, 10T Project Access annual report. Page 102Retrieved fromhttps://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf Texas DepartmentofHousing andCommunityAffairs about/fact_sheet http://portal.hud.gov/hudportal/HUD?src=/program_offices/public_indian_houUS%20sing/programs/hcv/ US DepartmentofHousing andUrbanDevelopment. (n.d.) Ibid. tdhca.state.tx.us/section-8/ Texas DepartmentofHousing andCommunityAffairs e=Texas&statefp=48.0&year=2016 sets/il/il2016/2016summary.odn?inputname=STTLT*4899999999%2BTexas&selection_type=county&stnam- TexasStatewide IncomeLimitsfor [onlinedatatable].Retrieved from https://www.huduser.gov/portal/data- U.S. DepartmentofH tdhca.state.tx.us/section-8/ Texas DepartmentofHousing andCommunityAffairs manent_Supportive_Housing.pdf Retrieved fromhttps://www.usich.gov/resources/uploads/asset_library/Implementing_Housing_First_in_Per- CouncilonH US Interagency tions/hsgfirst.pdf homeless persons withseriousmentalillness. Page US DepartmentofHousing andUrbanDevelopment. (2007 Ibid. Substance Abuse andM annual report, Page 101. Retrieved fromhttps://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf Texas DepartmentofHousing andCommunityAffairs from http://www.nationalhomeless.org/publications/facts/Mental_Illness.pdf National CoalitionfortheHomeless. (2006). reportmanagement/published/CoC_PopSub_State_TX_2015.pdf programs homeless populationsandsubpopulations.Retrievedhttps://www.hudexchange.info/resource/ from US DepartmentofHousing andUrbanDevelopment. (20 Ibid. tac=&ti=10&pt=1&ch=1&rl=15 state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_ Integrated Housing Rule,10Tex. A e=Texas&statefp=48.0&year=2016 sets/il/il2016/2016summary.odn?inputname=STTLT*4899999999%2BTexas&selection_type=county&stnam- from http://www.tdhca.state.tx.us/multifamily/docs/16-QAP.pdf Texas Departmentof Housing andCommunityAffairs. (n.d.).2016Texas QualifiedAllocationPlan.Retrieved Retrieved fromhttp://www.csh.org/wp-content/uploads/2016/01/QAP_2015_AbbreviatedStateSummaries.pdf; happens_lihtc_v2.pdf. Properties atyear 15andbeyond. Page 2.Retrieved fromhttps://www.huduser.gov/portal/publications/what_ SMA10-4510/SMA10-4510-05-EvaluatingYourProgram-PSH.pdf your program (HHSPublicationNo. SMA 10-4509). Retrieved fromhttp://store.samhsa.gov/shin/content/ U.S. DepartmentofH Texas DepartmentofHousing andCommunity Affairs Texas DepartmentofHousing andCommunity Affairs Ibid. Ibid. Texas Department of Housing andCommunityAffairs tion-8/project-access/docs/TBRA-Roadmap.doc Assistance toassist TDHCA’s Section8Project Access clients . Retrieved fromhttp://www.tdhca.state.tx.us/sec- annual report. Retrieved from https://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf state.tx.us/home-division/ pdf 2015). Retrieved fromhttp://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2016-2017. ousing andUrbanDevelopment. (n.d.).FY2016IncomeLimitsDocumentationSystem: Section 811 Supportive Housing for Personsousing andUrban Development. (n.d.).Section811Supportive Housingfor with ental Health (2010). ServicesAdministration. Permanent supportive housing:evaluating omelessness. (n.d.)ImplementingHousingFirst inpermanentsupportive housing. ex. Admin. Code§5.801ex. Admin. (2014). Retrieved fromhttps://texreg.sos. dmin. Code§1.15(2003).Retrieved fromhttps://texreg.sos. 16). Housingcredit policiesin2015thatpromote supportive housing. Mental illness andhomelessness (NCHFact Sheet#5).Retrieved xxvi.Retrieved fromhttps://www.huduser.gov/portal/publica- . (2016). 2016StateofTexas low incomehousingplanand . (n.d.)HOMEdivision.Retrieved fromhttp://www.tdhca. . (2016). 2016StateofTexas Low-Income HousingPlanand . Retrieved. ProjectAccess fromhttp://www.tdhca.state. . (2016). 2016StateofTexas low incomehousing planand . (n.d.).Section8housing.Retrieved fromhttp://www. . (n.d.).Section8housing.Retrieved fromhttp://www. . (2013). Process utilizingHOME Tenant-Based for Rental . (2016). 2016StateofTexas low incomehousingplanand . (n.d.)Homedivision.Retrieved fromhttp://www.tdhca. tee Report,2015 Leg.,84 15). HUDcontinuumofcare homeless assistance 12). WhathappenstoLow-Income HousingTax Credit Housing ChoiceVouchers sheet.Retrieved from fact ). TheapplicabilityofHousingFirst modelsto th Reg.Sess., art.VII.(Tex. TDHCA 435 Reg. Sess., art. VII. (Tex. VII. (Tex. art. Reg. Sess., st . (2016). HHSCC Meeting Agendas and Materials. Re- Agendas HHSCC and Materials. . (2016). Meeting Morn- . BBC Research & Consulting in association with 2016 State of Texas low income housing plan and income housing low 2016 State of Texas . (2016). communication: Homeless Personal 19). July . (2016, income housing plan and low 2016 State of Texas . (2016). 2016 State of Texas low income housing plan and housing income low of Texas 2016 State . (2016). 811 Project. Communication: 17). May Personal . (2016, income housing plan and low Texas 2016 State of . (2016). Young Amy communication: Personal 19). July . (2016, . Retrieved Program Barrier Removal . (n.d.). Amy Young Emergency communication: Personal 19). July . (2016, plan and income housing low 2016 State of Texas . (2016). Supportive Housing Rent and Utility Assistance Program. Program. Assistance Housing Rent and Utility 16). Supportive , Mental Health and Substance Use Division. (2015). Home and Use Division. (2015). and Substance Health , Mental . 1, Conference Committee Report, 2009 Leg., 81 Report, 2009 . 1, Conference Committee Fair housing laws and presidential executive executive and presidential housing laws Fair (2016). ousing and Urban Development. , E., Marton, K., & Mondello, M., Technical Assistance Collaborative. (2014). State funded (2014). Collaborative. Assistance M., Technical , E., Marton, K., & Mondello, A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation . -8. Mental Health and Housing: How Texas can help its citizens through through can help its citizens Texas . (n.d.) Mental Health and Housing: How Texas Seals Central ., Easter trieved from http://www.tdhca.state.tx.us/hhscc/council-meetings.htm trieved plan for fair housing choice: State of Texas (2013). ingside Research and Consulting and Community Solutions. from https://www.tdhca.state.tx.us/fair-housing/docs/DRAFT-Fair- Retrieved 7.. of impediments. Page analysis HousingChoice-AI-Phase2.pdf 16 Ibid., Page 2. Ibid., Page 7 Ibid., Pages Ibid. Texas Department of Housing and Community Affairs Department of Housing Texas Department of H U.S. from http://portal.hud.gov/hudportal/HUD?src=/program_offices/fair_housing_equal_opp/ . Retrieved orders – 3619. §§ 3601 U.S.C. Act Housing is codified in 42 FHLaws; the Fair and Community Affairs Department of Housing Texas Retrieved from http://www.txcouncil.com/userfiles/ Based Services – Adult Mental Health. Retrieved Community files/2015%20conference%20presentations/The%20Direction%20and%20Impact%20of%20the%20 Home%20and%20Community.pdf from http://nlihc.org/rental-programs/catalog/supportive-housing-rent-and-utility-assistance-pro- Retrieved gram T Lavelle, Bergquist, R., Cooper Texas Department of State Health Services Department of State Health Texas Ibid. Coalition. (20 Housing Income National Low from http://www.easterseals.com/centraltx/ housing. Retrieved in supportive and innovation investment shared-components/document-library/integrate-housing-project.pdf from http://www.tacinc.org/media/43566/State%20Funded%20Hous- Retrieved programs. housing assistance ing%20Assistance%20Report.pdf Texas Department of Housing and Community Affairs Department of Housing Texas from https://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf 170. Retrieved . Page annual report and Community Affairs Department of Housing Texas Program. and Services Housing and Community Affairs Department of Housing Texas https://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf from Retrieved 103. Page annual report. 2009). Retrieved from http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2010-11.pdf Retrieved 2009). General Appropriations Act,General Appropriations S.B Texas Department of Housing and Community Affairs Department of Housing Texas and Community Affairs Department of Housing Texas and Community Affairs Department of Housing Texas and Community Affairs Department of Housing Texas Texas Department of Housing and Community Affairs Community and of Housing Department Texas Affairs and Community of Housing Department Texas Ibid. Ibid. Affairs and Community of Housing Department Texas Retrieved from http://portal.hud.gov/hudportal/HUD?src=/program_offices/housing/mfh/prog- Retrieved Disabilities. desc/disab811 fromhttps://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf Retrieved annual report. https://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf from 177. Retrieved . Page annual report Barrier Program. from http://www.tdhca.state.tx.us/htf/single-family/amy-young.htm Solutions Grants Program. from https://www.tdhca.state.tx.us/housing-center/docs/16-SLIHP.pdf 169. Retrieved Page annual report.

107 109 111 112 108 110 102 104 103 105 106 99 100 101 98 91 92 88 89 90 93 94 95 96 97 TDHCA 436 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas TVC 437 441 441 441 446 447 447 448 448 437 437 438 440 440 442 443 443 444 445 445 446 439 440 1

There are over 177,000 women veterans in Texas. in veterans women 177,000 over are There

2 Health Intervention Programs for Veterans Living in Rural Areas Areas Rural in Living Veterans for Programs Intervention Health

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Services Study on Veterans with Post-Traumatic Stress Disorder (PTSD) Disorder Stress Post-Traumatic with Veterans on Study A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Mental Health Intervention Programs for Female Veterans Veterans Female for Programs Intervention Health Mental oncerns an Peer Network Peer an onment A Benefits A The Texas Veterans + Family Alliance program Alliance Family + Veterans Texas The conditions receiving services through the Veterans Health Administration (VHA) had increased from 27 from increased had (VHA) Administration Health Veterans the through services receiving conditions cts C ofservices state and federal

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post-traumatic stress disorder (PTSD) and suicide among veterans among suicide and (PTSD) disorder stress post-traumatic ans by 2043. by ans of veterans among homelessness a comments about a person’s body or sexual activity, displays of pornographic material, and unwanted sexual sexual unwanted and ofdisplays material, pornographic activity, sexual or body person’s a about comments Mental Health Program (VMHP) and Other Supports Other and (VMHP) Program Health Mental Veterans Portal (TVP) Portal Veterans Veterans’ Assistance (FVA) (FVA) Assistance Veterans’ epresentation and Counseling Program Counseling and epresentation acts the needs of, outreach to, and services available to women veterans in the state the in veterans women to available services and to, outreach of, needs the

supports for veterans returning to civilian life after deployment after life civilian to returning veterans for supports SB 1305- Mental 1305- SB Inter 169- SB SB 55 – 55 SB HB 3404 – 3404 HB 1304- SB Military Veter Military Other VMHP Services Courts Specialty Texas V Women Policy Concerns Policy F Fast Chart Organizational Behavioral Health Services Health Behavioral st F st Funding Claims R Claims V for Eligibility VA Employment TVC for Fund Fifty-five out of out (including of out 38 and women 100 every harassed Fifty-five sexually been having report men 100 every offensive of prevalence the that found or health mental with Affairs veterans ofDepartment the by Veterans report 2016 A use substance Lack ofLack California. except state other any than more of veterans million 1.7 nearly to home is forces, armed the Texas of percent 16 up make to all projected are and population veteran the within group growing fastest the are Women veter living military. the in while advances), 2014. in percent 40 than more to 2001 in percent Continued expansion of expansion services specialist peer Continued veteran Tracking Coordination of risk High rates High Introduction Veterans Changing Envir Changing olicy a

· · · F · · P · · · · · At a Glance Commission Commission Veterans Texas Texas Veterans Veterans Texas · Veterans exhibit significantly higher suicide risk compared with the U.S. general population.6 The Department of Veterans Affairs 2016 Suicide Data Report concluded that 20 veterans die from suicide each day.7 Three out of five veterans who died by suicide were diagnosed as having a mental health condition.8 · Reports show that veterans are overrepresented in the U.S. homeless population, constituting 12.3 percent of all adults experiencing homelessness in the country but only 9.7 percent of the total US population.9 Organizational Chart

Data obtained from: Texas Veterans Commission. (2016). Texas Veterans Commission Organizational Chart. Retrieved from http://www. tvc.texas.gov/Documents/Organizational_Chart-FY_2016-4thQ.pdf

438 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas TVC 439 13 16,17 Thus, Thus, 15 Additionally, 55 out of 100 women Additionally, In comparison, only 7-8 percent of In comparison, only 7-8 14 11 TVC focuses on the following program areas: program areas: focuses on the following TVC

the

Veterans face a myriad of challenges from as they transition face a myriad Veterans 10 In addition to combat trauma, sexual assault while in military while assault In addition to combat trauma, sexual 12 Additionally,

tance

A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation 18 employment services employment services education Veterans’ Veterans’ Veterans’ and counseling Claims representation assis Funding

active duty to civilian life. Among these challenges duty to civilian life. active is an increased risk for behavioral of the Iraq and of veterans percent 11-20 Approximately health conditions. are diagnosed and Enduring Freedom) (Operations Iraqi Freedom wars Afghanistan disorder (PTSD). stress with post-traumatic · · · · American adults in the general will experience PTSD population at some point during their lifetime. and 38 of 100 men report having been sexually harassed, which includes behavior behavior been sexually harassed, which includes and 38 of 100 men report having of displays activity, body or sexual comments about a person’s such as offensive sexual advances while in the military. pornographic material, and unwanted duty (referred to as military sexual trauma) can also result in symptoms of PTSD. in symptoms trauma) can also result duty (referred to as military sexual The Texas Veterans Commission (TVC) serves veterans and their dependents in all veterans serves Commission (TVC) Veterans The Texas It is the designated benefits and rights. disability pertaining to veterans’ matters before the U.S. and its veterans the state to represent agency of Texas of the state VA The agency Affairs in filing veterans represents (VA). Department of Veterans dependents with and it assists appeals processes, claims and during VA disability benefits. survivor Unfortunately, only about half of all veterans with a diagnosed behavioral health with a diagnosed behavioral only about half of all veterans Unfortunately, received fewer have and even services, accessed appropriate condition have adequate care. Among those women who use Veterans Affairs (VA) health care, 23 out of 100 report Affairs (VA) Among those women who use Veterans sexual touching that involves physical (unwanted been sexually assaulted having military. some form of coercion) while in the Commission Introduction other more than any of the armed forces, to nearly 1.7 million veterans is home Texas California. except state Texas Veterans Veterans Texas veterans are at increased risk for developing mental health conditions and substance mental health conditions and substance are at increased risk for developing veterans from their military service. use problems stemming face a number of use conditions with mental health and substance Veterans a greater risk of suicide, a homelessness, increased risk factors including: chronic and incarceration. premature mortality, wide range problems, of serious medical TVC 440 2016. expand thisgrantprogramforthecurrentbiennium,which started inSeptember of HB 3404(84 DISORDER (PTSD) HB 3404–STUDY ON VETERANS WITH POST-TRAUMATIC STRESS found athttp://www.texasstateofmind.org/tvfa/. The most recentupdateson theTexas Veterans +Family Allianceprogramcanbe Twenty milliondollarswas appropriatedby the84 proposals (RFP)was releasedinDecember2015. state fundsand$1millionraisedthroughprivatelocal funds. Therequest for The programiscurrentlyinthepilot phaseandwas fundedthrough$1millionin Health Policy Institute (MMHPI)istheadministrator oftheone-year pilot program. an outsidestakeholder toadminister thepilot program.TheMeadows Mental services andtreatmentforboth veterans andtheirfamilies. must workwith HHSC program tosupportcommunitymentalhealthprograms thatprovide mentalhealth In 2015, the84 Changing Environment more information,visitwww.health.mil. health caretoactive dutyandretired U.S. militarypersonnelandtheirfamilies. For The U.S. DepartmentofDefenseMilitaryHealth System isresponsibleforproviding impact veterans’ abilitytoaccessbehavioral healthservices. Both theclaimsrepresentationandcounselingfunding assistance programs Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas evaluate the benefits of1)usinga PTSD standardized comprehensive trauma and and medicalschoolwithexpertise inbehavioral healthorPTSD. Thestudy will traumatic stress Thestudy disorder(PTSD). willbecoordinated withauniversity to conductastudy onthebenefitsofproviding integratedcareto veterans withpost- · · · The pilot programawardees are: · · Senate Bill55(84 SB 55– THE TEXAS VETERANS +FAMILY ALLIANCE PROGRAM coordinated directly through theTexas Veterans Commission (TVC). note thatthefollowing bills are related to veterans’ behavioral healthbutnot needs ofveterans inTexas throughseveral piecesoflegislation.Itisimportant to

