A Guide to Understanding Mental Health Systems and Services in Texas 2nd Edition – 2014 Acknowledgement
The foundation would like to acknowledge Graduate Research Assistants Amanda Ackerman, Stephanie Brosig and Ted Wilson, and Policy Fellow Jemila Lea, for the many hours of research and writing 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 term “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 Suggested Citation:
Hogg Foundation for Mental Health. (Month, 2014). A guide to understanding mental health systems and services in Texas. Retrieved from http://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 Dedication
In memory of Dr. Susan Stone, a fierce visionary and a sensitive soul, who was relentlessly dedicated to improving mental health systems and services in Texas.
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 3 Contents
Overview 11 Introduction 15 The National Context 19 Recent Federal Health Care Initiatives Impacting Behavioral Health 20 The New Freedom Commission and Transformation of Behavioral Health Care 20 Presidential Mental Health Initiatives 20 The Patient Protection and Affordable Care Act (ACA) 22 Key Features 22 Essential Health Benefits 23 Establishment of “Benchmark Plans” 23 Health Insurance Marketplace 24 Medicaid Expansion 24 Expanding the Health Care Workforce 25 Mental Health Parity and Addiction Equity Act 25 Established Federal Health Care Programs Impacting Behavioral Health 26 Medicare 26 Medicare and Medicaid (Dual Eligibility) 28 Texas Dual Eligibles Integrated Care Demonstration Project 29 Supplemental Social Income (SSI) and Social Security Disability Insurance (SSDI) 30
The Texas Environment 33 Impact of the Affordable Care Act on Behavioral Health Services in Texas 33 Federal Health Insurance Marketplace 33 Texas Department of Insurance and Rules for Navigators 35 Medicaid Expansion 35 Health Homes 37 Behavioral Health Implications of Health and Human Service Initiatives 38 Medicaid Managed Care Expansion in Texas 38 Senate Bill 58 (SB 58) 38 Senate Bill 7 (SB 7) 39 1115 Waiver: Texas Health Care Transformation and Quality Improvement Program 40 1915(i) State Plan Amendment: Home and Community-Based Services—Adult Mental Health Program (HCBS-AMH) 41 Health and Human Service Commission Sunset Review 42 Mental Health Workforce Shortages 44 Workforce Availability in Texas 45 Behavioral Health Professionals in Texas 46 Texas Mental Health Code 47 HB 3793 – Mental Health Advisory Panel 47 Addressing the Mental Health Needs of Individuals with Intellectual and Other Developmental Disabilities (IDD) 48 Boarding Homes 49 Peer Support Services 51 Youth Empowerment Services (YES) Waiver 52 Trauma-Informed Care 52 Forensic Restoration of Competency Lawsuit 53
4 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Public Behavioral Health Services in Texas 55
Texas Health and Human Services Commission 57
Funding 60 Changing Environment 62 SB 58 - Integration of Behavioral Health Services 62 SB 7 – Managed Care Expansion and Intellectual/Developmental Disability Redesign 63 Medicaid 64 State Medicaid Agency 64 Medicaid Funding 68 Eligibility for Medicaid Services 69 Demographics of Medicaid Recipients 71 Federally Qualified Health Centers 72 Medicaid Buy-In Programs (Adults and Children) 72 Medicaid Health Insurance Premium Payment Program (HIPP) 72 Texas Medicaid and Healthcare Partnership (TMHP) 73 Children’s Health Insurance Program (CHIP) 73 Eligibility for CHIP 73 Enrollment, Utilization and Costs 73 Behavioral Health Quality of Care Measures 75
Texas Department of State Health Services 77
Changing Environment 80 Trends and Prevalence 82 Funding 82 System Utilization 84 Waitlists 85 Timeline of Mental Health Service Initiatives 87 Access 88 Medicaid 88 Medically Indigent People 89 Priority Populations 89 Service Providers 90 Medicaid Managed Care 90 Local Mental Health Authorities 91 NorthSTAR 93 Community Mental Health Services 94 Texas Resilience and Recovery Framework 94 Adult Service Utilization and Costs 96 Quality of Care Measures 96 Youth Service Utilization and Costs 99 Quality of Care Measures 100 Crisis Services 100 Crisis Services Utilization and Costs 102 Quality of Care Measures 102 NorthSTAR Services 103 NorthSTAR Service Utilization and Costs 104 Quality of Care Measures 105 Inpatient Mental Health Hospital Services 105 Civil 105 Forensic 106 Maximum Security 106 Types of Inpatient Settings 106 State Hospitals 106 Funding 108 Institutions for Mental Diseases (IMD) Exclusion 108 State Hospital Utilization and Costs 109
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 5 Recidivism Rates 109 State-Funded Community and Private Hospitals 110 Competency Restoration 111 State Psychiatric Inpatient Competency Restoration 111 Outpatient Competency Restoration 112 Jail-Based Competency Restoration 112 Addressing the Shortage of Public Inpatient Beds 113 Substance Use Services 115 Access 116 Funding 116 Eligibility for Services 117 Priority Populations 117 Co-occurring Psychiatric and Substance Use 117 Disorders 117 Services 118 Utilization and Costs 119 Quality of Care Measures 121 Promising Practices in Substance Use Treatment 122 The Texas Recovery Initiative 122
Texas Department of Family and Protective Services 123
Changing Environment 126 Foster Care Redesign 126 Parental Relinquishment of Custody 127 Specialty Courts 128 Accessing Mental Health Services 132 Superior Health System (STAR Health) 132 Former Foster Care Children Program (FFCC) 132 Institutional Residential Services 134 Alternative Response System 134 System of Care 135 Continuing Issues 135 Child Fatalities in the CPS System 135 Disproportionality 137 Lesbian, Gay, Bisexual, Transgender, Queer Youth 138 Psychotropic Medications 139 Trauma-Informed Care 141 Seclusion and Restraint 142 Prevention and Early Intervention (PEI) 142 Adult Protective Services (APS) 145 Child Care Licensing 147
Texas Department of Aging and Disability Services 149
Prevalence of Behavioral Health Conditions for People with Disabilities and Aging Texans 152 People with Disabilities 152 Aging Texans 152 Changing Environment 153 SB 7 153 SB 45 153 SB 1226 153 Trauma-informed care and person-centered planning, training and technical assistance at San Angelo 154 and Mexia State Supported Living Centers 2013 Trauma-informed care trainings at DADS waiver conferences 154 Programs and Services for People with Disabilities Who Have Co-occurring Behavioral Health Conditions 154 Community Long-Term Services and Supports Medicaid 1915(c) Waiver Services 155 Role of Local Authorities in Connecting People to Waiver Services 158 Institutional Long-Term Services and Supports 158 Skilled Nursing Facilities 158 Community Intermediate Care Facilities 159
6 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas State Supported Living Centers 159 Additional Programs for People with Disabilities and Aging Texans 165 Non-Medicaid Services 165 Guardianship Program 165 Promoting Independence Initiative 165 Money Follows the Person Program 166
Texas Department of Assistive and Rehabilitative Services 167
Division for Early Childhood Intervention Services 170 Eligibility for Services 170 Services, Utilization, and Costs 171 Division for Rehabilitation Services 172 Vocational Rehabilitation Program 173 Program Overview 173 Eligibility Process 174 Services 174 Independent Living Services 175 Expansion 175 Eligibility 176 Services 176 Division of Disability Determination Services (DDS) 176 Process for Admission and Eligibility 178 Utilization 179 Division for Blind and Visually Impaired 179
Texas Department of Criminal Justice and Local Criminal 181 Justice Agencies
Changing Environment 184 83rd Session Criminal Justice and Mental Health Legislation 184 Overview of Texas Criminal Justice System 185 Texas Department of Criminal Justice 187 Financial Summary 188 Behavioral Health Services and Programs in the State Criminal Justice System 190 Access to Services 191 Behavioral Health Services 191 Post-Incarceration Community-Based Services 193 Medically Recommended Intensive Supervision 194 Release on Parole Special Programs 194 Special Concerns for Female Inmates 195 Local Criminal Justice Systems 195 Texas Commission on Jail Standards 196 Incarceration Prevention Programs 197 Jail Diversion 197 Specialty Courts 198
Texas Juvenile Justice Department (TJJD) and Local 201 Juvenile Justice Agencies
Changing Environment 205 Legislation 205 Trauma-Focused Cognitive Behavioral Therapy Pilot 205 Corsicana Residential Treatment Center 206 Juvenile Justice System Overview 206 Office of the Independent Ombudsman for the Texas Juvenile Justice Department 208 Disproportionality in the Texas Juvenile Justice System 208 Behavioral Health Services in the Juvenile Justice System 210 Behavioral Health Services in State Secure Facilities 210 Behavioral Health Services in County-Level Secure Facilities 212 Behavioral Health Services for Youth on Parole 213