Tropical Texas Behavioral H United Wa Texas Panhandle Centers HealthEmergence Center for BrainHealth 20 ThegrantfundingperiodwillcontinuethroughAugust 31,2017. th y ofDenton County , Thompson/Lucio)required Health andHumanServicesCommission th legislature appropriated funding to help to address the mental health legislatureappropriatedfundingtohelpaddressthementalhealth th , Nelson/S. King) directed HHSC toestablish anewgrant directedHHSC , Nelson/S. King) Network ealth 21 th legislaturetocontinueand 19

TVC 441

22 24 26 23 These disparities are compounded by the continued by These disparities are compounded 25 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation , Menéndez/ Minjarez) required DSHS to develop a mental health a mental required DSHS to develop Minjarez) , Menéndez/ , Menéndez/ Minjarez) also required DSHS to develop a mental health DSHS to develop also required Minjarez) , Menéndez/ th th , Uresti/King, S.) required health and human services agencies required health and human to ensure S.) , Uresti/King, th legislature did not appropriate funding in the biennial budget for the study study budget for the in the biennial appropriate funding did not legislature th required in HB 3404. As of print date, HHSCrequired in HB 3404. with for partnering options is exploring of higher education. institutions active duty members, or their spouses or dependents, do not lose their place on do not spouses or dependents, or their duty members, active certain by programs provided assistance for any lists waiting or other lists interest or dependents who are their spouses, impacts veterans, This provision agencies. that this as a result of military service. SB 169 states temporarily residing out of state is killed in duty, active ends one year after the military member leaves protection when his or is out of state action, or dies while in the service. If a military member agencies the individual’s will maintain list, her name reaches the top of the interest for this protection agencies Several already allow list. position on the interest consistency across This legislation provides and dependents. their spouses, veterans, DSHS, DARS, SB 169 applies to programs at DADS, program policies and agencies. agency Implementation varies by and program. and HHSC. initiative as part of the mental health intervention program for female veterans. veterans. program for female intervention as part of the mental health initiative trauma from military sexual face unique mental health concerns, veterans Women dual roles as soldiers and family caregivers. to consolidating initiative for veterans living in rural areas of the state. Of the 1.67 million veterans Of the 1.67 million veterans living in rural areas of the state. for veterans initiative in rural areas with limited or live 503,000) 30 percent (approximately in Texas, been historically in these areas have Veterans no access to mental health services. in this capacity. underserved SB 1304- MENTAL HEALTH INTERVENTION PROGRAMS FOR FEMALE PROGRAMS INTERVENTION HEALTH SB 1304- MENTAL VETERANS SB 1304 (84 assessment to identify and target evidence-based treatment services to provide to provide services treatment evidence-based and target identify to assessment of the treatment in members family 2) involving and for veterans; care integrated the a report describing HB 3404 requires Finally, with PTSD. diagnosed veterans 1, 2016. by December to be released this new effort results of shortage of mental health professionals in rural areas (see the Texas Environment Environment shortage in rural areas (see the Texas of mental health professionals shortage mental health workforce section for further discussion of the in rural areas). DUTY ACTIVE PROGRAMS FOR OF HHS LISTS WAIT AND SB 169- INTEREST MEMBERS SERVICE SB 169 (84 SB 1305- MENTAL HEALTH INTERVENTION PROGRAMS FOR VETERANS FOR PROGRAMS INTERVENTION HEALTH SB 1305- MENTAL AREAS LIVING IN RURAL SB 1305 (84 The 84 TVC 442 from http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=403&fy=2018 License PlateTrust Fund No. 0802,Governor’s Emer/Def Grant *Other fundsinclude:Fund forVeterans Assistance, Appropriated Receipts, Contracts, Interagency Source: Figure 167. TVC Funding Finance forFY byMethodof 2018-19 License PlateTrust Fund No. 0802,Governor’s Emer/Def Grant *Other fundsinclude:Fund forVeterans Assistance, AppropriatedReceipts, Contracts, Interagency from http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=403&fy=2018 Source: Legislative Budget Board. (2016). Figure 166. TVC Funding Finance forFY byMethodof 2016-17 as other funds. Note: TVC isnot partofthe Health and HumanServicesenterprise. The Texas Veterans Commission (TVC) receives both state andfederal funding, aswell Funding Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Legislative Budget Board. (2016). Veterans Commission, Legislative Appropriations Request Fiscal Years 2018-2019. Veterans Commission, Legislative Appropriations Request Fiscal Years 2018-2019. Retrieved Retrieved TVC 443 Veterans Veterans 28

27 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Indirect Administration Indirect Retrieved Retrieved 2018-2019. Years Fiscal Request Appropriations Legislative Commission, Veterans (2016). Board. Budget Legislative http://docs.lbb.state.tx.us/display.aspx?DocType=LAR&agy=403&fy=2018 Goal 1. Goal Description benefits due all receive survivors and dependents their veterans, Ensure 2. Goal services housing and health, mental assistance, general receive veterans Ensure 3. Goal Program Exemption Hazlewood for Reimbursements and Administration Provide 4. Goal are assigned to one of eight priority groups upon enrollment. The higher priority are assigned to one of eight priority groups upon enrollment. The following sections describe VA benefits eligibility and available VA behavioral healthVA behavioral available benefits eligibility and sections describe VA The following of an individual independently or with the assistance services that can be accessed by throughout the state. counselors work with veterans TVC counselors. TVC Eligibility for VA Benefits VA for Eligibility occurs upon discharge including health services, benefits, VA Eligibility for most when under dishonorable conditions. military service, except from active TVC’s claims representation and counseling program helps veterans and their family program helps veterans claims representation and counseling TVC’s TVC VA health care programs. benefits and enroll in members apply for disability direct representation in to provide the VA 75 counselors accredited by over employs with the process of securing benefits claims and appeals as well as general assistance (VISN) integrated service network veterans Claims counselors at many facilities. with veterans medical facilities and assist and VA veteran the act as liaisons between benefits. compensation applications for VA Claims Representation and Counselingand Representation Claims Program Source: Source: from Figure 168. TVC Funding by Strategy for FY 2016-17 2016-17 FY for Strategy by Funding TVC 168. Figure TVC 444 sexual trauma counseling, and bereavement counseling services. FY 2015 andprovided 1,663,011 no-cost visitsfor readjustment counseling,military Centers served atotal of 219,509 veterans, servicemembers, andmilitaryfamilies in of active dutymilitarypersonnel andveterans. The VA alsoprovides behavioral healthservicesforfamilymembersandsurvivors services such as outreach, case management, andsocialservices referrals.services suchasoutreach, casemanagement, nationwide provide psychological counselingforwar-related traumaandother · · · · · facilities, andcommunitylivingcenters. Servicesandprogramsinclude: care clinics, andspecialtyoutpatientmentalhealthclinics, general residential care provide both inpatientand outpatientbehavioral healthservices, includingprimary counseling programsdescribedabove. Thereisawidearray ofVA settings that instead itlinksveterans totheseservicesthrough theclaimsrepresentationand The TVC doesnot directlyoperateorprovide behavioral healthservicestoveterans; http://www2.va.gov/directory/guide/state.asp?State=TX&dnum=ALL. 65 andolder, orhave permanentdisability. is amonetary benefitpaidmonthlyto veterans withlow ornoincomewhoareaged multiple clinicsandvet centers throughoutthestate. VA Heart ofTexas Health CareNetwork, whichislocated inArlington,alongwith services tohelpveterans adjust tolifepost-combat. Texas hasoneVISN, VISN17: outpatient clinicsandvet centers, whichprovide counseling,outreach,andreferral a hierarchy ofmedicalcenters, on-siteoutpatientclinics, community-based by asystem eachcontaining of23veterans integratedservicenetworks (VISN), Nationally, veterans’ healthcareservicesareadministered onaregionallevel VA Behavioral Health Services rehabilitation. awarded specialeligibilityduetoadisability incurredduringtreatmentorvocational withadisabilitydischarged incurred oraggravated inthelineofduty, andveterans prisoners ofwar, PurpleHeart Medal recipients, Medal ofHonor recipients, veterans groups includeveterans withservice-connecteddisability ratings, includingformer Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas specified limit(dependingonspouse/dependents). wartime (combatexperience not required)andafamilyincomelower thana (depending ondatesofservice)active dutywithoneday duringaperiodof Connectedpensioninclude:having served 90days or24 months for aNon-Service service, regardlessoftheircombatexperience. veterans whosufferedaninjuryorillnessincurredaggravated duringmilitary Service Connected.Service-Connectedcompensation isamonetary benefitpaidto There aretwotypesofcompensation available: 1)Service-Connectedand2)Non- va.gov/healthbenefits/resources/priority_groups.asp

Substance use services Evidence-based ps Suicide prevention programs Psychosocial services Specialized PTSD 29 rehabilitation and recovery services, For acomplete listing ofalleightprioritygroups, seehttp://www. ychotherapy programs, and . , , 31 Additional eligibilityrequirements Additional 30 34 A Non-Service Connectedpension ANon-Service Additionally, 300Vet Centers 32 33 . For moreinformation,see 36 Therewerea total 35 Vet Vet TVC 445

44 Other 40 37 Veterans Veterans 45 Housing for Texas for Texas Housing 43 41 46 42 The TVC offers employment services to assist to assist services employment offers The TVC 39 , eroes Grants, A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Mental Health Grants, and Grants, Health Mental Grants. Court Treatment Gainful employment is therefore key to ensuring that veterans live live to ensuring that veterans is therefore key Gainful employment 38 General Assistance Grants Assistance General H for Housing Veterans Veterans

Veterans Mental Health Grants fund projects that provide direct mental health Grants fund projects that provide Health Mental Veterans and their families through a range of services such as peer services to veterans group therapy, counseling, PTSD treatment, traumatic brain injury (TBI) services, and co-occurring disorder counseling, among others. equine therapy, qualified veterans in finding and obtaining meaningful and long-term employment. and long-term employment. obtaining meaningful in finding and veterans qualified and resume job coaching, job training, provide representatives employment Veteran and conduct access to education programs, They can also provide assistance. the hiring of veterans. to promote outreach to businesses and employers The FVA is funded through four primary sources: the sale of $2 scratch-off lottery tickets, tickets, of $2 scratch-off lottery primary sources: the sale is funded through four The FVA and the State Employee donations, registration vehicular online or check donations, · local grants reimburse charitable organizations, General Assistance FVA service organizations (VSO) and veterans agencies, government for providing including housing assistance, families, and their direct support services to veterans to medical transportation counseling for PTSD and traumatic brain injury, services. to other and information and referrals appointments, The Fund for Veterans’ Assistance (FVA) is operated by the TVC and is funded the TVC is operated by (FVA) Assistance for Veterans’ The Fund four awards The FVA funds and private donations. through a combination of state direct services to veterans categories organizations that provide of grants to eligible The four categories include: and their families. · · Fund for Veterans’ Assistance Assistance (FVA) Veterans’ for Fund · TVC Employment Services Employment TVC health and economic mental negative can have among veterans Unemployment in securing stable for veterans additional obstacles which creates consequences, housing. For a comprehensive description of federal benefits and services available to services benefits and of federal description a comprehensive For visit http://www.va.gov/opa/publications/ members and survivors, family veterans, benefits_book.asp. 8.97 million veterans enrolled in the VA Health Care system in FY 2015. system Care Health VA in the enrolled veterans million 8.97 independently and self-sufficiently. independently and employment-related services for veterans include intensive services, vocational vocational services, include intensive services for veterans employment-related services. supportive referrals to training, and other services, Treatment Court Grants assist Texas veterans in obtaining services through in obtaining veterans Texas Treatment Court Grants assist Treatment Court programs. Veterans Heroes grants support nonprofit or local government organizations that provide that provide organizations grants support nonprofit or local government Heroes and their families. for veterans temporary and permanent housing assistance TVC 446 veterans mentalhealthacrossthestate foratotal ofover $1millionfor2016. Health Services(DSHS). chapters acrossthestate and issupportedby grantsfrom theDepartmentofState rules, notwopeergroupsarethesame. TheMilitaryVeteran Peer Network has37 group meetings intheircommunities. Becausemembersofthegroupset theirown Leaders aretrainedinpeersupportandmentalhealth awareness andestablish peer community resourcesforveterans andprovide peercounseling services. Peer Group affiliation of veterans andfamilymemberswhoactively identify andadvocate for TexVet network istheMilitary Veteran Peer Network. Thisorganization isan One oftheVeterans resourcesavailable onthe Mental Health Program (VMHP) M partners acrossthestate. that veterans areproperlyconnectedtotheservicesthattheyneedby knowledgeable veteran communitythroughitsnetwork andevent-based activities, whichensures successfully accessservices. TexVet forthe hasinitiateda“NoWrongpolicy Door” veterans, militarymembers, andtheirfamilieswithreferralsinformationto providers, communityorganizations, andvolunteers whoarecommitted toproviding TexVet, aninitiative by theTexas A&MHealth ScienceCenter, isanetwork ofhealth population. Veterans exhibitsignificantlyhighersuicideriskcomparedwiththe U.S.general (VMHP) and Other Supports Veterans Mental Health Program www.tvc.texas.gov/Grants-Awarded.aspx For alist ororganizationsandgrantawards beginningJanuary 1,2016, visithttp:// Charitable ContributionCampaign. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas another Veteran, apeer.” –MilitaryPeer Veteran Network “No oneisbetterprepared to speakwithaVeteran aboutherexperiences than day. most recentstudy ofitskind)concludesthat20veterans diefromsuicideeach responded tomorethan48,000 texts. or smartphonewithconfidential,round-the-clocksupport, andsincethenhas to provide another way forveterans toconnectthroughtheirpersonalcellphone In November 2011, theVeterans CrisisLineintroducedatext-messaging service online chatservice,addedin2009, inmorethan267,000 hasengaged onlinechats. services tocallersincrisisover 56,000 times. TheVeterans CrisisLineanonymous Crisis Linehasanswered over 2millioncallsandinitiatedthedispatchofemergency will beconnectedwithatrainedVA responder. Sinceitslaunchin2007, theVeterans friends. Callerscanreachthehotline viatelephone,text, oronlinechatwherethey including suicidecrises, andcanbeaccessedby veterans, theirfamilies, and/or ilit 50 TheVeterans CrisisLineisaresourceavailable duringmentalhealthcrises, a ry 49 TheDepartmentofVeterans Affairs2016 SuicideDataReport(the V eter 53 52 a

For moreinformation,visit:http://texvet.org. n P eer 47 TheFVA funded11organizationsinvolved in 51 N etwork 48 TVC 447 55 Smith Webb Williamson Harris Hays Hidalgo Midland Montgomery Nueces Tarrant Travis Rockwall

· · · · · · · · · · · · ervices S

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· · · · · · · · · · As of May 2016, there are twenty-three veterans courts operating throughout the courts veterans there are twenty-three 2016, As of May counties: in the following state · S lead to involvement use conditions may health and substance Left untreated, mental a process, Under the typical criminal justice system. in the criminal justice facing charges is assigned to a judge unfamiliar with the be veteran who may and TBI, depression, such as PTSD, veterans, returning unique challenges faced by court may in a specialty veterans a judge sitting Alternatively, use issues. substance conditions and veteran-specific of the mental health understanding a better have The judge more also be may that can increase risks for criminal behavior. struggles available to services and benefits familiar with the range of community-based and often include case managers experience and court clerks with military veterans be more capable of courts may veterans Thus, or familiarity working with veterans. linking them and and instead system from the criminal justice veterans diverting and supports. services, their families to benefits, cases began accepting located in Harris County, Texas, court in veterans The first Hidalgo, Harris, Paso, El Dallas, courts (Bexar, veterans Results from seven in 2009. were assessed veterans included: 651 total counties) in FY 2013 and Travis Tarrant, enrolled in the program, program, 451 veterans for eligibility to participate in the successfully completed veterans and 124 were new enrollees, 226 of the 451 veterans the program. The Veterans Mental Health Program also provides additional services including: services including: additional also provides Program Health Mental The Veterans health professionals, for licensed mental training Cultural Competency Military organizations for community-based training Awareness Health Mental Veterans programming Involved of Justice and Coordination organizations, and faith-based agencies. system through engagement, with justice training, and cooperation O TVC 448 organizations. The84 throughout thestate, andcoordinatingservicessupportswithlocalcommunity veterans, by helpingthemobtain theirbenefits, increasingservicesforwomen veterans The TVC createdtheTexas Women’s Initiative inaneffort tobetter serve women resources areresponsive totheneedsofwomanveterans. including mentalhealthandsubstance useservices, supportservices, andtransitional sexual trauma,PTSD, homelessness and financial stress, itisimportantthathealthcare, than militarymen. than men. woman veterans. population,womenaremorelikely todevelop Inthegeneral PTSD of femaleveterans, theVA hasembarked oneffortstounderstand how tobetter serve to make up16percentofalllivingveterans by 2043. Women arethefastest growing groupwithintheveteran populationandareprojected W dpuf. The Texas Veterans Portal is available at · · · · · · · · · asked questions. CurrentlytheTVPcollaborateswith: download pertinentforms, locatecommunityresources, andreviewfrequently employment, andhealthservices. Additionally, TVPisasingleaccesspoint to ofinformationaboutveteran’saccess toacomprehensive range benefits, education, for Texas veterans, theirfamilies, andserviceproviders. Thesiteprovides online several state andcommissionstoprovide agencies assistance, services, andbenefits The Texas Veterans Portal by (TVP),managed theTVC, isacollaborative effortof T Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas nonveteran women. less peryearthanmaleveterans andareuptofourtimesmorelikely tobehomelessthan lack privateinsurance,andhave poorerhealth. initiatives toserve womenveterans. Visit DSHS tocreateaninitiative focusedonthementalhealthneedsofwomenveterans.

ex Carter’s offices Texas Workforce Commission TVC Texas Army NationalGuard(CampMabry). Staff from Texas State Texas Departmentof Information Office of the Gov TexVe 2-1- Texas Ve omen http://www.tvc.texas.gov/Women-Veterans.aspx formoreinformationon other a 1 (Texas Health &Human Services Commission) s t (Texas A&MHealth Science Center) 58 V It is unclear whether the incidence of PTSD is higher among military women Itisunclearwhetherhigheramongmilitarywomen theincidenceofPTSD terans LandBoard (Texas General Land Office) eter V eter 59 ernor 61,62 However, woman veterans aremorelikely tohave lower incomes, a th legislaturepassedSB1304(84 Because of their heightened risk for having experienced military Becauseoftheirheightenedriskforhaving experiencedmilitary ns a Representative Chris Turner andU.S. Representative John ns P ort a Resources l ( www.texas.gov/veterans#sthash.96yEX5Qf. TVP 60 56 Female veterans earnalmost $10,000 ) 57 Recognizing the growing number Recognizingthegrowing number th , Menéndez/ Minjarez), requiring TVC 449 http:// Retrieved from Retrieved Presentation to House Defense and Veterans’ Affairs: Veteran Services Services Veteran Affairs: Defense to House Presentation and Veterans’ . (2016). Services Veteran Affairs: to House Defense Presentation and Veterans’ . (2016). Retrieved from http://www.capitol.state.tx.us/ Retrieved SB 1304 Bill Analysis. from http://www.capitol.state.tx.us/ Retrieved SB 1305 Bill Analysis. Co-occurring disorders in veterans and in veterans disorders Services Administration. (n.d.). Co-occurring ental Health Critical Issues Facing Veterans and Mili- Veterans Facing Critical Issues Services Administration. (2016). ental Health Pg. 9. 9. and Other Americans 2001-2004. Pg. Suicide Among Veterans (2016). Affairs. eterans Federal benefits for veterans: Dependents and survivors, 2014 Edition. Dependents and survivors, benefits veterans: for Federal (2014). Affairs. eterans from Retrieved Network. Health Care Heart of Texas VA VISN 17: (2016). Affairs. eterans 2014 Edition. Dependents and survivors, benefits veterans: for Federal (2014). Affairs. eterans Retrieved from http://www. Retrieved population (as of 9/30/2014). Veteran (2016). Affairs. eterans from http://www.ptsd.va.gov/pub- Retrieved common is PTSD? How (2015). Affairs. eterans Page 4. Page and Other Americans 2001-2004. Suicide Among Veterans (2016). Affairs. eterans Retrieved from http://www. Retrieved 9/30/2014). (as of population Veteran (2016). Affairs. eterans http://www.ptsd.va.gov/pub- from Retrieved is PTSD? common How (2015). Affairs. eterans 8. Page and Other Americans 2001-2004. Suicide Among Veterans (2016). Affairs. eterans Suicide Risk among 1.3 million veterans who were on active duty during the Iraq and the Iraq duty during on active who were million veterans 15). Suicide Risk among 1.3 A Guide to Understanding Mental Health Systems and Services in Texas and Services in Systems Guide to Understanding Mental Health | A for Mental Health Hogg Foundation Retrieved from http://www.tvc.texas.gov/ Non-service connected pension. Retrieved terans Commission. (2016). Retrieved from http://www.tvc.state.tx.us/ Retrieved plan FY 2013 - 2017. Strategic terans Commission. (2012). from http://www.tvc.texas.gov/ Retrieved Service-connected compensation. terans Commission. (2016). Retrieved from http://www.tvc. Retrieved commission. veterans to the Texas Welcome terans Commission. (2014). from http://www.tvc.texas.gov/Doc- Update. Retrieved TCCVS Legislative terans Commission. (2015). s Mental Health Policy Institute. (2016, August 17). Personal Communication: Texas Veterans + Family + Family Veterans Communication: Texas 17). Personal August (2016, Institute. Policy Health s Mental Texas Veterans + Family Alliance – About the program. Re- Alliance – About the program. + Family Veterans Texas (2015). Institute. Policy Health s Mental Epidemiologic Reviews. 37 37 Epidemiologic Reviews. veterans. among U.S. for Risk factors . & Rosenheck, R.A. (2015). homelessness Epidemiologic Reviews. 37 (1), 37 Epidemiologic Reviews. among US veterans. for Risk factors . & Rosenheck, R. (2015). homelessness Project Veteran population from 2013 to 2043. to 2013 from population Veteran Project (2016). Affairs. Veterans of Department Retrieved from http://www.va.gov/opa/publications/benefits_book/2014_federal_benefits_for_veterans_en- Retrieved glish.pdf Non-Service-Connected-Pension.aspx http://www.va.gov/directory/guide/region.asp?ID=1017 from http://www.va.gov/opa/publications/benefits_book/2014_federal_benefits_for_veterans_en- Retrieved glish.pdf documents/TVC_Strategic_Plan_2012_electronic.pdf Service-Connected-Compensation.aspx Alliance Pilot Program. Alliance Pilot - navpanes=0 tlodocs/84R/analysis/pdf/SB01304F.pdf - navpanes=0 tlodocs/84R/analysis/pdf/SB01305F.pdf state.tx.us/Home.aspx. from http://www.texasstateofmind.org/tvfa/ trieved Session.pdf 84th Legislative uments/TCCVS from https://hhs.texas.gov/sites/hhs/files//031716-hd- Retrieved 2016] on March 17, [PowerPoint & Initiatives. va-presentation.pdf https://hhs.texas.gov/sites/hhs/files//031716-hd- from Retrieved 2016] on March 17, [PowerPoint & Initiatives. va-presentation.pdf va.gov/vetdata/docs/SpecialReports/State_Summaries_Texas.pdf lic/PTSD-overview/basics/how-common-is-ptsd.asp from http://epirev.oxfordjournals.org/content/37/1/177.long Retrieved (1), 177-195. Retrieved from http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf Retrieved from http://media.samhsa.gov/co-occurring/topics/military/index.aspx . Retrieved military service members www.va.gov/vetdata/docs/quickfacts/Population_slideshow.pdf from http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf Retrieved from http://epirev.oxfordjournals.org/content/37/1/177.long Retrieved 177-195. Annals of Epidemiology, 25(2), 96-100. Retrieved from http://www.ncbi.nlm.nih.gov/ from Retrieved 25(2), 96-100. Annals of Epidemiology, Afghanistan wars. pubmed/25533155 http://www.samhsa.gov/veterans-military-families/critical-issues from Retrieved tary Families. va.gov/vetdata/docs/SpecialReports/State_Summaries_Texas.pdf lic/PTSD-overview/basics/how-common-is-ptsd.asp from http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf Retrieved Ibid. Department of V U.S. Department of V U.S. U.S. Department of V U.S. Ibid. Ve Texas Ve Texas Senate Research Center. (2015). (2015). Senate Research Center. and Human Services Health Texas Ve Texas Texas Ve Texas and Human Services Health Texas (2015). Senate Research Center. Substance Abuse and M Abuse Substance Ve Texas Meadow Meadow Ibid. Ibid. Ibid. J Tsai, Department of V U.S. Tsai, J Tsai, of V Department U.S. Department of V U.S. Ibid. Kang, H.K. et al. (20 H.K. et Kang, of V Department U.S. and M Abuse Substance U.S. U.S. Ibid. Department of V U.S. of V Department U.S. U.S. Department of V Department U.S.

33 29 30 32 34 28 31 22 25 26 20 21 23 24 27 11 12 14 15 16 17 13 18 19 3 8 10 4 7 9 1 2 5 6 Endnotes TVC 450 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 62 61 60 56 55 54 52 51 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 59 58 57 53 50

Ibid. Ibid. Ibid. Ibid. Mulhall, E.(2009). W U.S. TexVe Office ofthe Governor GregA Texas CoordinatingCouncilforVe Military Veteran P TexVe U.S. DepartmentofV U.S. DepartmentofV Kang, H.K.et al.(20 Texas Ve Ibid. Texas Ve Texas Ve Ibid. Ibid. Texas Ve Ibid. Texas Ve U.S. DepartmentofV Institute forVe U.S. DepartmentofV U.S. DepartmentofV U.S. DepartmentofVeterans Affairs. (2016). VA benefits&healthcare utilization. Retrieved fromhttp://www. ty. Retrieved from http://gov.texas.gov/files/cjd/Specialty_Courts_By_County_April_2016.pdf www.tvc.texas.gov/documents/TCCVS_Report_2014.pdf milvetpeer.net/page/MVPN_PSC mentalhealth.va.gov/suicide_prevention/index.asp from http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf ed.aspx texas.gov/About-Us.aspx Veterans-Mental-Health-Grants.aspx texas.gov/About-Us.aspx ment-Services.aspx glish.pdf Retrieved fromhttp://www.va.gov/opa/publications/benefits_book/2014_federal_benefits_for_veterans_en- ployment-and-Well-Being.pdf Well-being. Retrieved fromhttp://toolkit.vets.syr.edu/wp-content/uploads/2012/12/GP-Implications-for-Em- va.gov/vetdata/docs/pocketcards/fy2016q2.pdf va.go stan Veterans ofAmericawebsitehttp://media.iava.org/IAVA_WomensReport_2009.pdf www.va.gov/vetdata/docs/quickfacts/Population_slideshow.pdf pubmed/25533155 wars.Afghanistan AnnalsofEpidemiology, 25(2),96-100. Retrievedhttp://www.ncbi.nlm.nih.gov/ from Department of Veterans Affairs. (2016). v/vetdata/docs/pocketcards/fy2016q2.pdf t. (2016). Texas Veterans Portal. Retrieved from http://www.texvet.org/partners/texasgov t. (2016). Missions. Retrieved from http://www.texvet.org/about terans Commission.(2016). Grants Awarded. Retrieved fromhttp://www.tvc.texas.gov/Grants-Award- terans Commission.(2016). Fund forVeterans’ Assistance: About Us. Retrieved fromhttp://www.tvc. terans Commission.(2016). Veterans mentalhealthgrants. Retrieved fromhttp://www.tvc.state.tx.us/ terans Commission.(2016). FundVeterans’ for Assistance: AboutUs. Retrieved fromhttp://www.tvc. terans Commission.(2016). Employment services.Retrieved fromhttp://www.tvc.texas.gov/Employ- terans andMilitaryFamilies, SyracuseUniversity. Employment (2012). and Implicationsfor eer Network. (2016). MVPNPeer ServicesCoordinator Map.Retrieved fromhttp://www. 15). SuicideRiskamong1.3 millionveterans whowere onactive dutyduringtheIraq and eterans Affairs. (2014). Federalfor veterans, benefits dependentsandsurvivors, 2014Edition. eterans Affairs. (2016). VA benefits&healthcare utilization. Retrieved fromhttp://www. eterans Affairs. (2016). Vet Center Program. Retrieved fromhttp://www.vetcenter.va.gov/ eterans Affairs. (2016). MentalHealth:Veterans CrisisLine.Retrieved fromhttp://www. eterans Affairs. (2016). SuicideAmongVeterans andOtherAmericans2001-2004.Retrieved omen warriors: Supportingshewhohasbornethebattle.Retrieved from IraqandAfghani- bbott. (2016). CriminalJusticeDivisionPrograms –Texas SpecialtyCourts byCoun- terans Services. (2014). SecondReport,October2014.Retrieved fromhttp:// Project Veteran population from 2013 to 2043. Retrieved from http:// Appendices Appendices

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 451 452 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas List of Figures