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 7 Community-Based Behavioral Health Services Offered by Local Juvenile Probation Departments 213 Funding Sources 215 State-Funded Programs Available to Local Juvenile Probation Departments with Behavioral Health 215 Service Components Prevention and Intervention Programs 216 Community-Based Services 216 Diversion Programs for Youth with Behavioral Health Conditions 217 Specialty Juvenile Courts 218 Special Needs Diversionary Program 218 Other Privately and Federally Funded Diversion Programs 219 The Front-End Diversionary Initiative 219 Identifying Youth with Brain Injuries 219
Texas Education Agency and Local School Districts 221
Delivery of Mental Health Services in Schools 224 Changing Environment 225 Special Education Services 226 Special Education Funding through IDEA 227 Special Education Funding through Medicaid 227 Eligibility for Special Education 228 Special Education Services and Service Utilization 228 Mental Health Support Systems for Schools 230 Education Service Centers 230 Coordinated School Health Model 231 Communities in Schools 232 Holistic Approaches to Student Mental Health 232 School Wide Positive Behavioral 232 Interventions and Supports 232 Social and Emotional Learning 234 Trauma-Informed Care 234 Exclusionary Discipline in Schools 235 In-School Suspensions (ISS) and Out-of-School Suspensions (OSS) 236 Disciplinary Alternative Education Programs (DAEPs) 236 Mandatory v. Discretionary Removal 236 Juvenile Justice Alternative Education 237 Programs (JJAEPs) / Expulsion to the Streets 237 School Ticketing – Class C Misdemeanors 239 Use of Force in Schools 241 Alternatives to Exclusionary Discipline 242
Texas Department of Housing and Community Affairs 245
Changing Environment 249 Affordable Housing 250 Funding 251 Permanent Supportive Housing 252 Housing and Service Programs for People with Behavioral Health Conditions 253 Poverty and Homeless Prevention Programs 254 Emergency Solutions Grants Program 254 Homeless Housing & Services Program 254 Community Services Block Grant Program 254 Programs for Persons with Disabilities 255 HOME: Texas Homebuyer Assistance Program 255 Home Tax Credit Program 255 Multifamily HOME Direct Loan Program 255 HOME: Tenant-Based Rental Assistance 255 Section 8 Housing: Project Access Program 256 Section 811 Supportive Housing for People with Disabilities 257 Real Choice Systems Grant 257 Amy Young Barrier Removal Program 258 Impediments to Fair Housing Choice 258
8 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Texas Veterans Commission 261
Claims Representation and Counseling Program 264 Eligibility for VA Benefits 264 TVC Employment Services 265 Fund for Veterans’ Assistance (FVA) 266 Other Programs 266 Women Veterans 266 Veterans Support Networks 267 Specialty Courts 267
Best Practices 269 Best Practice: Recovery and Peer Support 270 Mental Health Certified Peer Specialists and Substance Use Certified Recovery Specialists 271 Family Partner Certification 271 Military Veteran Peer Support 272 Consumer-Operated Service Providers 272 Wellness Recovery Action Plan (WRAP®) Self-Directed Planning 272 Recovery-Oriented Systems of Care for Substance Use 272 Recovery to Practice Curriculum 272 Best Practice: Clubhouse International Clubhouse Model 273 Best Practice: Outcome Measures 274 Best Practice: Integrated Primary, Mental Health, and Substance Use Care 275 Best Practice: Prevention and Early Intervention 275 Best Practice: Seclusion and Restraint Alternatives 277 Best Practice: Trauma-Informed Approach 278 Best Practice: Jail Diversion 279 Best Practice: Outpatient Competency Restoration 280 Best Practice: Child and Family Mental Health System of Care 281 Best Practice: Telemedicine/Telehealth 281 Best Practice: Suicide Awareness and Prevention 282 Best Practice: Housing 283 Housing First 283 Permanent Supportive Housing 284 Oxford House 285
Appendices 287 List of Figures 289 List of Acronyms 292 Additional Resources 296 Agency Websites 296 Certified Peer Specialists 296 Child Welfare 296 Children’s Mental Health 296 Civil Rights 297 Consumer and Family Organizations 297 Criminal/Juvenile Justice and Mental Health 297 Cultural and Linguistic Competency 297 Early Childhood and Mental Health 298 General Information on Mental Health and Substance Use 298 Housing 298 Integrated Physical and Mental Health Care 298 Intellectual Disability with Co-occurring Mental Health Conditions 298 Mental Health in Schools 299 Mental Health Workforce Development 299 Promotores(as) 299 Recovery and Wellness 299 Suicide Prevention 300 Telemedicine and Telehealth 300 Veterans Services 300 Glossary: Common Behavioral Health Terms 301 Texas Medicaid Managed Care Plans 310
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 9 Advisory Committees 313 Texas Health and Human Services Commission (HHSC) 313 Texas Department of Aging and Disability Services (DADS) 315 Texas Department of State Health Services (DSHS) 316 Texas Department of Family and Protective Services (DFPS) 317 Texas Sunset Advisory Commission Recommendations Impacting Mental Health 318 Health and Human Services Commission (HHSC) 318 Department of State Health Services (DSHS) 319 Department of Aging and Disability Services (DADS) 320 Department of Family and Protective Services (DFPS) 320 Endnotes 323
10 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Overview
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 and individuals receiving mental health services, especially those with little experience or knowledge of this system of care, understanding the complexities of the patchwork 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 Individuals can enter the is a useful reference tool, it does not provide significant detail on the various programs but instead focuses on the general behavioral health system infrastructure, funding and services provided. The report is designed to provide the reader with a basic understanding of how through multiple points behavioral health services are provided, the populations that are served, and the challenges of meeting the growing and often of entry. 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:
· National Context: A basic overview of national activities and initiatives related
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 11 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). · 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. · Public Behavioral Health Services in Texas: An overview of the multiple Texas state agency 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, and the Texas Veterans Commission. · Best Practices: A discussion of best practices for providing behavioral health services, including a discussion of such topics as: the integration of primary and behavioral health care services to provide a more efficient and coordinated level of care, peer-support services, prevention and early intervention initiatives, and the behavioral health needs of individuals accessing services through the criminal justice system.
The second edition of the guide offers various improvements to help navigate the vast amount of information provided. Each agency described in the Public Behavioral Health Services in Texas section starts with an “At-a-Glance” overview. This overview outlines topics covered, provides an organizational context, details policy concerns and highlights specific statistics relevant to the agency and behavioral health. The agencies also contain a section on the “Changing Environment” for that particular agency, emphasizing recent major system changes within the organization and affecting the organization.
Included in the Appendix of the report is a list of figures, a list of acronyms, additional resources, 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. Additionally the Appendix has information on managed care organizations (MCOs) in Texas, advisory committees, and the August 2014 Sunset Committee recommendations on the Health and Human Services agencies.
The Hogg Foundation wants to emphasize that this report focuses primarily on state 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.
12 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 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.
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 13 14 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Introduction
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 health should be prioritized for individuals, communities and societies throughout the world.
Meeting the mental health care needs of Texans requires critical Behavioral health is the policy analysis and decision-making to ensure a coordinated term typically used when system of supports and services that are effective, appropriate referring to mental health and fiscally responsible. The maze of behavioral health services and substance use. The goal in Texas is complex, making it difficult to understand and, of behavioral health policy consequently, difficult to improve. should be recovery. Behavioral health is the term typically used when referring “Recovery is a process of to mental health and substance use. The goal of behavioral change through which health policy should be recovery. Recovery from mental illness individuals improve their and substance use is possible. Recovery is not synonymous health and wellness, live a with a cure. It is an ongoing process that enables individuals self-directed life, and strive to experiencing mental health challenges to become empowered to reach their full potential.” manage their illness and take control of their lives. Recovery does not happen in isolation but requires holistic support from peers, Source: Substance Abuse and Mental Health family, friends and other stakeholders in the healthcare system, Services Administration. (2011, December 22). especially mental health professionals and supports provided by SAMHSA announces a working definition of “recovery” from mental disorders and substance public mental health systems. use disorders. Retrieved from http://www.samhsa. gov/newsroom/advisories/1112223420.aspx Although the recovery journey will look different for each individual, effective supports, interventions and evidence-based
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 15 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 Introduction 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 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 · Department of Assistive and Rehabilitative Services · Texas Department of Criminal Justice · Texas Department of Juvenile Justice · Texas Education Agency · Texas Department of Housing and Community Affairs · Texas Veterans 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. For example, the Texas Public Policy Foundation has reported that 17% of the 1 million Texans jailed in 2011 had previously received services through a local mental health authority.2 A 2012 Travis County analysis3 found:
Adults with multiple inpatient psychiatric hospitalizations had serious mental illness (major depressive disorder, bipolar disorder or schizophrenia), very high rates of co-occurring substance use, an average of 40 emergency department visits each, and much higher rates of homelessness.
Due to system fragmentation and the lack of data across state agencies, it is difficult to identify the total amount spent on behavioral health services in Texas. Data gathered across state agencies is not congruent and there is no ongoing mechanism to collect and analyze financial data solely related to behavioral health services. While the total cross-agency spending on behavioral health services is not clear, the Kaiser Family Foundation has determined that mental health spending per capita in Texas by the primary state mental health agency (the Department of State Health Services) is one of the lowest in the nation. The study found that annual per capita mental health spending in Texas is estimated at $38.99, while the national average is $122.56.4
16 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Over the past decade, the low level of spending and the underfunding of preventive, Introduction community and crisis services have resulted in higher costs in jails, prisons and hospitals, which in turn, has led to higher spending for other health conditions such as diabetes and heart disease. Chronic homelessness is also often the result of untreated mental illness, further adding to societal costs and creating additional challenges for both the individual and the community. Increased funding during the 83rd legislative session enabled a significant enhancement of service accessibility, treatment and infrastructure. Despite this funding increase, however, more needs to be done to fully address the behavioral health need of Texans. Failure to do so is costly in terms of personal impact as well as economic consequences. The following statistics illustrate some of these costs:
· Adults with untreated mental health conditions are eight times more likely to be incarcerated.5 · Between 60% to 70% of youth in contact with the juvenile justice system meet criteria for a mental health disorder. Sixty percent of these youth have a co-occurring substance use disorder. 6 · For every dollar spent by federal and state governments on substance use services, 95.6 cents covered costs to public programs outside of the behavioral health agency, such as criminal justice, and only 1.9 cents funded prevention and treatment programs.7 · One in five school-age children has a mental health condition and 5% have a mental health condition that results in significant functional impairment.8 · Serious mental illness costs America $193.2 billion in lost earnings per year.9 · Suicide is the tenth leading cause of death in the U.S. (more common than homicide) and the third leading cause of death for those ages 15 to 24 years. More than 90 percent of those who die by suicide had one or more mental disorders.10 · In Texas, people with severe mental illness served in the public mental health system die an average of 29 years earlier than the general population.11
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 83rd legislative session increase 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.
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 17 Introduction 18 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas The National Context National Context
Behavioral health policy decisions made at the federal level can have significant impact on programs and services in Texas. Currently, two major pieces of federal legislation are having a SAMHSA significant impact on the access, service delivery and financing of mental health services in Texas. The combination of the Mental The Substance Abuse and Health Parity and Addiction Equity Act (MHPAEA) and the Mental Health Services Patient Protection and Affordable Care Act (ACA) have influenced Administration (SAMHSA) is the design of health insurance benefits for both public and private the agency within the U.S. health plans that insure the majority of Texans. The impact of Department of Health and these acts on behavioral health is discussed later in this section. Human Services charged with advancing behavioral health A national paradigm shift is underway to transform behavioral and reducing the impact of health delivery systems. Initiatives supported at the federal level substance abuse and mental by key federal agencies such as the Substance Abuse and Mental illness throughout the nation. Health Services Administration (SAMHSA) and the Centers for Medicare and Medicaid Services (CMS) emphasize recovery, SAMSHA also retains the wellness and self-directed care and encourage the use of innovative, responsibility for administering evidence-based service delivery strategies, such as expanding the a combination of competitive use of certified peer specialists and integrating primary care and innovation mental health and behavioral health care. This movement in treatment strategy, substance use grants and combined with the expanding role of affected individuals and their block grants to states, as well families in policy discussions and the decision-making process, as collecting data, conducting offers a new approach to treatment that is designed to provide the and publishing research, and right care at the right time and in the right setting. running a variety of behavioral health programs and campaigns. The roots of this movement can be traced back many decades, For more information about but were clearly articulated in the report of the New Freedom SAMHSA’s publications, grants Commission on Mental Health (created in 2002 by President and resources, visit www. George W. Bush). They have continued today in recent samhsa.gov/home.com. initiative and grant opportunities made available by SAMHSA and through services funded by Medicaid.12
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 19 Recent Federal Health Care Initiatives Impacting Behavioral Health
The New Freedom Commission and Transformation of Behavioral Health Care
In 2002, President George W. Bush created the President’s New Freedom Commission on Mental Health to study the mental health system and to identify goals and strategies that would significantly improve the lives of children and adults with serious behavioral health conditions. Despite the report being over a decade old, National Context National the New Freedom Commission’s goals address a number of issues that are still highly relevant today, including:13
· An emerging systemic shift in behavioral health services toward recovery from mental illness. · The benefits of providing opportunities to consumers and families for more self- directed care. · The importance of peer-operated programs and services. · The overall lack of access to behavioral services. · The role of stigma as a barrier to seeking treatment. · The need for housing and supported employment for persons with serious mental illness. · The complexity of the public multi-agency safety net system and how that hinders access to services. · The importance of screening and early intervention through integrated primary and behavioral health care approaches. · The need to address racial, cultural and linguistic disparities in access to care. · The increased use of technology, including telemedicine/telehealth and electronic health records, to increase access to services in rural and underserved areas and to improve provider coordination. · The need to more quickly move research-based interventions into common provider practice.
The New Freedom Commission’s philosophy and strategies have positively influenced the priorities of federal agencies, especially the Substance Use and Mental Health Services Administration (SAMHSA) and state public mental health agencies, including agencies within the Texas Health and Human Services enterprise, discussed in Section 4. Public Behavioral Health Services in Texas. Presidential Mental Health Initiatives
The Newtown shootings and other recent tragedies have again brought the conversation about mental health to the national level. On June 3, 2013, the White House hosted a National Conference on Mental Health, the first conference of this type and magnitude in 14 years, with the goal of increasing awareness and understanding of mental health services. The conference brought together an array of stakeholders, including consumers of mental health, their families, mental health
20 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas advocates, health care providers, educators, faith leaders, veterans and local, state, and federal representatives to explore how people can work together to reduce stigma and create an environment which encourages people experiencing mental health issues to seek help.
During the conference, President Obama highlighted the following four goals necessary to address challenges in the nation’s mental health system:14
· Improve the recognition of mental health issues in children and make it easier for
Americans of all ages to seek treatment. National Context · Ensure the availability of mental health treatment to those who seek it. · Invest in science and basic research to make it easier to detect and treat disease early. · Improve mental health services for troops and veterans.
The President’s National Conference on Mental Health was intended to mark the beginning of an increased national effort to address mental health concerns. Following the conference, SAMHSA launched a series of community conversations to increase understanding about mental health. 15 Part of the effort to increase open dialogue is called Creating Community Solutions (CCS). More information about CCS can be found at http://www.creatingcommunitysolutions.org/.