Figure 1. Coordinated Statewide Behavioral Health Expenditures Proposal for FY 2017 19 Figure 2. Federally Designated Mental Health Professional Shortage Areas as of July 2015 20 Figure 3. Mental Health Professional Shortages: Distribution of Psychiatrists in Texas, 2006-2015 21 Figure 4. The Aging Mental Health Workforce in Texas 22 Figure 5. Proposed Health and Human Services Transformation Timeline 33 Figure 6. Map of Regional Healthcare Partnerships (RHPs) and Managed Care Service Delivery Areas (SRAs) in Texas: January 2016 39 Figure 7. The Growth of Telemedicine/Telehealth Services in Texas: 2005 - 2013 43 Figure 8. Demonstration Project: County, Number Served, and Health Plans 45 Figure 9. Coverage Gap for Adults in States Without the ACA’s Medicaid Expansion 59 Figure 10. All SSDI Beneficiaries in December 2014 63 Figure 11. SSI and SSDI Differences 64 Figure 12. Health and Human Services Regions 74 Figure 13. Proposed Health and Human Services Transformation Timeline 76 Figure 14. Former DARS Programs 80 Figure 15. Health and Human Services Enterprise Budget by Agency (2016-2017) 83 Figure 16. Health and Human Services Enterprise Budget by Method of Finance (2016-2017) 83 Figure 17. Health and Human Services Commission Budget by Item of Appropriation (2016-2017) 84 Figure 18. HHSC Funding Trends 84 Figure 19. 2018-19 Legislative Appropriations Request by Method of Financing, Baseline Budget 84 Figure 20. Coordinated Statewide Behavioral Health Expenditures Proposal for Fiscal Year 2017 87 Figure 21. Medicaid-Funded Programs Across HHS Agencies Included in or Transitioning to HHSC (2016) 90 Figure 22. Texas Medicaid and CHIP Managed Care Programs 92 Figure 23. Texas Federal Medical Assistance Percentage (2004-2017) 95 Figure 24. Medicaid Funding Trends 95 Figure 25. Income Limits for Select Medicaid and CHIP Eligibility Categories 96 Figure 26. Annual Household Income for Federal Poverty Level Guidelines (2016) 97 Figure 27. Approved Medicaid Behavioral Health Services 97 Figure 28. Texas Medicaid Caseload and Expenditures by Age and Disability Status (2016) 98 Figure 29. CHIP Funding Trends 99 Figure 30. Monthly CHIP Enrollment (2010-2015) 100 Figure 31. Selected Behavioral Health Quality of Care Measures for Medicaid and CHIP Programs (2012-2014) 101 Figure 32. Timeline of Selected Major Developments Within the Texas Public Mental Health System 107 Figure 33. Youth Empowerment Services (YES) Waiver Enrollment: 2011-2016 113 Figure 34. Examples of Performance Measures Used by DSHS as Performance-Based Incentives to Withhold 115 Quarterly GR Funding (per Rider 58) Figure 35. Mental Health Funding Trends 117 Figure 36. Texas Public Behavioral Health Annual Spending: 2003-2015 118 Figure 37. Map of LMHAs and 39 Service Regions 120 Figure 38. Texas Resiliency and Recovery (TRR) Levels of Care (LOC) for Adults 124 Figure 39. Texas Resiliency and Recovery (TRR) Levels of Care (LOC) for Children and Adolescents 126 Figure 40. Eligibility Levels For Subsidized Coverage in Texas in 2014 (Left) and Annual Income Levels Required 129 to Obtain Coverage (Right) Figure 41. LMHA Client Population 131 Figure 42. Unmet Needs for Community Mental Health Services: Adults in FY 2014 132 Figure 43. Unmet Needs for Community Mental Health Services: Children and Adolescents in FY 2014 132 Figure 44. Utilization/Cost for Adult Community Mental Health Services 133 Figure 45. Utilization/Cost for Child and Adolescent Community Mental Health Services 133 Figure 46. Selected Measures for Children and Adolescents Receiving Community Mental Health Services 133 Figure 47. Adult Waiting List and Adults Served Through Community Mental Health Centers: FY 2010 (Q1) – FY 2015 (Q4) 135 Figure 48. Child and Adolescents Waiting List and Children Served Through Community Mental Health Centers: 135 FY 2010 (Q1) – FY 2015 (Q4) Figure 49. Available DSHS Crisis Services 137 Figure 50. Utilization/Cost for Crisis Behavioral Health Services 138 Figure 51. State Mental Health Hospitals and Waco Center for Youth: 2016 141 Figure 52. State-Operated Inpatient Psychiatric Beds In State Hospitals: 2016 141 Figure 53. State-Funded Psychiatric Bed Capacity: FY 1994-2015 142 Appendices Figure 54. Utilization and Costs for State-Operated Hospitals in FY 2015 145 Figure 55. Number of Individuals Admitted to State Hospitals 3+ Times in 180 Days: September 2013 — May 2016 146 Figure 56. Purchased Community & Contracted Private Hospital Beds: Allocated Funds and Number of Beds in FY 2016 147 Figure 57. Snapshot of Daily Civil vs. Forensic Patient Population in State Hospitals: 2001-2016 148 Figure 58. Deferred Maintenance Funding Requests for State Hospitals: FY 2008-2017 151 Figure 59. Placement Determination For Competency Restoration Programs 153

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 453 Appendices 454 Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure 60. Most Important Factors OCR Programs Impacting Success of Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 126. Diversion Strategies at Sequential Intercept Point Examples of 125. The Sequential Intercept Model 124. Completed Suicides in Number of Texas County Jails Between CY 2011 and CY 2015 123. Specialized Programs within TDCJ’s Parole Division 122. Reentry Assistance Services Provided by TCOOMMI and LMHAs 121. Substance Use Service Descriptions 120. Specialized Programs for Individuals with Mental Illness or a Developmental Disability 119. Health Service Level of 118. Behavioral and Mental Health-Related Divisions within TDCJ 117. Facility Types, Capacities, and Populations in FY 2015 116. TDCJ FY 2016 Operating Budget by Agency Goal 115. TDCJ FY 2016 Operating Budget by Funding Source 114. Common Criminal Justice Definitions 113. Individuals With and Experiences of Without Mental Illness Prior to and During Their Incarceration 112. Percentage Mental Health Symptoms Self-Reported of by Jail Inmates 111. TWC Programs & Services with Program Overview 110. Key Transition Dates 109. TWC Funding by Strategy FY 2016-17 108. TWC Requested Funding Finance FY by Method of 2018-19 107. Finance FYTWC Budget by Method of 2016-17 106. TWC Beneficiary and Coordinated Action 105. Childcare Operations Overseen and Regulated by CCL 104. Prevention and Early Intervention (PEI) Programs and Services in Texas 103. Psychotropic Reduction of Medication Use in The Texas Foster Care 102. Disproportionality in CPS: Racial and Ethnic Differences in FY 2015 101. Child Fatalities in Texas: FY 2015 100. Health Insurance Programs for Former Foster Care Children 99. Child How CPS Investigates Abuse Allegations of 98. SourceAbuse/Neglect Reports of Received by State-wide Intake in 2015: CPS and APS In-Home Programs 97. Total Finance DFPS Requested for FY Budget by Method of 2018-19 96. Finance for FY DFPS Budget by Method of 2016-17 80. September 1 DSHS as of Organizational Structure of 79. Disability Determination Services in Utilization of Texas 95. DFPS Budget by Strategy for FY 2016-17 94. Agency-Wide DFPS’ Model of Transformation 93. Family Department of Protective Services (DFPS) Divisions 92. Child Protection Map of Courts and Covered Regions 91. Percentage SSLC of Residents with a Behavioral Health Diagnosis 90. State Medicaid Costs Per Person, Per Month* 89. SSLC Funding Trends and Requests 78. Disability Claims Process for SSI and SSDI Benefits 88. SSLC Eligibility and Behavioral Health-Related Services 87. State Supported Living Center Enrollment Trend and Projections, Fiscal Years 2010-2019 86. Utilization and Costs for State-Operated Hospitals in FY 2015 85. Utilization/Cost for Crisis Behavioral Health Services 84. Selected Measures for Adults Receiving Community Mental Health Services 83. State-Operated Inpatient Psychiatric Beds In State Hospitals: 2016 82. State Mental Health Hospitals And Waco Center for Youth: 2016 81. DSHS organizational structure After September 1, 2017 (Post-Transformation) 77. Children Who Received Services in FY 2015 76. Individuals utilizing ECI Services Characteristics of 75. Reasons for Eligibility for X Programs/Services 74. Services for Individuals Who Are Blind and Visually Impaired Services 73. Percentage People of Enrolled in DADS Programs with a Behavioral Health Diagnosis 72. Institutional Care Eligibility and Behavioral Health-Related Services 71. State Supported Living Center Enrollment Trends and Projections, Fiscal Years 2010-2019 70. Community-Based Waiver Eligibility and Behavioral Health-Related Services for people with Disabilities 69. LTSS Funding Trends and Requests 68. Care Selected Quality of Measures for Youth Substance Use Services 67. Care Selected Quality of Measures for Adult Substance Use Services 66. Utilization and Costs for Child & Adolescent Substance Use Services 65. Utilization and Costs for Adult Substance Use Services 64. Funding Trends for Substance Use Services 63. Available HHSC Substance Use Treatment Services 62. Major Programs within Substance Abuse Prevention, Intervention, and Treatment (SAPIT) 61. Competency Comparison Restoration of Programs**

, 2016

315 315 313 310 308 307 307 306 305 303 302 302 300 296 295 289 284 282 281 281 280 266 263 260 258 256 254 251 249 247 246 246 194 192 244 236 235 230 230 230 229 185 229 220 220 219 219 218 214 213 184 183 180 177 176 175 172 170 163 162 162 161 159 158 157 156 155 Figure 127. Travis County MHPD Office Outcomes between FY 2011 and FY 2011 320 Figure 128. Prevalence of Mental Health Conditions, Substance Use Disorders, and Traumatic-Event Exposure Among U.S. Youth 330 Figure 129. Terms and Concepts 337 Figure 130. Common Juvenile Justice Definitions 337 Figure 131. Differences in Cost Per Day Between the Adult and Juvenile Justice Systems 339 Figure 132. TJJD FY 2016 Operating Budget by Funding Source 339 Figure 133. TJJD FY 2016 Operating Budget by Agency Goal 340 Figure 134. Funding Breakdown for Local Juvenile Probation Departments in FY 2015 341 Figure 135. Top Five Arrest Categories for Texas Juveniles in 2014 342 Figure 136. Referrals and Dispositions of TJJD Youth in 2015 343 Figure 137. Texas Rates of Juvenile Justice Involvement by Race and Ethnicity in FY 2013 344 Figure 138. Account of Site Visits, Youth Contact, and Cases Closed by the IO 346 Figure 139. TJJD Secure Facilities 347 Figure 140. Specialized Treatment Programs in Texas 349 Figure 141. Number (and Percentage) of Post-Adjudication Facilities with Specific Services in Texas 350 Figure 142. Offense Type for Juveniles Referred to Juvenile Probation Departments 352 Figure 143. Youth Discharged and Linked to Community Services, including Behavioral Health Treatment, 353 Care Management, and Support Services in FY 2015 Figure 144. Number of Community-Based Programs in Which Youth with Behavioral Health Needs Participated 353 Figure 145. Youth Beginning and Exiting Prevention and Intervention Programs in FY 2015 355 Figure 146. Average Expected Length of Stay in Various Community Programs 356 Figure 147. Percentage of Youth in the FEDI Program and Under Traditional Supervision Who Accessed Community Services 358 Figure 148. Juveniles Entering, Exiting, and Successfully Completing the SNDP in FY 2015 360 Figure 149. Organizational Structure of TEA (Unaffected by Transformation) 371 Figure 150. Youth Suicide Rates in Texas (Ages 6-24): 2000-2014 374 Figure 151. TEA Budget by Method of Finance FY 2016-17 376 Figure 152. TEA Budget by Method of Finance FY 2018-19 376 Figure 153. TEA Budget by Strategy FY 2016-17 377 Figure 154. Mental Health Service Delivery Methods 379 Figure 155. Reasons for Special Education Eligibility in Texas Schools: 2015-2016 382 Figure 156. Federal Share of Special Education Funding Through IDEA: 2002-2024 384 Figure 157. Map of Education Service Center Regions 385 Figure 158. Overrepresentation of Youth in Special Education in Exclusionary Discipline 388 Figure 159. Expulsions in Texas Public Schools: 2007-2015 392 Figure 160. Hierarchical Model of Positive Behavioral Interventions & Supports 396 Figure 161. TDHCA Housing Support Continuum Activities 413 Figure 162. TDHCA Funding by Method of Finance for FY 2016-17 419 Figure 163. TDHCA Funding by Method of Finance for FY 2018-19 419 Figure 164. TDHCA Funding by Program for FY 2016-17 420 Figure 165. TDHCA Expenditures, from Direct and Indirect Funding Sources (2015) 421 Figure 166. TVC Funding by Method of Finance for FY 2016-17 442 Figure 167. TVC Funding by Method of Finance for FY 2018-19 442 Figure 168. TVC Funding by Strategy for FY 2016-17 443 Appendices

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 455 Appendices 456 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas List of Acronyms

ACA - Patient Protection and Affordable Care Act AFSP - American Foundation for Suicide Prevention AMFI - Area Median Family Income ANSA - Adult Needs and Strengths Assessment APS – Adult Protective Services ARS - Alternative Response System ASCA - American School Counselor Association ASD - Autism Spectrum Disorder ASSET - Achieving Successful Systems Enriching Texas [initiative grant] AYBR - Amy Young Barrier Removal [program] BISQ - Brain Injury Screening Questionnaire CANS - Child and Adolescent Needs and Strengths [assessment] CAS -Community Attendant Services CBA - Community-Based Alternatives CBT – Cognitive Behavioral Therapy CCL – Child Care Licensing CCRC - Criss Cole Rehabilitation Center CDC - Centers for Disease Control and Prevention CEU - Continuing Education Unit CFP - Certified Family Partner CHIP - Children’s Health Insurance Program CIHCP - County Indigent Health Care Program CIL - Center for Independent Living CINS – Conduct in Need of Supervision CIS - Communities in Schools CIT - Crisis Intervention Team CLASS - Community Living Assistance and Support Services [waiver program] CMS - Centers for Medicare and Medicaid Services COG - Council of Governments COPE - Collaborative Opportunities for Positive Experiences COPSD - Co-occurring Psychiatric and Substance Use Disorder COSP - Consumer-Operated Service Provider CPS – Child Protective Services CPS- Certified Peer Specialist CRC- Certified Recovery Coaches CRCG - Community Resource Coordination Group CSBG - Community Services Block Grant CSU - Crisis Stabilization Unit DADS – Department of Aging and Disability services DAEP - Disciplinary Alternative Education Program DAHS - Day Activity Health Services Appendices DARS – Department of Assistive and Rehabilitative Services DBMD - Deaf-Blind with Multiple Disabilities [waiver program] DBS - Division for Blind and Visually Impaired Services DDS - Division of Disability Determination Services DFPS – Texas Department of Family and Protective Services