Over his tenure, President Obama has shown a strong commitment to supporting young people in addressing their mental health needs. The President’s FY2014 budget allocated $130 million for the following new initiatives: 1) supporting teachers and other adults to recognize signs of mental illness in students and make appropriate referrals, 2) supporting innovative state-based programs to improve mental health outcomes for people ages 16-to-25, and 3) helping train 5,000 additional mental health professionals with a focus on serving students and young adults.16 Additionally, the President’s proposed budget for 2015 includes $164 million to support the “Now is Time” initiative, which expands mental health treatment and prevention services across SAMSHA and the Centers for Disease Control and Prevention (CDC). The proposed funding for Now is the Time includes $55 million for Project AWARE (Advancing Wellness and Resilience in Education), which provides resources to enhance proper referral for children with behavioral needs to appropriate services, It also provides Mental Health First Aid training in schools and communities.
As a result of increased national attention for the mental health of U.S. veterans, the Department of Veteran Affairs (VA) hosted 150 conferences focusing on mental health and issues related to mental health throughout the country between July and September of 2013. These summits helped build or sustain collaborative efforts with community providers to enhance mental health and well-being for veterans and their families. The goal of the summits was to identify and link community-based resources to support the mental health needs of veterans and their families, as well as to help increase awareness of available VA programs and services. 17, 18
For more information about national mental health initiatives, supports and goals visit, www.mentalhealth.gov/. This website also provides tools and tips around the basics of mental health, how to recognize the signs of mental illness, how to talk about mental health, and how to locate help and other resources.
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 21 The Patient Protection and Affordable Care Act (ACA)
The 2010 Patient Protection and Affordable Care Act (ACA) includes a number of provisions that have the potential to significantly change access to both public and private mental health and substance use health care services. The law includes specific benefit requirements and more general insurance reforms that will affect all enrollees, not just those in need of behavioral health care.
KEY FEATURES
As of January 1, 2014, most provisions applying to individual and group health insurance plans had been put in place. There are a number of key features of the Affordable Care Act that seek to contribute to the overall goal of the ACA to give National Context National more Americans access to affordable and quality health insurance while reducing the amount of health care spending in the U.S. Below are the key features of the ACA.
1. Improving quality and lowering health care costs through: · Free preventive care. · Prescription discounts for seniors. · Protection against health care fraud. · Small Business Tax Credits. 2. Consumer protection: · Prohibits lifetime limits and annual limits on covered health care services. · Provides an appeals process for consumers. · Prohibits rescinding coverage once a plan has been issued. 3. Young adult coverage: · Extends dependent coverage, allowing children to stay on a parent’s policy until they reach the age of 26.
A number of the reforms are particularly important for individuals with a history of mental health or substance use conditions, including the following:
· Provides coverage for any preexisting health conditions (including mental or substanceuse). · Prohibits using health-status factors as a basis for eligibility for coverage or to denycoverage, including preexisting physical and mental illness, genetic information, receipt of health care for a prior or current condition, disability, or any other health status factor. · Requires acceptance of any applicant regardless of age, gender or health status and prohibits cancellation or non-renewal under limited circumstances (such as financial solvency issues or loss of the company’s license). · Includes comprehensive behavioral health services as required essential health benefits.
A fundamental provision of the ACA requires people to obtain insurance that meets “minimum essential coverage” requisites or pay a penalty for noncompliance. This is often referred to as the “individual mandate.” Although a number of states challenged the constitutionality of the individual mandate, in June 2012 the Supreme Court upheld this provision of the law.19
22 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas ESSENTIAL HEALTH BENEFITS
The Affordable Care Act requires that health plans sold in the 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 requirement of offering essential health benefits, a health plan must at least include items and services within the 10 essential health benefit categories, noted below. Mental health and substance use disorder services, including behavioral health treatment such as counseling and psychotherapy, are included as one of the 10 essential health benefits: National Context
· Ambulatory patient services. · Emergency services. · Hospitalization. · Maternity and newborn care. · Mental health and substance use disorder services, including behavioral health treatment. · Prescription drugs. · Rehabilitative and habilitative services and devices. · Laboratory services. · Preventive and wellness services and chronic disease Mental health and management. · Pediatric services, including oral and vision care. substance use disorder
Millions of Americans will therefore have better access to services, including behavioral health treatments, which may in turn result in higher job productivity, lower overall healthcare costs, and behavioral health treatment savings in the criminal justice system.20 such as counseling and ESTABLISHMENT OF “BENCHMARK PLANS” psychotherapy, are The ACA established a process to require that health plans adequately cover all 10 essential benefits. This process relies included as one of the 10 on the use of a “benchmark” plan that is used to set a standard of coverage for each of the 10 broad categories of essential essential health benefits. health benefits. Each state is directed to select a benchmark plan from delineated options while retaining some discretion on what specific services will be included in each essential benefit category.
The federal government has identified 10 plans from which states may select their benchmark plan: the state’s three largest small-group plans, three largest state employee health plans, three largest federal employee health plans, and the largest non-Medicaid health maintenance organization. If the benchmark plan selected by the state does not include all of the required essential health benefits, the state must supplement the missing benefits by using benefits from other benchmarks to fill in gaps in coverage. For example, if a benchmark plan does not cover maternity services, the state must select maternity benefits from another benchmark plan to supplement coverage in the state’s selected plan.
Regardless of whether a state sets up its own exchange or participates in a
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 23 federal exchange, the state will determine the benchmark plan and any required supplemental benefits. Selection of a benchmark plan and determination of essential health care benefits will strongly impact how insurers define “behavioral health services” and the specific services that will be available through the exchange.
HEALTH INSURANCE MARKETPLACE
The ACA requires every state to provide a Health Insurance Marketplace, also called the health exchange,(either federal or state-operated), through which people may purchase insurance that meets the federal standards. All health exchanges were required to be fully operational on January 1, 2014. To assist people in paying for their health insurance, the law provides subsidies in the form of tax credits for individuals and families earning between 100 percent and 400 percent of the federal poverty level. (The ACA does not extend the tax credits to individuals below 100 National Context National percent of the federal poverty level (FPL) because the law as drafted also included a requirement that states would expand Medicaid coverage to the all legal residents with incomes below 138 percent FPL.)
Consumers are able to buy approved health insurance plans from the Health Insurance Marketplace. States may opt to operate their own marketplace (state- based marketplace) or choose a hybrid called the State Marketplace Partnership wherein the federal government operates the marketplace but states are still able to run certain functions to tailor the marketplace to local conditions and needs. A state that does not choose either of the state-run options will default to a federally- facilitated marketplace, which will be operated by the U.S. Department of Health and Human Services (DHHS). During the 2013-2014 enrollment period, there were 17 state-based marketplaces, seven partnership marketplaces, and 27 federally- facilitated marketplaces.21 The State of Texas had a federally- facilitated marketplace. As of April 2014, over 8 million persons nationwide have enrolled in a health insurance plan Following release of the through the Health Insurance Marketplace, of whom 733,757 were from Texas.22 Supreme Court decision, MEDICAID EXPANSION Governor Rick Perry In addition to the individual mandate, the ACA requires states announced that Texas to expand Medicaid coverage to adults and children up to 133 percent of the federal poverty level. In Texas this expansion would not participate in would primarily cover low-income adults generally not eligible for Medicaid unless they are receiving social security the Medicaid expansion. income (SSI) as a result of a disability. The Supreme Court’s decision, however, prohibited the federal government from This decision has created a withholding Medicaid payments to states for non-compliance with the expansion provision. Consequently, states may gap in coverage for adults choose whether or not to expand their Medicaid program. If a state chooses to expand coverage, the federal government below 133 percent of the pays 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. federal poverty level. Following release of the Supreme Court decision, Governor Rick Perry announced that Texas would not participate in
24 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas the Medicaid expansion. This decision has created a gap in coverage for adults below 100 percent of the federal poverty level. See ACA in Texas Environment for more information.