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 457 Appendices 458 LGTBQ –Lesbian,Gay, Transgender, Bisexual,Queer LBB –Legislative Budget Board JDTR -Jail Diversion andTrauma Recovery JJAEP -Juvenile Justice Alternative EducationProgram IST Suspension ISS -In-School ISD -IndependentSchoolDistrict IMD -Institution forMental Disease IFSP -IndividualizedFamily ServicePlan IEP –IndividualizedEducationPlan IDEA -IndividualswithDisabilities EducationAct IDD -intellectualanddevelopmental disabilities ICF -IntermediateCareFacility ICCD -InternationalCenterforClubhouseDevelopment HUD -U.S. DepartmentofHousing andUrbanDevelopment HTF -Housing Trust Fund HTC -Home Tax Credit [program] HMO -Health MaintenanceProgram HIPP -Health InsurancePremiumPayment [program] HHSP -Homeless Housing and ServicesProgram -Health andHumanServicesCommission HHSC HHS- Health andHumanServices HEDIS -Healthcare Effectiveness DataandInformationSet -Home andCommunity-Based Mental Services—Adult HealthHCBS-AMH [program] HCBS -Home andCommunity-Based Services -TexasHBA Homebuyer Assistance –GeneralResidentialOperations[facility] GRO - U.S.GAO Office GeneralAccounting –GlobalAssessmentofFunctioningGAF -GeneralizedAnxiety Disorder GAD FVA FTAS -Failure toAttend School FQHC -Federally FPL –Federal Poverty Level FPG -Federal Poverty Guideline FMAP -Federal Medical Assistance Percentage FFCHE -Former Foster CareinHigherEducation[program] FFCC -Former Foster CareChildren[program] FDA -Food andDrugAdministration SolutionsGrants -Emergency ESG EPSDT -EarlyandPeriodic Screening,DiagnosisandTreatment ECI -EarlyChildhoodIntervention [program] ECT -Electroconvulsive Therapy EBP -Evidence-Based Practice EAP -Employee Assistance Plan DSRIP -Delivery System ReformIncentive Pool DSM-V -Diagnostic andStatistical ManualforMental Disorders, FifthEdition DM-ID -Diagnostic Manual–IntellectualDisability DRS -DivisionforRehabilitationServices DHHS -U.S. DepartmentofHealth andHumanServices Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas –Incompetent toStandTrial -Fund forVeterans’ Assistance

Qualified Health Center LIHTC - Low Income Housing Tax Credit [program] LMHA - Local Mental Health Authority LOC – Level of Care LSSP - Licensed Specialist in School Psychology LTSS - Long-Term Services and Supports MAYSI - Massachusetts Youth Screening Instrument MCO- Managed Care Organization MCOT - Mobile Crisis Outreach Team MDCP - Medically Dependent Children Program MDD - Major Depressive Disorder MH – Mental Health MHFA - Mental Health First Aid MHPAEA - Mental Health Parity and Addiction Equity Act MOU - Memorandum of Understanding MRSA- Medicaid Rural Service Area MTFCY - Medicaid for Transitioning Foster Care Youth NAMI - National Alliance on Mental Illness NCEC - Non-Categorical Early Childhood NCTSN - National Child Traumatic Stress Network NCTIC - National Center for Trauma Informed Care NGRI - Not Guilty By Reason of Insanity NNTY - National Network for Youth Transition OCD - Obsessive-compulsive Disorder OCR – Outpatient Competency Restoration OIO - Office of the Independent Ombudsman OSS - Out-of-School Suspension PASRR – Pre-Admission Screening and Resident Review PCP - Primary Care Physician PE - PASRR Evaluation PEI – Prevention and Early Intervention PHA - Public Housing Agency PHC - Primary Home Care PPCD – Pre-school Program for Children with Disabilities PPO – Preferred provider organization PRA - Project Rental Assistance [demonstration program] PRC - Prevention Resource Center PSH - Permanent Supportive Housing PTSD - Post-Traumatic Stress Disorder RDM - Resiliency and Disease Management RHP - Regional Healthcare Partnership ROSC – Recovery-Oriented System of Care RTC - Residential Treatment Center SAMHSA - Substance Abuse and Mental Health Services Administration SAPIT - Substance Abuse Prevention, Intervention, and Treatment SED – Severe Emotional Disturbance Appendices SEL - Social and Emotional Learning SHAC - School Health Advisory Council SHARS - School Health and Related Services SMVF - Service Members, Veterans, and Family Members SNAP - Supplemental Nutrition Assistance Program

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 459 Appendices 460 YES -Youth Empowerment Services[waiver] WRAP® -Wellness Recovery Plan Action WHO -World Health Organization -VeteransVSO ServiceOrganization VR -Vocational Rehabilitation VISN -Veterans IntegratedServiceNetwork VA UC TYC TxHmL -Texas Home Living[waiver program] TVC TRR -Texas andRecovery Resiliency TRI -Texas Recovery Initiative TMHP -Texas Medicaid andHealthcare Partnership TJPC -Texas Juvenile ProbationCommission TJJD TIC -Trauma-InformedCare TEA –Texas EducationAgency TDI -Texas DepartmentofInsurance TDHCA –Texas DepartmentofHousing andCommunityAffairs TDCJ –Texas DepartmentofCriminalJustice TCPA -Texas Police ChiefsAssociation TCOOMMI -Texas CorrectionalOfficeonOffenderswith Medicalor MentalImpairments TBSI -Texas Behavior SupportInitiative TBRA -Tenant-Based RentalAssistance TBI -TraumaticBrainInjury TAY TANF -Temporary Assistance forNeedyFamilies SWPBIS –School-wide Positive Behavioral Interventions andSupports STP STARS -StateofTexas Alternatives toRestraint andSeclusion SSLC -StateSupportedLivingCenter SSI -SupplementalSecurityIncome SSDI -SocialSecurityDisability Insurance SSA –SharedServicesArrangement SSA- SocialSecurityAdministration Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas –U.S. DepartmentofVeteran Affairs -Uncompensated Care -SignificantTraditionalProvider -Transition-Age Youth -Texas Youth Commission -Texas Veterans Commission –Texas Juvenile Justice Department Additional Resources Agency Websites

Texas Health and Human Services Commission (HHSC): https://hhs.texas.gov/

Texas Department of State Health Services (DSHS): www.dshs.state.tx.us

Texas Department of Family and Protective Services (DFPS): www.dfps.state.tx.us

Texas Department of Aging and Disability Services (DADS): www.dads.state.tx.us

Texas Department of Assistive and Rehabilitative Services (DARS): http://www.dars. state.tx.us/

Texas Department of Criminal Justice (TDCJ): www.tdcj.state.tx.us

Texas Juvenile Justice Department (TJJD): http://www.tjjd.texas.gov/

Texas Education Agency (TEA): www.tea.state.tx.us

Texas Department of Housing and Community Affairs (TDHCS): www.tdhca.state.tx.us

Texas Workforce Commission: www.twc.state.tx.us Certified Peer Specialists and Certified Recovery Coaches

Carter Center, Pillars of Peer Support: Transforming Mental Health Systems of Care Through Peer Support Services http://www.pillarsofpeersupport.org/final%20%20 PillarsofPeerSupportService%20Report.pdf

Centers for Medicaid and Medicare Services, Letter to state Medicaid directors regarding peer support services: www.magellanhealth.com/training2/peersupport/ magellanmodule1/graphics/cms.pdf

Copeland Center for Wellness and Recovery: http://copelandcenter.com/

Georgia Certified Peer Specialist Project: http://www.gacps.org/

Institute for Recovery and Community Integration: http://www.mhrecovery.org/ home

Mental Health of America: http://www.mentalhealthamerica.net/peer-services Appendices

NAADAC (The Association for Addiction Professionals), Understanding the Role of Peer Recovery Coaches in the Additional Profession: www.naadac.org/understand- ingtheroleofpeerrecoverycoachesintheadditionprofession

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 461 Appendices 462 Texas Network ofYouth Services:http://tnoys.org/ Texans CareforChildren:http://texanscareforchildren.org/ www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/index.shtml National Institute ofMental Mental Health, Health: ChildandAdolescent http:// National Federation ofFamilies forChildren’s Mental Health: http://www.ffcmh.org/ National ChildTraumaticStressNetwork: http://www.nctsnet.org/ Child Welfare LeagueofAmerica:http://www.cwla.org/ wide/bhw/ Child Welfare InformationGateway: https://www.childwelfare.gov/topics/system- Initiative: http://www.buildingbridges4youth.org/index.htmlBuilding Bridges Success-for-All-Children.aspx Bazelon CenterforMental Health Law: http://www.bazelon.org/Where-We-Stand/ Ch Via Hope –Texas Mental Health Resource:http://www.viahope.org/ SoberHood: www.soberhood.org Pillars ofPeer Support:http://www.pillarsofpeersupport.org/ ncbi.nlm.nih.gov/pubmed/23576121 Peer Services:AQualitative StudyUsingSelf-Determination Theory:https://www. NCBI, Motivations ofPersons withPsychiatric Disabilities toWork inMental Health www.ncmhr.org/downloads/References-on-why-peer-support-works-4.16.2014.pdf National CoalitionforMental Health Recovery, Peer Support:Why ItWorks http:// wp-content/uploads/2016/01/Peer-Supports.pdf Mental withSeriousMental Health Illness:http://nashp.org/ IntegrationforAdults National Academy forStateHealth Policy, UsingPeers toSupportPhysical and Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Judge David L.BazelonCenterforMental Health Law: http://www.bazelon.org Disability RightsTexas: https://www.disabilityrightstx.org/ American CivilLibertiesUnionofTexas: https://www.aclutx.org/ C ivil ild R W ig el h ts fa re/ Ch ildren’s M ent a l He a lt h Consumer and Family Organizations

Texas Catalyst for Empowerment: http://www.mytce.org/

Via Hope – Texas: http://www.viahope.org/

Prosumers of San Antonio: http://www.prosumersinternational.org/

Mental Health America: http://www.mentalhealthamerica.net/

Mental Health America – Texas: http://www.mhatexas.org/

National Alliance on Mental Illness: http://www.nami.org/

National Alliance on Mental Illness – Texas: http://www.namitexas.org/

National Empowerment Center: http://www.power2u.org/ Criminal/Juvenile Justice and Mental Health

Council on State Governments Justice Center. Criminal Justice and Mental Health Consensus Project: http://csgjusticecenter.org/mental-health-projects/report-of-the-consensus-project/

National Center for Mental Health and Juvenile Justice: http://www.ncmhjj.com

SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation: http:// gainscenter.samhsa.gov/

Texas Appleseed: https://www.texasappleseed.org/

Texas Criminal Justice Coalition: http://www.texascjc.org/

Texas Public Policy Foundation: http://www.texaspolicy.com/ Cultural and Linguistic Competency

Georgetown University National Center for Cultural Competence: http://nccc. georgetown.edu

Hogg Foundation for Mental Health. Enhancing the delivery of health care: Elimi- nating health disparities through a culturally and linguistically centered integrated health care approach: http://muse.jhu.edu/article/545273 Appendices NAMI Multicultural Action Center: http://www2.nami.org/namiland09/MACmate- rialslist.pdf

U.S. Department of Health & Human Services: Office of Minority Health: http:// www.minorityhealth.hhs.gov

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 463 Appendices 464 ta-source/uniform-reporting-system org/#!urs-client-level-data/cz0l andhttps://www.healthypeople.gov/2020/da- Health ServicesUniformReportingSystem &ClientLevel Data:http://www.nri-inc. Substance UseandMental Health CenterforMental ServicesAdministration, Substance UseandMental Health http://www.samhsa.gov/ ServicesAdministration: National Institute ofMental Health: http://www.nimh.nih.gov/index.shtml National CouncilforBehavioral Health: http://www.thenationalcouncil.org/ Institute: http://www.nri-inc.org/ National AssociationofStateMental Health ProgramDirectors–NationalResearch Meadows Mental Health Policy Institute ofTexas: http://www.texasstateofmind.org a G grams/success-by-6/ United Way forGreaterAustin: http://www.unitedwayaustin.org/strategic-pro- hood-mental-health/ Zero toThree:http://www.zerotothree.org/child-development/early-child- Texas AssociationforInfantMental Health: http://taimh.org/ TexProtects: http://www.texprotects.org/ Ea ship): http://www.tapartnership.org/COP/CLC/default.php Technical Assistance Partnership forChildandFamily Mental Health (TA Partner- Race, andEthnicity:www.surgeongeneral.gov/library/mentalhealth/cre U.S. General’s Surgeon OfficeSupplementalReporton Mental Health-Culture, Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Texas DepartmentofHousing & CommunityAffairs:https://www.tdhca.state.tx.us/ Technical Assistance Collaborative: http://www.tacinc.org/ National AlliancetoEnd Homelessness: http://www.endhomelessness.org/ department/permanent-supportive-housing-initiative Neighborhood Housing and CommunityDevelopment: http://www.austintexas.gov/ Coalition forSupportive Housing: http://www.csh.org/csh-in-the-field/texas Housing nd ener rly S ubst Ch a l ild I n a f nce h orm ood U a se tion on a nd M ent M a ent l He a l He a lt h a lt h

U.S. Department of Housing and Urban Development: http://www.huduser.org/ Integrated Physical and Mental Health Care

Academy for Integrating Behavioral Health and Primary Care: http://integrationacademy.ahrq.gov/

Advancing Integrated Mental Health Solutions (AIMS) Center: http://aims.uw.edu/

Hogg Foundation for Mental Health: http://hogg.utexas.edu/what-we-do/integrated-health-care-2

Integrated Behavioral Health Project (IBHP): http://www.ibhp.org/

National Council on Community Behavioral Health’s Center for Integrated Solu- tions: http://www.thenationalcouncil.org/consulting-best-practices/center-for-integrated-health-solution/ Intellectual Disability with Co-occurring Mental Health Conditions

The National Association for the Dually Diagnosed: http://thenadd.org/

Accessible Mental Health Services for People with Intellectual Disability: A Guide for Providers: http://3dn.unsw.edu.au/sites/default/files/ddn/page/Accessible%20 Mental%20Health%20Services%20for%20People%20with%20an%20ID%20-%20 A%20Guide%20for%20Providers_current.pdf

NCTSN and the Hogg Foundation for Mental Health, The Road to Recovery: Sup- porting Children with Intellectual Disabilities Who have Experienced Trauma toolkit (must create a free account to access the toolkit): http://learn.nctsn.org/enrol/ index.php?id=370

Karyn Harvey, Positive Identity Development: An Alternative Treatment Approach for Individuals with Mild and Moderate Intellectual Disabilities (book) http://www. karynharvey.com/

Karyn Harvey, Trauma-informed Behavioral Interventions: What Works and What Doesn’t (book) http://www.karynharvey.com/

Texas Advocates, a coalition of self-advocates throughout the state working to support one another: http://arctx.convio.net/site/PageServer?pagename=TXA_homepage

Mental Health Care for Adults with Intellectual and Developmental Disabilities toolkit: http://vkc.mc.vanderbilt.edu/etoolkit/mental-and-behavioral-health/ Appendices

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 465 Appendices 466 USA CenterforRuralPublic Health Preparedness:http://www.usacenter.org/ pubmed/22367256 Promotoras inMental Health: ALiteraryReview:https://www.ncbi.nlm.nih.gov/ cle&id=67&Itemid=65 http://www.migranthealth.org/index.php?option=com_content&view=arti- Migrant Health Promotion TrainingandSupportforPromotores/Promotoras: P um=email ting+to+Work+Report+&utm_campaign=Getting+to+Work+Report&utm_medi- munity%20Integration/Olmstead/Getting%20to%20Work.pdf?utm_source=Get- Mental Illness:http://www.bazelon.org/portals/0/Where%20We%20Stand/Com- Bazelon CenterforMental Health Law, Promoting Employment ofPeople with tal healthworkforce: http://www.ncbi.nlm.nih.gov/pubmed/21190075 US NationalLibraryofMedicine NationalInstitutes ofHealth, Developing themen- napoliscoalition.org/ The AnnapolisCoalitiononBehavioral Health Workforce Development: http://an- tion-plan-on-the-behavioral-health-workforce pared by TheAnnapolisCoalition:http://annapoliscoalition.org/?portfolio=ac- PlanforBehavioral HealthSAMSHA, AnAction Workforce Development pre- M http://csmh.umaryland.edu/ University ofMaryland Technical Assistance CenteronSchoolMental Health: SchoolMental HealthUCLA Project:http://smhp.psych.ucla.edu/ vices/esc/ Texas http://www.tea.state.tx.us/regional_ser- EducationServiceCenters(ESCs): Texas http://www.tea.state.tx.us/ EducationAgency: fault.aspx?name=homepage Texas Behavior Support(TBS)Networks: http://www.txbehaviorsupport.org/de- Communities inSchools(CIS)ofTexas: http://www.cisoftexas.org/ Center forHealth andHealth CareinSchools:http://www.healthinschools.org/ M Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas romotores( ent ent a a l He l He a a lt lt a h h s)

in W ork S c h f ools orce D evelopment Recovery and Wellness

National Empowerment Center: http://www.power2u.org/

National Council on Alcoholism and Drug Dependence, Inc.: https://www.ncadd. org/