Because Congress assumed that all U.S. citizens below 100 percent 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). While many of these individuals will be exempt from the individual mandate based on their financial status, they are also likely to remain uninsured since they will not be eligible for Medicaid and will be unable to afford private coverage without the subsidy. National Context
As of June 10, 2014, 27 states, including D.C. have decided to expand their Medicaid coverage. According to the Kaiser Family Foundation, 21 states decided to not move forward with the Medicaid expansion, and three states are in “open debate” (states noted as ‘Open Debate’ are based on analysis of state addresses, recent public statements made by the Governor, issuance of waiver proposals or passage of a Medicaid expansion bill in at least one chamber of the legislature). 23 It is estimated that a total of five million very low income, uninsured adults will be affected in the states that do not expand Medicaid.24 Because these five million individuals have incomes below the threshold to qualify for Marketplace premium tax credits but are not eligible for Medicaid either because their income is too high or because they don’t meet Medicaid’s categorical eligibility requirements (e.g. have a disability), they fall into a “coverage gap” and are likely to remain uninsured.25
EXPANDING THE HEALTH CARE WORKFORCE
The ACA provides incentives to address the insufficient supply of professionals providing behavioral health services. These include increasing the number of primary care physicians (who provide a great deal of behavioral health care) and educating existing primary care staff about behavioral health care. Other provisions seek to increase the supply of behavioral health professionals through loan repayment and expanded residency training programs and increased use of certified peer specialists.26 Mental Health Parity and Addiction Equity Act
In 2008, Congress enacted the Mental Health Parity and Addiction Equity Act (MHPAEA) to further expand the mental health parity requirements included in the 1996 Mental Health Parity Act. The 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 prohibits insurers or health plans that offer mental health services from imposing lower limits on the scope or duration of mental health services than those imposed on other medical or surgical services. This includes frequency of treatment, number of visits, days of coverage, or any other limits that are less than the limits imposed on coverage for physical health care.
Previously, the MHPAEA did not require that behavioral health services be included in every group plan. However, the Affordable Care Act (ACA) expanded the parity law by requiring the inclusion of mental health and substance use services as Essential Health Benefits in all group and individual health plans beginning January 2014.27 Under the ACA, mental health and substance abuse services will be treated like other
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 25 health services and insurance markets will no longer be able to exclude these services from benefit plans. Thus, more Americans will be able to receive services for the prevention, intervention and care of their mental health needs.
The Departments of Labor, Health and Human Services, and Treasury released the final MHPAEA rules in November 2013. Below are the most notable aspects of the final rules:28
· Health plans must cover the treatment of mental illness or drug or alcohol abuse at the same level (co-payments, deductibles and limits on visits to health care providers cannot be more restrictive or less generous) as they cover other health care treatment, although it does not mandate mental health benefits. · States may choose to mandate specific mental health benefits, and MHPAEA requires that such benefits must be in parity with medical/surgical benefits in the National Context National same policy. · The general parity requirement applies separately for each type of financial requirement (deductibles, co-payments, co-insurance and out-of-pocket maximums) or treatment limit. · Offers clarity on how parity applies to residential treatments and outpatient services, where much of the care for addictions or mental illness occurs. · Mental health parity provisions do not apply to coverage provided under Medicaid or Medicare.
Established Federal Health Care Programs Impacting Behavioral Health
Medicare
Over 3 million Texans get their health insurance coverage through Medicare. For these individuals, Medicare coverage is typically the deciding factor in what mental health services they will be able to access.
Medicare is a federal health care program that provides inpatient and outpatient care for individuals age 65 or older. Medicare also covers people under age 65 with certain disabilities, and people of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant).29 In 2012, 2,613,612 Texans were eligible for Medicare because of their age, while 573,720 were eligible for Medicare because of a disability.30 The program also provides prescription drugs for individuals who enroll. The program is funded and administered by the federal government and is divided into four coverage areas (parts A, B, C and D), described below.
26 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Medicare Coverage Areas Related to Mental Health Part A (Hospital Medicare Part A provides inpatient hospital insurance and covers inpatient mental Insurance) health care if provided in a general or psychiatric hospital. The care includes semi-private rooms, meals, nursing, medication as part of the inpatient treatment, and other related services and supplies. Part A pays for up to 190 days of inpatient psychiatric care during a lifetime. Most Americans over age 65 automatically qualify for Part A based on their work history and payroll deductions for the program. People who do not qualify can pay
to enroll. National Context Part B (Medical Medicare Part B covers outpatient diagnostic and treatment services provided by Insurance) physicians, including psychiatrists, as well as clinical psychologists, social workers, psychiatric nurse specialists, nurse practitioners, and physician assistants. Medicare reimburses these clinicians only if they are certified as participants accepting Medicare. Medicare covers mental health diagnostic and lab testing, a yearly depression screening, psychiatric evaluations, individual and group psychotherapy, family counseling that relates to the individual’s treatment, and medication management. Substance use treatment in an outpatient treatment center is covered if the treatment center has agreed to participate in the Medicare program. Medicare also covers partial hospitalization programs including those that offer intensive psychiatric treatment. Medicare reimbursement is limited to partial hospitalization programs that are located in hospital outpatient departments or community mental health centers. Partial hospitalization services must be provided under the direct supervision of a physician according to an individualized treatment plan, and the services must be essential for treatment of the person’s condition. Individuals must actively enroll in Part B and must pay a monthly premium. For low-income individuals who qualify, Medicaid pays the monthly premium. Part C (Medicare Medicare Advantage is run by Medicare-approved private insurance companies. It Advantage) is not available statewide, but is offered in most urban areas of Texas. Availability depends on the willingness of managed care organizations in a particular geo- graphic area to provide Medicare Advantage. Part C includes all benefits from Part A and Part B, and it often includes benefits from Part D. Enrollees volunteer to participate in Part C. In addition to a Part B premium, Part C participants may pay a monthly premium for their Medicare Advantage Plan. Medicare Advantage plans may offer extra coverage for vision, hearing, dental, and health and wellness programs. Medicare Advantage Plans must follow Medicare rules, but they may charge different out-of-pocket costs and have additional rules. Part D (Medicare Medicare Prescription Drug Coverage was created in 2003 and is available to all Prescription Drug Medicare eligible individuals, but requires premium payments that vary depending Coverage) on the plan the enrollee selects. Medicare drug plans must cover antidepressant, anticonvulsant and antipsychotic medications that may be necessary for mental health treatment. For dual eligible enrollees in both Medicare and Medicaid, prescription drug benefits are paid primarily under Part D, but Medicaid continues to pay some drugs not covered by Part D. Source: Texas Health and Human Services Committee. (2013, January). Texas Medicaid and CHIP in Perspective. Retrieved from http:// www.hhsc.state.tx.us/medicaid/about/PB/PinkBook.pdf
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 27 While Medicare covers a broad array of mental health services, special rules limit the scope of coverage and reimbursement. Medicare coverage of mental health benefits is not as extensive as coverage for other services. Though some benefits are arranged through Medicaid, a state-run program, the Medicare program is funded and administered by the federal government. Medicare and Medicaid (Dual Eligibility)
People who are eligible for both Medicare and Medicaid, commonly referred to as being dually eligible, typically have lower income and greater functional disability than other Medicare beneficiaries. Older people who are eligible for both programs are more likely to have physical health problems than those who are eligible only for Medicare. People less than 65 years of age who meet eligibility criteria for both Medicare and Medicaid are less likely to have physical health problems but much National Context National more likely to have a mental health condition than people who meet dual eligibility and are over 65 years old.31
If a person is eligible for both Medicare and Medicaid, Medicaid pays the Medicare cost-sharing obligations and provides certain Medicaid Medicaid is a jointly services not covered under Medicare. Dual eligible individuals can funded federal/state be fully or partially dual eligible. Fully dual eligible individuals have a health care program lower income and receive their state’s full Medicaid package. Partially authorized in Title XIX dual eligible individuals have a higher income than fully dual eligible of the Social Security and receive some assistance with Medicaid premiums, deductibles, Act. It was created as a and cost-sharing responsibilities but do not receive their state’s full way to provide health Medicaid package. In 2010, 7,267,210 individuals were fully dual eligible care benefits primarily to nationally.32 In 2012, 328,500 people were fully dual eligible in Texas.33 children in low-income families, pregnant Medicare and Medicaid are two separate systems that often do not women, and people with communicate information about a person’s care with each other. This disabilities. directly affects people who are dual eligible because their care is not
Visit the HHSC section in Public Behavioral coordinated between the two systems. According to the Centers for Health Services in Texas and www. Medicare & Medicaid Services, this fragmented system of care has medicaid.gov, for more information on compromised the quality and efficiency of care for many people who Medicaid and the State Medicaid Program. are dual eligible. Additionally, the lack of coordination between the two structures has caused a financial misalignment.34
Figure 1 details the number of Texans enrolled in Medicare and the number of Texans that are fully dual eligible.
Figure 1. Texas Medicare Enrollment and Fully Dual Eligible
2010 2011 2012 Total Medicare 2,852,000 3,044,936 3,187,332 Fully Dual Eligible 396,649 327,530 328,500 Sources: Kaiser Family Foundation. (2012). Texas: Medicare enrollment. Retrieved from http://kff.org/medicare/state-indicator/dual- eligible-beneficiaries/?state=TX, Millwee, B. (2012). Texas dual eligible integrated care demonstration project: Application. Retrieved from Centers for Medicare and Medicaid website: http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid- Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/TXProposal.pdf
28 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Texas Dual Eligibles Integrated Care Demonstration Project
To address the concerns of the fragmented system that dual eligible people have to navigate, the Centers for Medicare & Medicaid Services (CMS) is working 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.35
On May 23, 2014, Texas and CMS entered a partnership to test a new model intended National Context to better coordinate and provide a more person-centered care experience for dual eligible individuals.36 This demonstration project is called “Texas Dual Eligibles Integrated Care Demonstration.”37 Texas and CMS will contract with managed care organizations to work toward the goal of a more enhanced, coordinated system for fully dual eligible individuals who reside in specific parts of the state. The demonstration project will begin no sooner than March 1, 2015.38
All of the following criteria must be met to participate in the Texas demonstration project:39
· Age 21 or older at the time of enrollment. · Entitled to receive Medicare Part A, and enrolled in Medicare Parts B and D. · Receiving full Medicaid benefits. · Receiving services through the STAR+PLUS program. · Residing in one of the following counties: Bexar, Dallas, El Paso, Harris, Hidalgo, or Tarrant. See Figure 2 below.
Figure 2. Texas Dual Eligibles Integrated Care Demonstration
Source: Traylor, C., & Ghahremani, K. (2014). Presentation to the Senate Health and Human Services Committee: SB 7 implementation [PowerPoint slides]. Retrieved from https://www.hhsc.state.tx.us/news/presentations/2014/SB-7-implementation.pdf
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 29 For more information about the Texas Dual Eligibles Integrated Care Demonstration Project, view the Memorandum of Understanding (MOU) between the CMS and Texas at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare- and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/ FinancialAlignmentInitiative/Downloads/TXMOU.pdf Supplemental Social Income (SSI) and Social Security Disability Insurance (SSDI)
Supplemental Social 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 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 National Context National taxes. In most states, including Texas, individuals who receive SSI benefits are also immediately eligible for Medicaid under the same eligibility requirements. In 2011, the nation had 8,112,773 SSI beneficiaries and Texas had 640,422 SSI beneficiaries.40 The monthly maximum SSI federal amounts for 2014 are $721 for an eligible individual and $1,082 for an eligible individual and an eligible spouse. In January 2013, 8.3 million individuals received monthly SSI benefits averaging $536.41
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 paid enough money into the Social Security program. In 2012, the total number of SSDI beneficiaries was 9,306,256 nationally and 610,328 in Texas.42 The national average monthly benefit for SSDI recipients in 2012 was $1,078.83.43 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.
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 3 below details the major difference between the two programs.
30 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Figure 3. SSI and SSDI Differences
Program Supplemental Social Income (SSI) Social Security Disability Insur- ance (SSDI) Funding Financed through general revenue from Financed through Social Security taxes. Benefits are not based on prior work taxes paid by workers, employers history. and self-employed persons. Eligibility Have limited income and resources to meet Worker must earn sufficient
cost of living. Must be a U.S. citizen or have credits based on taxable work National Context eligible noncitizen status. to be insured for Social Security purposes.
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 -widow(er)s -adults who have had a disability since childhood
Payment Payment amount varies up to the maximum Payment amount is based on the federal benefit rate, which may be supple- Social Security earnings record of mented by the state. the insured worker. Source: The United States Social Security Administration. (2012). Federal Benefit Rates, Total Annual Payments, and Total Recipients. Retrieved from http://www.ssa.gov/policy/docs/statcomps/ssi_asr/2012/sect01.pdf
The United States Social Security Administration. (2012). Texas SSI. Retrieved from http://www.ssa.gov/policy/docs/statcomps/ ssi_sc/2012/tx.pdf
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 31 National Context National
32 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas The Texas Environment The TexasEnvironment
A primary barrier to effective and efficient mental health services in Texas is the fragmentation of services and lack of coordination among multiple funding silos. Texas should carefully evaluate all of the opportunities to improve behavioral health services to ensure the development of a comprehensive and cohesive system. Toward this end, a number of major initiatives and reform efforts that could impact behavioral health service delivery and financing are being implemented or are currently under consideration. It is critical that these initiatives and opportunities are considered in the context of the entire state system and not in isolation.
Impact of the Affordable Care Act on Behavioral Health Services in Texas
Federal Health Insurance Marketplace
Open enrollment in the federal Health Insurance Marketplace began on October 1, 2013. The federal Health Insurance Marketplace, or Healthcare.gov, is an online portal where individuals and small businesses can buy qualified health benefit plans in a new, transparent and competitive insurance marketplace. Prior to the marketplace opening, states had the choice to develop their own marketplace, use the federal marketplace, or use a system that involves collaboration between the state and the federal government. Texas elected to use the federal marketplace. Texas has the option to move to a state partnership or state-based marketplace at any time, and can do so through either legislation or an executive order from the Office of the Governor. Approximately 733,757 Texans signed up for health insurance through the federal marketplace during the first enrollment between October 1, 2013 and March 31, 2014.44,45 Open enrollment for 2015 starts November 15th, 2014.46
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 33 Plans in the marketplace are divided into five categories: catastrophic, bronze, silver, gold, and platinum. Catastrophic plans are only available to people under the age of 30 or those eligible for a hardship exemption. Hardship exemptions are granted to people based on income or other factors that prevent an individual from accessing health care coverage. Each type of plan pays a different percentage of the average overall cost of 733,757 Texans signed up for providing essential health benefits to members. The overall health insurance through the cost includes the insurance plan’s monthly premium, federal marketplace during the deductibles, copayments, coinsurance, and out-of-pocket first enrollment between October maximums. The average amount each type of plan pays are as 1, 2013 and March 31, 2014 follows: catastrophic, less than 60%; bronze, 60%; silver, 70%; gold, 80%; platinum, 90%.47 The actual percentage a person pays in total or per service depends on the services used in a year. In general, individuals pay a higher monthly premium for gold and platinum plans but pay less of the cost when services are used. With bronze, silver, and catastrophic plans, individuals have a lower monthly premium but pay more of the cost when services are used. Individuals whose income is less than 250% of the federal poverty level can also get additional assistance in paying for out of pockets costs, such as copayments. Purchasing the Silver Plan is required to access this additional assistance.
Figure 4 shows the average costs of silver plan premiums and all category plan premiums that Texans paid in 2014. Figure 5 breaks down the costs of monthly premiums and shows the percentage of Texans within specific ranges of monthly
The Texas Environment Texas The premium costs paid in 2014.