Recovery Innovations: http://riinternational.com/

SAMHSA- Recovery and Recovery Support: http://www.samhsa.gov/recovery

Texas Department of State Health Services, Recovery-oriented systems of care (ROSC): https://www.dshs.state.tx.us/substance-abuse/ROSC/

Via Hope Recovery Institute: http://www.viahope.org/programs/recovery-institute

Recovery Support Center, Houston: http://wellnessandrecovery.org/recovery-coaching.html

Association of Recovery Community Organizations: http://www.facesandvoicesofrecovery.org/who/arco

Recovery Community Organization toolkit: http://www.facesandvoicesofrecovery. org/sites/default/files/resources/7.13.15%20FINAL%20Recovery%20Communi- ty%20Organization%20Toolkit.pdf Suicide Prevention

A Report of the Surgeon General: 2012 National Strategy for Suicide Prevention: http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full-report.pdf

Preventing Suicide: A toolkit for High Schools: http://store.samhsa.gov/product/ Preventing-Suicide-A-Toolkit-for-High-Schools/SMA12-4669

SAMHSA – Suicide Prevention: http://www.samhsa.gov/prevention/suicide.aspx

Texas Suicide Prevention: http://www.texassuicideprevention.org/

Texas Suicide Prevention Resource Center: http://www.sprc.org/states/texas

Texas Department of State Health Services, Texas Suicide Prevention: http://www. dshs.state.tx.us/mhsa/suicide/Suicide-Prevention.aspx

Telemedicine and Telehealth Appendices

American Telemedicine Association: http://www.americantelemed.org/

University of Colorado Denver Telemental Health Guide: http://www.tmhguide.org/

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 467 Appendices 468 US. DepartmentofVeterans Affairs:http://www.va.gov/ TexVet: www.texvet.org Texas Veterans Commission:http://www.tvc.texas.gov/ Military Veteran Peer Network: http://www.milvetpeer.net/ connection.net/ Make theConnection:Share experiencesandsupportsfor veterans: http://makethe- V Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas eter a ns S ervices Glossary: Common Behavioral Health Terms

1115 Waiver: A waiver under section 1115 of Social Security Act that allows CMS and states more flexibility in designing programs to ensure delivery of Medicaid services.

Acute: Refers to a disease or condition that develops rapidly and is intense and of short duration.

Adjudication: Is a finding that a youth has engaged in delinquent conduct or “conduct in need of supervision.” It is similar to a “conviction” in adult court.

Affect: Feeling or emotion, especially as manifested by facial expression or body language.

Affordable housing: Housing units that are affordable for people who have an income below the median family income of a specific area. Affordable is often considered to be 30% or less of a person’s monthly income.

Alternative therapy: Mental health care that is used instead of or in addition to conventional mental health services.

Anxiety: A sense of fear, nervousness, and apprehension about something.

Anxiety disorders: A group of chronic disorders ranging from feelings of uneasiness to immobilizing bouts of terror. Anxiety disorders include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), phobias, and generalized anxiety disorder.

Behavioral health care: Continuum of services for individuals at risk of, or currently living with, one or more mental health conditions, substance use disorders or other behavioral health disorders.

Behavioral therapy: Therapy focusing on changing unwanted behaviors through rewards, reinforcements and desensitization. Desensitization, or exposure therapy, is a process of confronting something that arouses anxiety, discomfort or fear and overcoming the unwanted responses.

Biomedical treatment: Treatment involving medication. The kind of medication a psychiatrist prescribes varies with the disorder and the individual being treated; also referred to as psychopharmachology. Appendices

Bipolar disorder: A mood disorder in which a person alternates between episodes of major depression and mania.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 469 Appendices 470 destructive. can leadtofeelingsandbehaviors that may betroublesome, self-defeating,orself- Cognitive therapy: Aimstoidentifyandmodify distorted thinkingpatterns that Chronic: Referstoadiseaseorcondition thatpersists over alongperiod oftime. substance useservices. have accesstohealthcare,includinginpatientandoutpatient mentalhealthand up to200percentofthefederalpoverty level sothatlow-income childrencan state andfederalgovernments 0–19 andisavailable forchildrenaged withincome AswithMedicaid, CHIPisjointlyfundedbyTitle XXIoftheSocialSecurityAct. the Children’s Health Insurance Program(CHIP):CHIPwas createdin1997under specialists have received approved trainingandhave passedacertificationexam. and recovery supporttoother peoplewithsimilardiagnoses. Certified peer struggles withmentalillnessorsubstance useenablesthemtoprovide assistance Certified Peer Specialist (CPS):Individualswhosepersonalexperienceand have received approved trainingandhave passedacertificationexam. way thatothers canbenefit fromtheirexperiences. Certified peerrecovery coaches Their lifeexperiencesandrecovery allow themtoprovide recovery supportinsuch who areinrecovery fromsubstance useorco-occurringmentalhealthdisorders. Certified Peer Recovery Coach-Peer Recovery SupportSpecialists areindividuals support toother parentsinsimilarcircumstances. training andpassedacertificationexam.Afamilypartner provides informationand involvement withthe publicmentalhealthsystem and have received approved with mental,emotional orbehavioral healthdisordersand have hadpersonal Certified Family Partner (CFP):Individualswithexperienceparentingachild Program. that administers Medicare, Medicaid, andtheStateChildren’s Health Insurance Centers forMedicare andMedicaid (CMS):TheU.S. Services federalagency advocate andfacilitator.] for personswithmentalhealthneedsandtheirfamilies. [Alsoservicecoordinator, Anindividualwhoorganizesandcoordinatesservicessupports Case manager: psychiatrists, familymembersandmentors. professionals. Caregivers may includesocialworkers, teachers, psychologists, health conditions. Caregivers canbe,butarenot requiredtobe,mentalhealth Caregiver: Apersonwhohasspecialtrainingtohelppeoplewithmental treatment required. a medicalprovider isgiven aset feeperpatient(asby anHMO)regardlessof Capitated: Relatingto, participatingin,orbeingahealth-caresystem inwhich where theresidentsareunrelatedtoowner. transportation, toatleast threeresidentswhohave adisability and/or areelderly, home:AbusinessthatprovidesBoarding basiccare,suchasmealsand Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Cognitive behavioral therapy (CBT): A combination of cognitive and behavioral therapies that help people identify and modify maladaptive thought patterns, beliefs, and behaviors. Counseling is intended to be brief, time-limited and focused.

Conduct in need of supervision (CINS): Generally conduct committed by a minor that, if committed by an adult, could result in only a fine, or conduct that is not a violation if committed by an adult, such as truancy or running away from home.

Consumer: A person who is obtaining, or has obtained, conventional or alternative treatment or support for a mental health condition.

Consumer-operated service providers: Independent organizations operated and governed by individuals in recovery that deliver services through subcontracts with Local Mental Health Authorities (LMHAs), such as peer support, outreach, education and advocacy. A fundamental component of COSPs is peer support.

Crisis: A situation in which, due to a mental health condition, an individual presents an immediate danger to self or others or is at risk of serious deterioration of mental or physical health, or a situation in which an individual believes that he or she presents an immediate danger to self or others, or that his or her mental or physical health is at risk of serious deterioration.

Crisis intervention services: Interventions provided in response to a crisis in order to reduce symptoms of severe and persistent mental illness or serious emotional disturbance and to prevent admission of an individual to a more restrictive environment. This service may be delivered to anyone experiencing a mental health crisis. This service does not require prior authorization.

Cyclothymia: A mood disorder characterized by periods of mild depression followed by periods of normal or slightly elevated mood.

DSM-V (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition): A book published by the American Psychiatric Association that gives general descriptions and characteristic symptoms of different mental illnesses. Physicians and other mental health professionals use the DSM-V to confirm diagnoses for mental illnesses.

DM-ID (Diagnostic Manual – Intellectual Disability): A textbook of diagnoses of mental disorders in persons with intellectual disabilities. This manual was developed cooperatively by the National Association of the Dually-Diagnosed and the American Psychiatric Association.

Day treatment: Treatment including special education, counseling, parent training, vocational training, skill building, crisis intervention and recreational therapy for at least 4 hours a day. Appendices

Deductible: The amount an individual must pay for health care expenses before insurance (or a self-insured company) begins to pay its contract share. Often insurance plans are based on yearly deductible amounts.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 471 Appendices 472 preventive caremeasures, varioushealthcarescreeningsandwellnessactivities. part of,orseparatefrom, employer-sponsored healthplans. EAPs typicallyprovide Employee assistance plan(EAP):Resourcesprovided by employers eitheras mania andsomeformsofschizophrenia. electrical stimulation ofthe braintotreatsomeformsofmajordepression,acute Electroconvulsive therapy(ECT): Ahighlycontroversial techniqueusing from theclassroom. Exclusionary discipline:Disciplinarypracticesinschoolsthatremove students depressive disorder. and feelingsofhopelessness. Symptoms arelesssevere thanthoseofmajor appetite, disturbed sleep patterns, lackofenergy, decreasedabilitytoconcentrate of interest orpleasureinusualactivities, andsomeorallofthefollowing: altered Dysthymic disorder:Amooddisordercharacterizedby feelingsofsadness, loss health condition. developmental orintellectualdisabilities andasubstance usedisorderormental disorder andamentalhealthcondition,oranindividuallivingwithonemore conditions. Thetermisoften usedwhenanindividualhasboth asubstance use Dually diagnosed:Thistermreferstoanindividualwhohasco-occurring medication. Dose: Aquantitytobeadministered atonetime,suchasaspecifiedamountof particular grouporsystem. Disproportionality: Overrepresentation ofaparticulargrouppeoplein that ismanifested by acharacteristic set ofphysical findingsorspecific symptoms. Disorder: Aninterruption ofthenormalstructure orfunction of thebodyormind who ultimatelyreceive adiagnosisofthediseaseinquestion. findings andspecific symptoms thatarecommonamonganumberofindividuals Disease: Animpairmentofhealthorfunctioningoften characterizedby physical are individuallyplannedandcoordinated. supports, orother formsofassistance thatareof lifelong orextended durationand and sequenceofspecial,interdisciplinary, services, orgeneric individualized and(e)reflectstheindividual’seconomic self-sufficiency; needforacombination learning,mobility,language, self-direction,capacityforindependentliving,or more ofthefollowing areasofmajorlifeactivity:self-care,receptive andexpressive likely tocontinueindefinitely; (d)resultsinsubstantial functionallimitationsin3or ismanifested beforetheindividualattains22;(c)is age physical impairments;(b) is attributable toamentalorphysical impairmentorcombinationofmentaland Developmental disability: asevere, chronicdisability ofanindividualthat:(a) contradicted by accepted whatisgenerally asreality. Delusion: Anidiosyncratic belieforimpressionthatismaintaineddespitebeing Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Euthymia: Mood in the “normal” range, without manic or depressive symptoms.

Evidence-based practices (EBP): Integration of best research evidence, clinical experience, and patient values.

Food and Drug Administration (FDA): A federal agency whose responsibilities include protecting the public health by assuring the safety, efficacy, and security of prescription and over-the-counter drugs.

Forensic commitment: Patients on a forensic commitment fall into one of the following two categories: 1) the patient has been admitted to a hospital by judicial order because they have been determined not to have the capacity to stand trial, or 2) the patient has been determined to be not guilty by reason of insanity (NGRI).

Generalized anxiety disorder (GAD): An anxiety disorder characterized by consistent feelings of anxiety for a period of at least six months and accompanied by symptoms such as fatigue, restlessness, irritability and sleep disturbance.

Generic: Drugs that do not have a brand name but are typically required to be equivalent to a brand-name counterpart, with the same active ingredients, strength and dosage form and have the same medical effect. Some drugs are protected by patents and supplied by only one company. When the patent expires, other manufacturers can produce its generic version.

Genetic: Inherited; passed from parents to offspring through genes.

Group-model health maintenance organization (HMO): A health care model involving contracts with physicians organized as a partnership, professional corporation or other association. The health plan compensates the medical group for contracted services at a negotiated rate, and that group is responsible for compensating its physicians and contracting with hospitals for care of their patients.

Group therapy: Therapy involving groups of usually 4 to 12 people who have similar experiences and who meet regularly with a mental health professional. The mental health professional uses the emotional interactions of the group’s members to help them get relief from distress and possibly modify their behavior.

HMO (health maintenance organization): A type of managed care plan that acts as both insurer and provider of a comprehensive set of health care services to an enrolled population. Services are furnished through a network of providers.

Halfway house: A residential center or home where drug users, sex offenders, persons with mental illness, or individuals convicted of a felony are placed immediately after their release from a primary institution such as a prison, hospital or rehabilitation facility. The purpose of a halfway house is to allow the persons to begin the process of reintegration with society, while still providing monitoring and Appendices support; this is generally believed to reduce the risk of recidivism or relapse when compared to a release directly into society.

Hallucination: The perception of something, such as a sound or visual image, that is not actually present.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 473 Appendices 474 students whoreceive specialeducationservices. behavioral supportsandinterventions tobeprovided by theschooldistrict forthe Individualized EducationPlan(IEP):Aplandeveloped thatspecifiesthe a recurringbutintermittent needforskillednursingservices. disabled clientswhoseprimaryneedisfordevelopmental servicesandwhomay have habilitation, developmental, andsupportive healthservicestodevelopmentally developmentally disabled isafacilitythatprovides 24-hour personalcare, Intermediate CareFacilities (ICF-IDD): Intermediatecarefacility/ or other facilityandrequiresatleast oneovernight stay. Inpatient care:Thetermreferstomedicaltreatmentthatisprovided inahospital needed tokeep theirhousingandavoid returning tohomelessness. the supportive servicesandconnectionstothecommunity-based supportspeople possible forindividualsandfamiliesexperiencinghomelessness, andthenprovides Housing first: Anapproachthatofferspermanent,affordablehousingasquickly than 30percentofitstotal incomebeforetaxes anddeductionstoward housing. Housing cost burden:Ahousingcost burdenexists whenahouseholdpays more adequate nighttime residence. 42§11302(a)):Anindividualwholacksafixed,Homeless regular, (USC and ofpreventing institutionalization.goal Medicaid beneficiariestoreceive servicesintheir own homeorcommunitywiththe Home andCommunity (HCBS):provides BasedServices opportunitiesfor services andsupportstotreatthewholeperson. integrate andcoordinateallprimary, acute,behavioral health,andlong-term for peoplewithMedicaid whohave chronicconditions. Health Home providers Medicaid StatePlanbenefitfor states toestablish Health Homes tocoordinatecare Health HomesAct createdanoptional : Section2703oftheAffordableCare details forhealthinsuranceplans. Insurance Marketplace alsolets youcompareprices, coverage levels, and other accessible online.Itallows apersontoshopandenrollforhealthplan.TheHealth the healthexchange,Act andis was developed asaresultoftheAffordableCare Health InsuranceMarketplace: TheHealth InsuranceMarketplace, alsocalled Department ofAssistive andRehabilitative Services(DARS). (DFPS), Texas DepartmentofAgingandDisability Services(DADS) andTexas of StateHealth Services(DSHS),Texas DepartmentofFamily Protective Services includingtheTexasHealth andHumanServicesCommission(HHSC), Department Health (HHS)Enterprise:referstostate under the andHumanServices agencies Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas health servicesaddressing theneedsofwholeperson. Integrated healthcare: Thesystematic coordination ofprimaryandbehavioral

Juvenile defendant: A person who is at least 10 years old but not yet 17 at the time he or she committed an act defined as “delinquent conduct” or “conduct in need of supervision.”