Figure 4. Federal Marketplace in Texas: Silver Plan Averages and All Catego- ries Averages Monthly Premium Costs
Average Average Average Tax Average Per- Percent of Monthly Pre- Monthly Credit Amount cent Reduction Individuals mium Before Premium After in in Premium Who Selected Tax Credit Tax Credit after Tax Credit Account with Tax Credits Silver $314 $68 $246 78% 94% All Categories $305 $72 $233 76% 84% Source: U. S. Department of Health and Human Services. (2014). Premium affordability, competition, and choice in the health insurance marketplace, 2014. Retrieved from http://www.aspe.hhs.gov/health/reports/2014/Premiums/2014MktPlacePremBrf.pdf
34 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Figure 5. 2014 Federal Marketplace in Texas: Percentage of Individuals Sepa- rated by Monthly Premium Costs After Tax Credits
$50 or less $51-$100 $101-$150 Greater than $ 150 Percent 50% 24% 12% 14% Source: U. S. Department of Health and Human Services. (2014). Premium affordability, competition, and choice in the health insurance marketplace, 2014. Retrieved from http://www.aspe.hhs.gov/health/reports/2014/Premiums/2014MktPlacePremBrf.pdf
Texas Department of Insurance and Rules for Navigators
Under the Affordable Care Act (ACA), the federal government provides training, certification, and funding for navigators to help people enroll in health insurance through the Health Insurance Marketplace. Navigators provide important assistance to individuals who are trying to understand their health insurance options, some for the first time. The TexasEnvironment
Effective on September 1, 2013, SB 1795 of the 83rd Legislative Session (Watson) directed the Texas Department of Insurance (TDI) to determine if federal navigator regulations were sufficient to ensure navigators could perform their required duties. If not, TDI was to establish state standards and qualifications.48 In December 2013, TDI released proposed rules for navigators that many health care advocates felt were restrictive and burdensome.49 After receiving feedback from community stakeholders, TDI made revisions to the proposed rules and released final rules for navigators that went into effect on February 10, 2014.50 Advocates felt that many of the changes were helpful, but were still concerned about the timeline imposed on navigators. These rules required navigators to complete registration with TDI by March 1, 2014.51 It also required navigators to complete 20 hours of state mandated training in addition to the 20-30 hours of federal training required for federal navigators by May 1, 2014.52 Medicaid Expansion
Texas elected not to expand Medicaid in 2013, an option available to all states through the ACA. During the 83rd legislative session legislators failed to pass any Medicaid expansion initiatives. Specifically, HB 3791 (Zerwas), known as the “Texas Solution,” attempted to create a state alternative to Medicaid expansion. This bill would have pulled down federal health care funds to subsidize private health insurance for low income individuals. Parties interested in a “Texas Solution” contend that any agreement reached for the expansion of Medicaid would allow the state to develop a tailored insurance product for the expansion population that could leverage private markets by building on Texas’ current Medicaid managed care model.
ACA Medicaid expansion would provide coverage to people with incomes up to 138% of the federal poverty level, an annual income of about $32,900 for a family of four in 2014.53,54 In states that expand Medicaid, the federal government pays 100% of the increased cost through 2016 and no less than 90% of the increased cost after 2019.55 By choosing not to expand Medicaid, Texas may be missing out on as much as an estimated $100 billion federal dollars between 2013 and 2023.56 As of June 2014,
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 35 27 states (including the District of Columbia) were in the process of implementing Medicaid expansion, 3 states were having open debates, and 21 states were not moving forward with Medicaid expansion.57
Advocates argue that whether by expanding traditional Medicaid or developing a “Texas Solution,” the available federal health care funds could benefit Texas taxpayers in the following ways:
· “Save local property tax dollars that currently cover local health programs and unpaid emergency room bills for the uninsured. · Reduce insurance premiums that currently compensate for the high number of uninsured and unhealthy Texans. · Create more than 200,000 jobs in three years, including many high-paying health jobs. · Prevent Texas employers from paying tax penalties that could total $339 million for failing to insure their employees. · Provide insurance for low-wage workers who typically don’t have access to preventive care, mental health services, cancer treatment, and other services that save lives and money. · Provide insurance for more t han 66,000 veterans and their spouses. · Prevent an estimated 9,000 deaths per year. · Ensure healthier workers, healthier parents raising children, and healthier mothers deliver healthier babies.”58
In addition, the National Association of State Mental Health Program Directors
The Texas Environment Texas The (NASMHPD) points out that if Medicaid were expanded, many of the individuals receiving state funded mental health and substance use services could receive Medicaid, increasing the amount of general revenue available to support other state priorities. 59
In addition to providing states the option to expand Medicaid, the ACA, as noted previously, provides premium subsidies through tax credits for people with an income between 100%-400% of the federal poverty line to buy private health insurance on the Health Insurance Marketplace. However, since childless adults do not qualify for Medicaid at any income level and those who are parents are eligible only if their income is below 15% of the federal poverty level (3,577.50 for a family of four), over one million adult Texans who have an income less than 100% of the federal poverty line fall do not quality for premium tax subsidies or Medicaid coverage. This is known as the “coverage gap.”60 The American Mental Health Counselors Association estimates that nearly a quarter of all individuals eligible for Medicaid In addition, the National Association of expansion or an alternative solution have a mental State Mental Health Program Directors health or substance use condition.61 (NASMHPD) points out that if Medicaid were expanded, many of the individuals In addition to the benefits people with mental receiving state funded mental health health conditions receive from timely treatment, and substance use services could receive increasing access to health care coverage for those Medicaid, increasing the amount of falling in the gap can have a positive economic general revenue available to support other impact on Texas. Untreated mental health state priorities. conditions can lead to expensive crisis and inpatient care for those who are uninsured, as opposed to less costly preventive care available to individuals with health coverage.62
36 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Health Homes
Section 2703 of the ACA allows states to amend their Medicaid plans to provide care coordination services through health homes for beneficiaries with chronic conditions, including serious and persistent mental health conditions. This section of the ACA provides an opportunity for states to improve care by providing federal funding for certain Medicaid-covered health home services, including comprehensive care management, care coordination, health promotion, comprehensive transitional care, beneficiary and family support services, and referral to community and social support services.63 A health home can be a health team or a single provider within a team of health professionals. The health home services should provide a holistic care approach for individuals with multiple chronic health conditions or serious and persistent mental health conditions.A Commonwealth Fund study found, even before the Centers for Medicare and Medicaid Services (CMS) issued guidance, “the health home initiative attracted great interest across states, with the majority of state Medicaid directors indicating on a nationwide survey that they would likely establish health homes under this new authority.”64 As The TexasEnvironment of June 2014, 30 states have established or are planning to Preliminary data establish a home health system.65 Implementation of Medicaid health homes is still in the beginning stages, but data concerning people from Missouri’s health home initiatives suggest improved health care outcomes. Preliminary data concerning people enrolled in Missouri’s enrolled in Missouri’s health home initiatives showed a reduction in hospital admissions by 12.8% per 1,000 people health home initiatives and a reduction in ER usage by 8.2% per 1,000 people during the first year of implementation in 2012.66 This same showed a reduction preliminary data revealed a net savings of approximately $82 per member per month.67 This data suggests that health in hospital admissions homes have the potential to reduce state dollars spent on Medicaid services. by 12.8% per 1,000
Texas has not established health homes through the people and a reduction ACA, but health homes have been created as a part of Medicaid managed care organizations (MCOs). During the in ER usage by 8.2% 82nd Legislation Session in 2011, SB 7 (Nelson) required Medicaid MCOs to provide health home services, such as per 1,000 people comprehensive care coordination, family-centered care, and data management.68 However, without seeking a Medicaid during the first year State Plan Amendment to add the health home benefit to the Texas Medicaid plan, Texas cannot draw down the additional of implementation in federal match for these health home services. 2012. More information on the Affordable Care Act is available in the National Context section.
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 37 Behavioral Health Implications of Health and Human Service Initiatives
Medicaid Managed Care Expansion in Texas
In recent years, Texas Medicaid has moved towards the managed care approach in an attempt to improve service delivery and access to healthcare services for Medicaid recipients. Under the Medicaid managed care system, the Health and Human Services Commission (HHSC) contracts with managed care organizations (MCOs) to arrange, manage and deliver acute and long-term services and supports (LTSS) for Medicaid beneficiaries. HHSC pays the MCO a “capitated” or predetermined rate for each member enrolled every month, eradicating the traditional fee-for-service payment method. A Medicaid recipient chooses a health plan or MCO and receives services through the health plan’s coordinated network of providers. The health plan must provide all required services and assumes the financial risk if actual costs exceed the capitated rate paid by HHSC.
There are six Texas Medicaid managed care programs available or under development for differing populations, including: STAR, STAR Health, STAR+PLUS, NorthSTAR, CHIP, and STAR Kids (beginning in September 2016). For more information about
The Texas Environment Texas The these managed care programs refer to Figure 14 in the HHSC section.
Several initiatives have resulted in the growth of the managed care system in Texas. The Texas Healthcare Transformation and Quality Improvement Program, known as the 1115 Transformation waiver, is a five-year demonstration waiver beginning in 2011 that has transitioned nearly 1 million Medicaid enrollees from the traditional fee-for-service Medicaid into privately run managed care plans. The 1115 waiver expanded STAR and STAR-PLUS programs to new areas of the state and extended managed care’s role in the delivery of the prescription drug benefit. As a result of the 1115 waiver, managed care has become the primary vehicle through which most Medicaid recipients receive services. More information on the 1115 waiver is available below in 1115 Waiver: Texas Health Care Transformation and Quality Improvement Program. Additionally, during the 83rd legislative session in 2013 the Texas Legislature furthered the expansion of the Medicaid managed care system, most significantly through SB 58 (Nelson) and SB 7 (Nelson) described below. (See HHSC and DADS for a more in-depth look at these bills.)