Local Mental Health Authorities (LMHAs): Also known as community mental health centers, LMHAs provide services to a specific geographic area of the state, called the local service area. LMHAs are required by the state to plan, develop policy, coordinate, allocate and develop resources for mental health services in the local service area.

Long-Term Services and Supports (LTSS): May be provided in institutional settings or through community-based services. This may include assistance with activities of daily living, such as getting dressed, taking medication, preparing meals, habilitation, attendant care, specialized therapies, respite, managing money and more.

Major Depressive Disorder (MDD): A mood disorder characterized by intense feelings of sadness and hopelessness that persist beyond a few weeks.

Mania: Feelings of intense mental and physical hyperactivity, elevated mood and agitation.

Manic-depression: See bipolar disorder.

Managed care: An organized system for delivering comprehensive health services that allows the managed care entity to determine what services will be provided to an individual in return for a prearranged financial payment. Generally, managed care controls health care costs and discourages unnecessary hospitalization and overuse of specialists. The health plan operates under contract to a payer.

Managed care organizations (MCOs): An organization that combines the functions of health insurance, delivery of care and administration. Services are available primarily through a network of providers contracting with the MCO.

Medicaid: A federal-state funded health insurance assistance program for low- income children and families and people with disabilities.

Medicare: A federal insurance program serving individuals with disabilities and persons over the age of 65. Most costs are paid via trust funds that beneficiaries pay into over the courses of their lives; small deductibles and co-payments are required.

Medication training and support services: Includes education on diagnosis, medications, monitoring and management of symptoms, and side effects.

Medically indigent: an individual who: (1) possesses no property; (2) has no person Appendices legally responsible for the patient’s support; and (3) is unable to reimburse the state for the costs of the patient’s support, maintenance and treatment.

Medication therapy: Prescription, administration, and assessment of drug effectiveness and monitoring of potential side effects of psychotropic medications.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 475 Appendices 476 health carefacility. Outpatient care:Health carethatdoesnot require anovernight stay inahospitalor interventions andsupportshave ontheindividualsor communities. Outcome measure:Athatidentifiestheresultsorimpact services, behaviors (compulsions). recurrent thoughts, feelings, ideasorsensations (obsessions)orrepetitive, ritualized Obsessive-compulsive disorder(OCD):Ananxiety disordercharacterized by careorganizationand isnotmanaged integratedwithprimarycareservices. “carve-out,” asbehavioral healthservicesareprovided throughabehavioral health Rockwall andKaufman counties. Thisservicedelivery model isreferredtoasa health servicestotheeligibleresidentsofDallas, Ellis, Collin,Hunt,Navarro, NorthSTAR careapproachtothedelivery ofbehavioral: apubliclyfundedmanaged another by crossingthespace between twoadjacentneurons. Neurotransmitters: Chemicalsthattransmitinformationfromoneneuronto disorder, oftencombinedwithanantidepressant. Mood stabilizer: Lithiumand/or ananticonvulsant fortreatmentofbipolar depressive disorderanddysthymic disorder. combination ofbipolarIandIIdisorders, cyclothymic disorder, major manifested asoneormoreepisodesofmania,hypomania, depression,orsome Mood disorders:Disordersinwhichtheessentialfeatureisadisturbance ofmood offers strategies onhow tosupportindividualsexperiencing amentalhealthcrisis. illnesses andaddictions, includingriskfactorsandwarning signs. Thetrainingalso Mental Health First Aid(MHFA): Anin-persontrainingtolearnaboutmental distress. feelings, mood,abilitytorelateothers ordailyfunctioningandcausestheperson Mental healthcondition:Aconditionthatdisrupts aperson’s thinking, and many other professionals. mental healthcounselors, professionalcounselors, peerprofessionals, pharmacists psychiatrists, clinicalpsychologists, clinicalsocialworkers, psychiatric nurses, mental healthortotreatconditions. includes Thisbroadcategory practitioner whooffersservicesforthepurposeofimproving anindividual’s Mental healthprofessionals:Amentalprofessionalisacare reinforcing conditionsthatpromote healthy behaviors and lifestyles. and systems tomeet oflifeevents andtransitions by thechallenges creatingand Mental healthprevention: Aproactive processthatempowers individuals fruitfully, andisabletomake acontributiontohisorhercommunity. own abilities, cancopewiththenormalstresses oflife,canworkproductively and Mental health:Astate ofwell-beinginwhichtheindividualrealizeshisorher Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Panic disorder: An anxiety disorder in which people have feelings of terror, rapid heartbeat and rapid breathing that strike suddenly and repeatedly without reasonable cause.

Patient Protection and Affordable Care Act (ACA): A United States federal statute established in March 23, 2010 that is characterized as the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965.

Permanent supportive housing: An evidence-based practice that combines stable and affordable living arrangements with access to flexible health and human services designed to promote recovery for people with behavioral health conditions.

Pharmacological management services: Includes supervision of administration of medication, monitoring of effects and side effects of medication, and assessment of symptoms. Includes one psychiatric evaluation per year.

Phobia: An intense or irrational fear of something. Examples of phobias include fear of closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs and injuries involving blood.

Post-Traumatic Stress Disorder (PTSD): A mental health condition that is triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event.

Primary care physician (PCP): The PCP is responsible for monitoring an individual’s overall medical care and referring the individual to more specialized physicians for additional care. Typically PCPs are included in the following specialties: group practice, family practice, internal medicine, obstetrics/gynecology and pediatrics.

Promising practice: A prevention or treatment intervention that shows positive outcomes but does not have the same level of rigorous scientific evaluation as evidenced-based practice.

Psychiatric/psychotherapeutic/psychotropic medications: Medications capable of affecting the mind, emotions and behavior that are used to treat or manage a psychiatric symptom or challenging behavior.

Psychiatrist: A medical doctor who specializes in the diagnosis, treatment and prevention of mental illness.

Psychologist: A health care professional who diagnoses and treats mental, nervous, emotional and behavioral conditions. Appendices

Psychosis: A severe mental health condition in which thought and emotions are so impaired that a person loses contact with external reality.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 477 Appendices 478 serotonin deficiency. sleep, appetite andmood.People experiencingdepressionoranxiety oftenhave a Serotonin: Aneurotransmitter thatmost likely contributestotheregulationof mechanical, orchemical. (seclude) orrestrict (restrain) movement ofindividuals. Restraints may bephysical, andRestraint:Seclusion Techniques usedby administrators andstaff toisolate well asadministration ofinstruments toassesstreatmentprogress. access toresourcesandservicescoordination ofservices withtheindividual,as Aformofservicethatincludesbasicfacilitation Routine casemanagement: care facility. Residential treatment:Behavioral healthservicesprovided ataresidentialhealth specific unit. rent. Asubsidypays thedifferencebetween thatamount and themarket rentforthe funds allow eligibletenantstopay approximately 30percentoftheirincometoward rent atornearmarket ratefor specifiedhousingunits. Typically, rentalassistance Rental assistance: Rentalassistance fundshelptenantswithlow incomesafford a temporaryimprovement. Relapse: Thereoccurrenceofsymptoms ofadisease;deterioration inhealthafter management. issimilartotheMedicaidrehabilitative casemanagement serviceoftargetedcase issimilartobasicservicecoordinationandhashighercaseloads,case management psychological, educationalandother appropriatesupportservices. Whereroutine of integratedsupporttopeopleincludingassistance inaccessing medical,social, AformofservicethatprovidesRehabilitative avariablelevel casemanagement: wellness, live aself-directedlife,andstrive toreachtheirfullpotential. Recovery: throughwhichindividualsimprove Aprocessofchange theirhealthand torelapseintoaprevioustypeofbehavior.Recidivism: Thetendency the receptor resides. neurotransmitters andhormones, andtransmits themessage intothecellonwhich Receptor: Amoleculethatrecognizesspecificchemicals, including mixed states, withinhours, days ormonths. inmoodfrommaniatomajordepression,or Rapid cycling:Experiencingchanges operation ofsubsidizedhousingandrentalassistance programs. Public Housing (PHA): Agovernmental entitythat isresponsibleforthe Agency understand how past experiencesaffectcurrentbehaviors. Psychotherapy theirthoughtorbehavior patterns canhelpindividualschange and health professionalandaconsumerdiscussneedsfeelingstofindsolutions. Psychotherapy: Atreatmentmethod formentalhealthconcernsinwhicha Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Signs: Indications of illness that are observed by the examiner rather than reported by the individual.

Skilled Nursing Facility: Licensed healthcare facility that serves chronically ill, usually elderly patients, and provides long-term nursing care, rehabilitation, and other services.

Social Security Disability Insurance (SSDI): A federal supplemental income for individuals or their family members who have a disability, have worked in a job covered by Social Security, and have paid enough money into the Social Security program. SSDI is funded by Social Security taxes.

Social Security Income (SSI): A federal supplemental income funded by general tax revenue, not Social Security taxes. SSI is for people with limited income and who have a qualifying disability or are over 65.

Serious Emotional Disturbance (SED): A group of psychiatric disorders in children and adolescents which cause severe disturbances in behavior, thinking and feeling.

State hospital: A hospital run by the state for the care and treatment of patients affected with acute or chronic mental illness; also called a mental health hospital or a state psychiatric facility.

State Supported Living Center (SSLC): Large institutions that provide 24-hour residential services to people with intellectual and developmental disabilities; formerly called state schools.

Stigma: A negative stereotype about a group of people.

Supported employment: A service that provides individualized assistance in choosing and obtaining employment at integrated work sites in the community of the consumer’s choice. It includes supports provided by identified staff that will assist individuals in keeping employment and finding another job as necessary. This may include the services of a job coach to support the individual at the job site.

Symptom: An indication of a disease or other disorder experienced by the patient

Syndrome: A collection of physical signs and symptoms that, when occurring together, are characteristic of a specific condition.

System of Care: An organizational philosophy and framework that involves collaboration across agencies, families, and youth for the purpose of improving services and access and expanding the array of coordinated community-based services for youth with a serious emotional disturbance and their families Appendices

Substance use disorder: A medical condition that includes the abuse or dependence on alcohol or drugs.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 479 Appendices 480 Various medical dictionaries Texas ResilienceandRecovery Substance Abuse Mental Health (SAMHSA) ServicesAdministration U.S. Dept. ofHealth andHumanServices National Institute ofMental Health Institute ofMedicine Sources: provision ofjobexperiencetoindividuals. development, assessmentandenhancementofwork-related skills, aswell Vocational rehabilitationservices:Servicesthatincludejobfinding, Veteran: Somebodyformerlyinthearmedforces. health careexpensesofanother entity. Third-party payer: Apublicorprivateorganizationthatisresponsibleforthe penetrating headinjurythatdisrupts thenormalfunctionofbrain. Traumatic BrainInjury(TBI):Causedby abump, blow orjolttotheheada issues. Trauma-informed supportshouldalsoconsidercultural,historical, andgender peer support,collaborationandmutuality, empowerment, voice, andchoice. A trauma-informedapproachhasthefollowing principles:safety, trustworthiness, the consequencesoftraumaonanindividualandaredesigned tofacilitatehealing. Trauma-informed approach:Treatmentinterventions thatspecificallyaddresses social, emotional, orspiritualwell-being. and thathaslasting adverse effectsontheindividual’s functioningandphysical, experienced by anindividualasphysically oremotionally harmfulorthreatening Trauma: Occursfromanevent, seriesofevents, orset ofcircumstances thatis Telemedicine/Telehealth: Theuseoftechnologytodeliver healthcareservices. operates efficientlyandeffectively. in ordertodetermine whether anagency’s functionsarestill neededandwhether it Sunset review: Council’s TheSunset Advisory periodicevaluationofstate agencies Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Advisory Committees

Texas Health and Human Services Commission (HHSC)

Advisory Committee on Qualifications for Health Care Translators and Interpreters: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/advisory- committee-qualifications-health-care-translators-and-interpreters · Advises on various items related to qualifications for health care interpreters and translators.

Aging and Disability Resource Center Advisory Committee (ADRCAC): https://hhs.texas.gov/about-hhs/leadership/advisory-committees/adrc-advisory- committee · Assists in developing and implementing an ADRC program in Texas to include program and policy development, designing and operating ADRCs, and obtaining stakeholder input.

Aging Texas Well Advisory Committee: https://hhs.texas.gov/about-hhs/community-engagement/age-well-live-well/aging- texas-well · Advises the department and makes recommendations to state leadership on implementation of the Aging Texas Well Initiative.

Behavioral Health Advisory Committee: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/behavioral- health-advisory-committee · Provides customer/consumer and stakeholder input by making recommendations regarding the allocation and adequacy of behavioral health services and programs within the state of Texas.

Behavioral Health Integration Advisory Committee: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/behavioral- health-integration-advisory-committee · Charged with addressing initial planning and development needed to integrate Medicaid behavioral health services into managed care by September 1, 2014. Phase II recommendations will address systemic changes needed to create a truly integrated system.

Board for Evaluation of Interpreters (BEI):

https://hhs.texas.gov/about-hhs/leadership/advisory-committees/board- Appendices evaluation-interpreters-bei · Ensures that prospective interpreters are proficient in their ability to meaningfully and accurately comprehend, produce, and transform ASL to and from English.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 481 Appendices 482 employment-first-task-force https://hhs.texas.gov/services/disability/employment/employment-first/ Employment First Task Force: committee https://hhs.texas.gov/about-hhs/leadership/advisory-committees/eci-advisory- Early ChildhoodIntervention AdvisoryCommittee: http://www.txvendordrug.com/advisory/index.shtml Drug UtilizationReview Board: https://hhs.texas.gov/about-hhs/council-children-and-families Council onChildrenandFamilies: consumer-direction https://hhs.texas.gov/about-hhs/leadership/advisory-committees/texas-council- Consumer DirectionWorkgroup: rules-and-workgroups https://hhs.texas.gov/about-hhs/leadership/advisory-committees/1115-waiver- Executive Waiver Committee: council https://hhs.texas.gov/about-hhs/leadership/advisory-committees/childrens-policy- Children’s Policy Council: Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · · · · · ·

ECI system. development andimplementationofpoliciesthatconstitute thestatewide theDARSAdvises DivisionforEarlyChildhoodIntervention Serviceson across Medicaid programs. education interventions forMedicaid providers, drugusage andreviews clinical priorauthorizationsonoutpatientprescription drugs, recommends Develops andsubmitsrecommendationsforthepreferreddruglist, suggests coordination ofstate servicesforchildren. Established duringthe2009legislative sessiontohelpimprove the ordisability.regardless ofage freedom andexercise controlandauthorityover theconsumer’s choices, long-term servicesandsupportsthatenhanceaconsumer’s abilitytohave delivery ofservicesthrough consumerdirection,inallprograms offering onthedevelopment, implementation,expansion,and HHSC Advises Develops recommendations forthelegislatureandexecutive commissioner. policies andrelatedlong-termcarehealthprogramsforchildren. Helps indeveloping, implementing,andadministering familysupport Waiver. Provides withfeedback onthehospitalfinancecomponent ofthe 1115 adults. employment standards, responsibilities, andexpectationsasother working the expectationthatindividualswithdisabilities areabletomeet thesame Promotes competitive employment forpeoplewithdisabilities andsets Foster Care Redesign Public Private Partnership: https://www.dfps.state.tx.us/Adoption_and_Foster_Care/About_Foster_Care/ Foster_Care_Redesign/public-private.asp · Charged by DFPS in 2010 to serve as the guiding body for the development of recommendations for a redesigned foster care system. Includes members of the judiciary, foster care providers, advocates, provider associations, foster care alumni, a DFPS Advisory Council member, and DFPS executive staff.

Governor’s Emergency Medical Services (EMS) and Trauma Advisory Council: https://www.dshs.texas.gov/emstraumasystems/governor.shtm · Promotes, develops and maintains a comprehensive EMS/Trauma System that will meet the needs of all patients and that will raise the standards for community health care by implementing innovative techniques and systems for the delivery of emergency care for the entire population.

Health Information Exchange System: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/electronic- health-information-exchange-system-advisory-committee · Advises about the development and implementation of an electronic health information exchange system to improve the quality, safety and efficiency of health care services provided through Medicaid and the Children’s Health Insurance Program (CHIP).

Hospital Payment Advisory Committee: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/hospital- payment-advisory-committee · Advises HHSC to ensure reasonable, adequate, and equitable payments to hospital providers and to address the essential role of rural hospitals.

Intellectual and Developmental Disability System Redesign Advisory Committee: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/intellectual-anddevelopmental-disability-system-redesign-advisory-committee · Advises HHSC and DADS on the implementation of the acute care services and long-term services and supports system redesign for individuals with intellectual and developmental disabilities.

Interagency Obesity Council: https://www.dshs.texas.gov/CWWObesityInteragencyCouncil/ · Monitors and evaluates obesity prevention efforts in the state of Texas for children and adults.

Maternity Mortality and Morbidity Task Force: https://www.dshs.texas.gov/mch/maternal_mortality_and_morbidity.shtm Appendices · Studies maternal mortality and morbidity by studying and reviewing cases of pregnancy-related deaths and trends in severe maternal morbidity, determining the feasibility of the task force studying cases of severe maternal morbidity, and recommending ways to help reduce the incidence of pregnancy-related deaths and severe maternal morbidity in Texas.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 483 Appendices 484 administrator-advisory-committee https://hhs.texas.gov/about-hhs/leadership/advisory-committees/nursing-facility- Nursing Facility Administrators AdvisoryCommittee: https://www.dshs.texas.gov/newborn/NBSAdvComm.aspx Newborn AdvisoryCommittee: Screening advisory-committee https://hhs.texas.gov/about-hhs/leadership/advisory-committees/medical-care- Medical CareAdvisoryCommittee: https://dshs.texas.gov/medical-advisory-board/ Medical AdvisoryBoard: quality-based-payment-advisory-committee https://hhs.texas.gov/about-hhs/leadership/advisory-committees/medicaidchip- Medicaid/CHIP Quality-Based Payment AdvisoryCommittee: interdisciplinary-advisory-council https://hhs.texas.gov/about-hhs/leadership/advisory-committees/palliative-care- Palliative CareInterdisciplinaryAdvisoryCouncil: chip-regional-advisory-committees https://hhs.texas.gov/about-hhs/leadership/advisory-committees/medicaid-and- Medicaid andCHIPRegionalAdvisoryCommittees: Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · · · · · ·

screening andadditionalnewborntests. onstrategic planning,policy,Advises rulesandservicesrelatedtonewborn funded programs. director onproposedrulesthatinvolve Medicaid oraffect policy Medicaid- Federally mandatedtoreviewandmake recommendationstostate Medicaid and candidates. referred driver licenseesandcandidatesconcealedhandgun Texas DepartmentofPublicSafety regardingthemedicallimitationsof histories, providing medicalopinionsandmakingrecommendationstothe Helps reducetrafficdeaths, disability andinjury byevaluatingmedical providers andfacilities. efficiency, careorganizations, andaccountabilityofmanaged healthcare and benchmarksforqualityperformance,ofcare outcomes, onMedicaid andCHIPreimbursementsystems, HHSC Advises standards on theprogramtoHHSC. publicinputonMedicaidAccepts andCHIPprovides recommendations care consumerandprofessional informationandeducation program. maintenance, operationandoutcomeevaluationof the statewide palliative Consults withandadvisesonmatters relatedtotheestablishment, Nursing Facility LicensingProgram. Administrator Provides recommendationsforlicensuresanctions forthe andrulechanges Perinatal Advisory Council: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/perinatal- advisory-council · Develops and recommends criteria for designating levels of neonatal and maternal care, including specifying the minimum requirements to qualify for each level designation and a process for the assignment of levels of care to a hospital, makes recommendations for dividing the state into neonatal and maternal care regions, examines utilization trends in neonatal and maternal care, and recommends ways to improve neonatal and maternal outcomes.

Physician Payment Advisory Committee: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/physician- payment-advisory-committee · Functions as a subcommittee of the Medical Care Advisory Committee to advise the committee and HHSC about technical issues regarding physician payment policies.

Preparedness Coordinating Council: (No website available at print date) · Advises DSHS on activities regarding preparedness, training, planning, communications, and emergency response to public health and medical emergencies.

Promotor(a) or Community Health Worker Training and Certification Advisory Committee: (No website available at print date) · Advises on rules concerning training and regulation of promotores/ community health workers.

Promoting Independence Advisory Committee (PIAC): http://www.dads.state. tx.us/providers/pi/piac/ · Advises in the development of a comprehensive, effectively working plan to ensure appropriate care settings for persons with disabilities. Created in response to the U.S. Supreme Court’s Olmstead Decision.

Public Health Funding and Policy Committee http://dshs.texas.gov/phfpcommittee/default.aspx · Defines core public health services a local health entity should provide in a county or municipality; evaluates public health in the state and identifies initiatives for areas that need improvement; identifies funding sources available to local health entities; and establishes public health policy priorities.

SB 1220 Medicaid and CHIP Border Rates and Expenditures Advisory Committee: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/s-b- Appendices 1220-medicaid-and-chip-border-rates-and-expenditures-advisory-committee · Advises HHSC regarding eliminating the disparities between the Texas- Mexico border region and other areas of the state in capitation rates, fee-for- service per capita expenditures and total professional services expenditures for Medicaid and CHIP enrollees under age 19.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 485 Appendices 486 http://www.dshs.texas.gov/chs/shcc/ Statewide Health CoordinatingCouncil coalition-addressing-disproportionality-and-disparities https://hhs.texas.gov/about-hhs/leadership/advisory-committees/state-advisory- Disparities Statewide AdvisoryCoalitionforAddressingDisproportionality and (No websiteavailable atprintdate) State Preventive Health AdvisoryCommittee: managed-care-advisory-committee https://hhs.texas.gov/about-hhs/leadership/advisory-committees/state-medicaid- State Medicaid CareAdvisoryCommittee: Managed independent-living-council https://hhs.texas.gov/about-hhs/leadership/advisory-committees/state- State IndependentLivingCouncil: https://www.dshs.texas.gov/mch/child_fatality_review.shtm State ChildFatality Review Committee: (No websiteavailable atprint date) Advisory Council): Stroke Committee (Subcommittee ofthe Governor’s EMSandTrauma managed-care-advisory-committee https://hhs.texas.gov/about-hhs/leadership/advisory-committees/star-kids- STAR CareAdvisoryCommittee: KidsManaged Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · · · · · · ·

disproportionality anddisparities. disproportionality and disparitiesinTexasAddress by addressingracial Health andHealth Services BlockGrant. Works withHHStodevelop andimplementthestate planforthePreventive implementation andoperationofMedicaid care. managed Provides inputonthestatewide recommendationsandongoing advocates fortherightsofpeoplewithdisabilities. Leads, promotes, andadvancestheindependentlivingphilosophy and preventable deaths, andpromoting publicawareness. incidences ofchilddeaths, identifyingprocedurestoreducethenumberof Looks toreducepreventable childdeathsby understanding thecausesand careprogram. managed onthedevelopment andimplementationoftheSTARAdvises KidsMedicaid statewide transportplanandstroke stroke facilitycriteria. emergency Assists Governor’s Councilinthedevelopment ofa EMS&TraumaAdvisory health planningactivities. Ensures healthcareservicesandfacilitiesareavailable toallTexans through Task Force for Children with Special Needs: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/task-force- children-special-needs · Charged with developing a comprehensive five-year strategic plan to address the needs of children with chronic illnesses, intellectual or other developmental disabilities or serious mental illness.

Task Force on Domestic Violence: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/task-force- domestic-violence · Created during 2013 Texas legislative session to examine the effect of domestic violence on the health of mothers and children and ways to improve health services for domestic violence victims.

Telemedicine/Telehealth Advisory Committee: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/telemedicine- and-telehealth-advisory-committee · State-mandated advisory committee assists HHSC to evaluate reimburseable services and delivery processes, as well as monitor type of programs receiving these services.

Texas Brain Injury Advisory Council: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/texas-braininjury-advisory-council · Informs state leadership of the needs of people with brain injuries and their families.

Texas Center for Nursing Workforce Studies Advisory Committee: http://www.dshs.texas.gov/chs/cnws/default.shtm · Serves as a resource for data and research on the nursing workforce in Texas.

Texas Council on Alzheimer’s Disease and Related Disorders: https://www.dshs.texas.gov/alzheimers/meetings.shtm

Texas Council on Autism and Pervasive Developmental Disorders: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/texas-council- autism-and-pervasive-developmental-disorders · Advises and makes recommendations to state agencies and the state Legislature to ensure that the needs of persons of all ages with autism and other pervasive developmental disorders and their families are addressed and that all available resources are coordinated to meet those needs.

Texas Council on Cardiovascular Disease and Stroke: https://www.dshs.texas.gov/heart/Texas-Council-on-Cardiovascular-Disease-and- Appendices Stroke.aspx · Conducts health education, public awareness and community outreach; improves access to treatment; coordinates activities among state agencies; develops a database of recommendations for treatment and care.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 487 Appendices 488 http://www.txsystemofcare.org/ Texas System ofCareConsortium: https://www.dshs.texas.gov/schoolhealth/shadvise.shtm Texas Health School AdvisoryCommittee: https://www.dads.state.tx.us/taketimetexas/about.html#committee Texas RespiteAdvisoryCommittee: https://www.dshs.texas.gov/trab/ Texas RadiationAdvisoryBoard: council https://hhs.texas.gov/about-hhs/leadership/advisory-committees/texas-nonprofit- Texas NonprofitCouncil: https://www.dshs.texas.gov/hivstd/meds/advise.shtm Texas HIVMedication AdvisoryCouncil: http://www.dshs.texas.gov/diabetes/ Texas Diabetes Council: consumer-direction https://hhs.texas.gov/about-hhs/leadership/advisory-committees/texas-council- Texas CouncilonConsumerDirection: Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · · · · · ·

Helps Texas achiev health bes Provides active leadership intheidentificationanddisseminationofschool Helps develop s support tofamilycaregivers. improves thequalityofrespiteservices, andprovides training,educationand sources ofradiation. may berequiredonmatters relating todevelopment, use,andregulationof The boardalsomakes recommendationsandprovides technical advicethat andevaluatesstateReviews radiationpolicies guidance onfaith-basedandcommunity-based initiatives. Helps directtheworkofInteragenc and healthcareprofessionalswhoofferdiabetes treatmentandeducation. statewide system ofqualityeducationservicesforallpeoplewithdiabetes Texas Legislatureonlegislationthatisneededtodevelop andmaintaina issuesaffectingpeoplewithdiabetes inT Addresses Advises onthedevelopment, implementation,expansion,anddeliv Advises or disability. exercise controlandauthorityover theconsumer’s choices, regardlessofage services andsupportsthatenhanceaconsumer’s abilitytohave freedomand services throughconsumerdirection,inallprogramsoffering long-term t practices and resources for school policy makers. t practicesandresourcesforschoolpolicy trategies toreducebarriersaccessrespiteservices, e well-beingforchildren and youth. y CoordinatingGroupandprovides , programs, andproposedrules. exas andadvisesthe ery of Tobacco Settlement Permanent Trust Account Administration Advisory Committee: http://www.dshs.texas.gov/tobaccosettlement/advcom.shtm · Reviews the results of audit, disputes and rules regarding the state’s tobacco settlement.

Toxic Substances Coordinating Committee: http://www.tscc.state.tx.us/ · Protects and promotes the health and environment of Texas through the prevention and control of adverse health and environmental effects related to toxic substances and harmful agents.

Women’s Health Advisory Committee: https://hhs.texas.gov/about-hhs/leadership/advisory-committees/womens-health- advisory-committee · Advises on women’s health programs.

Youth Camp Advisory Committee: http://www.dshs.texas.gov/youthcamp/advisory-committee.aspx · Provides advice on the development of standards, procedures, and rules to implement the Youth Camp Act.

Note: All advisory committee information printed above was retrieved from the HHSC Advisory Committee page before or on October 13, 2016. Texas Department of Family and Protective Services

Advisory Committee on Promoting Adoption of Minority Children: (No website available at print date) · Advises DFPS on policies and practices that affect the licensing and recruitment of families for minority children awaiting adoption. Charged with studying, developing, and evaluating programs and projects relating to community awareness and education, family support, counseling, parenting skills and education, and reform of the child welfare system.

Foster Care Redesign Public Private Partnership https://www.dfps.state.tx.us/Adoption_and_Foster_Care/About_Foster_Care/ Foster_Care_Redesign/public-private.asp · Charged by DFPS in 2010 to serve as the guiding body for the development of recommendations for a redesigned foster care system. Includes members of the judiciary, foster care providers, advocates, provider associations, foster care alumni, a DFPS Advisory Council member, and DFPS executive staff.

Committee on Advancing Residential Practices:

(No website available at print date) Appendices · Residential Child Care Contractors, stakeholder associations, and DFPS representatives meet to improve communication and provide a venue for focusing on enhancements to the system that support increased safety, permanency, and well-being for children.

Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 489 Appendices 490 https://www.dfps.state.tx.us/Child_Protection/Family_Support/pcb.asp Statewide Parent CollaborationGroup: Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas oronOctober17,website before 2016. printedaboveNote: Alladvisorycommitteeinformation was retrieved from theDFPS (No websiteavailable atprintdate) Youth LeadershipCouncil: · ·

Allows inputfr to improve foster care, andimpartsadvocacy skills. allows foster youth to discussissuesofconcern andgenerate potential solutions Seeks youth inputonne evaluation oftheChildProtective Services program. om biological parents inthedesign,implementation, and w policiesandprograms beingdeveloped by DFPS,

Mission

The Hogg Foundation for Mental Health advances mental wellness for the people of Texas as an impactful grantmaker and catalyst for change.

Hogg Foundation for Mental Health Division of Diversity and Community Engagement The University of Texas at Austin | 3001 Lake Austin Blvd., Fourth Floor | Austin, TX 78703 512.471.5041 www.hogg.utexas.edu

The Hogg Foundation encourages and appreciates comments and corrections as well as ideas for improving this guide. If this document is found useful to the community, the foundation will consider updating it prior to future legislative sessions. Specific comments should reference the applicable section and page number(s). Please include citations for all factual corrections or additional information. All comments and recommendations should be emailed to [email protected]

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