SENATE BILL 58 (SB 58)
SB 58 requires targeted case management and mental health rehabilitative services to be integrated into Medicaid managed care with the goal of better care coordination for individuals enrolled in Medicaid. Prior to SB 58, Medicaid managed care already included several mental health services, such as medication management, counseling, and physician services. However, targeted case management and rehabilitative services for people with Medicaid were managed through local mental health authorities (LMHAs), not through MCOs. The delivery of services from two different systems made it difficult to seamlessly coordinate physical and behavioral
38 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas health treatment for individuals requiring both health services.
SB 58 requires MCOs to develop a network of providers for behavioral health services and ensure availability of services for adults with serious mental illness and children with serious emotional disturbance. SB 58 also requires HHSC and DSHS to develop the Behavioral Health Integration Advisory Committee. This committee must include people who have experience and/or expertise in the behavioral health field such as consumers, MCO representatives, public providers, private providers, Medicaid providers, and Medicaid-Medicare dual eligible providers. The committee has been tasked with addressing the planning and development of the behavioral health services network, seeking input from the behavioral health community for the implementation of SB 58, and issuing formal recommendations to HHSC.
SENATE BILL 7 (SB 7)
SB 7 is a multifaceted piece of legislation generating major system delivery changes that also significantly expand Texas Medicaid managed care. Major managed care expansion efforts mandated by SB 7 include: 1) expansion of STAR+PLUS Medicaid The TexasEnvironment Rural Service Areas (MRSA), 2) nursing facility carve-in, and 3) integration of acute care for adults with intellectual and developmental disabilities (IDD).
As a result of the legislation, by September 2014 STAR+PLUS will expand statewide (adding 164 rural counties) to deliver acute and long-term services and supports through the managed care system. Currently, 412,000 are being served by STAR+PLUS.69 An estimated 80,000 additional members will be served due to the STAR+PLUS expansion. By March 2015, approximately 56,800 nursing facility residents will transition into STAR+PLUS. The goal of the carve-in is to improve the quality of care in the least restrictive and most appropriate setting. Additionally, adults with IDD receiving services in community-based Intermediate Care Facilities (ICF- IDD) and/or individuals receiving services in certain DADS 1915(c) waiver programs will transition into STAR+PLUS for acute care services. Children with disabilities under the age of 21 are exempted from this requirement and may continue to receive acute care services through a fee-for-service delivery option until the implementation of STAR Kids or they may voluntarily elect to enroll in STAR+PLUS. Acute care services include physician visits, short term hospital stays and urgent care.70
SB 7 also requires the development and implementation of one or more managed care capitation pilots for delivery of long term services and supports for people with IDD no later than September 2016; the development of a cost effective option for delivery of attendant and habilitation services through the STAR+PLUS program (Community First Choice); and the establishment of the STAR Kids capitated managed care program to provide Medicaid benefits to children with disabilities not voluntarily enrolled in STAR+PLUS. Implementation of the STAR Kids program is currently scheduled for September 1, 2016. In addition, the legislation establishes multiple advisory committees to make recommendations relating to implementation of these changes.
The above is a listing of some of the major components of SB 58 and SB 7. For more information about the bills and to view copies of the legislation visit www.capitol. state.tx.us. Additionally, a copy of the Hogg Foundation summary of the legislation can be found www.hogg.utexas.edu/uploads/documents/83rd%20Lege%20 Summary3.pdf.
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 39 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 wavier of certain federal Medicaid regulations under section 1115 of the Social Security Act. This waiver is granted to states that apply in order to test alternate methods of financing and delivering Medicaid. The aim of the program is to improve managed care delivery while maintaining hospital supplemental payments. The five-year Medicaid 1115 demonstration waiver, also known as the Texas Healthcare Transformation and Quality Improvement Program, will run from September 2011 to September 2016.
The waiver creates two different funding pools– the Uncompensated Care (UC) and the Delivery System Reform Incentive Payment (DSRIP) pool – with funds totaling $29 billion over the five-year period.71 The UC Pool will replace upper payment limit funding for hospitals and will offset costs by allowing hospitals to receive payments for uncompensated care for Medicaid eligible patients and other uninsured patients. Funding through the DSRIP incentivizes the improvement of healthcare delivery systems through the creation of regional healthcare partnerships (RHPs). The goal of the 1115 waiver is to provide funding necessary to develop innovative care models focused on improving care for individuals, overall health and the efficiency of healthcare service delivery in the state. In order to receive funding from the DSRIP pool, projects must meet their project-specific performance metrics. Metrics
The Texas Environment Texas The 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.
The waiver creates 20 RHPs across Texas. As of August 2014, The goal of the 1115 there were 1,491 approved and active DSRIP programs across the RHPs.72 RHPs are local collaborations that fund the state waiver is to provide share of all waiver payments. Counties and other entities providing the state share will determine how their funds funding necessary to are used in the RHP consistent with waiver requirements. Each provider able to provide local match retains control develop innovative of its own fund use and commitments. While RHPs cannot dictate how local match is provided or how it is used, local care models focused matches are expected to promote collaboration and system transformation (improved access, quality, cost-effectiveness, on improving care for and coordination).
individuals, overall health Mental health services are being significantly expanded under the waiver. Texas made behavioral health a priority and the efficiency of by allocating 10% of the DSRIP funds to community mental health centers and including many behavioral health-focused healthcare service delivery project options in the DSRIP menu.73 Importantly, the waiver creates the option for local communities to expand behavioral in the state. health services without having to conform to the narrow eligibility requirements that exist for state-funded services in local mental health centers. In Texas, currently all 39 LMHAs
40 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas are participating in the program, and there are around 400 behavioral-health related projects.74 These projects are eligible to earn up to $937 million in DSRIP payments in the period from October 2012 to September 2014.
Examples of current behavioral health projects include additional crisis intervention response teams, the establishment of campuses for children with emotional problems and developmental delays, the integration of behavioral health into obstetrics outpatient services for the treatment of postpartum depression, and the integration of primary care and substance abuse services. Examples of performance metrics for behavioral health projects may include showings of reduced admission/ readmission into the criminal justice system, reduced emergency department visits, and improved quality of life.75
The DSRIP projects are still in their early implementation phase; it is expected that more will be known about the efficacy and success of the projects in the next two years as data on performance metrics becomes available.
1915(i) State Plan Amendment: Home and The TexasEnvironment Community-Based Services—Adult Mental Health Program (HCBS-AMH)
DSHS was granted an exceptional funding request during the 83rd Legislative Session through Rider 81, Home and Community-Based Services, and was appropriated approximately $2.7 million for FY 2014 and $5.2 million for FY 2015 from general revenue funds.76 These funds are to develop a Home and Community-Based Services (HCBS) program for adults with complex needs and extended or repeated stays in state inpatient psychiatric hospitals. The funds will also be used for DSHS to seek federal approval from Centers for Medicaid and Medicare Services (CMS) for a Medicaid 1915(i) State Plan Amendment to allow federal financial participation in the HCBS program. DSHS informally submitted the state plan amendment for the programto the CMS early in 2014 and received feedback. In the summer of 2014, DSHS worked with HHSC to refine the state plan amendment based on the feedback from CMS and formally to submit the plan to the CMS. DSHS hopes to receive approval from CMS and to begin the HCBS-AMH by late fall of 2014.77
With appropriated funds, DSHS will establish the HCBS-AMH as a mechanism to address issues in the psychiatric hospital system. Some individuals are forced to remain in inpatient facilities after they no longer need acute inpatient services due to the lack of community options. HCBS-AMH will provide a variety of support services to these individuals so their needs can be met in the community, instead of an inpatient psychiatric hospital. Individual homes, apartments, adult foster homes, assisted living facilities, and small (3-4 beds) community-based residences are all considered home and community based settings where HCBS-AMH services can be provided.
The Medicaid Services Unit at DSHS will administer the HCBS-AMH program. DSHS will contract with provider agencies using an open enrollment process to perform initial and ongoing independent assessments and evaluations of candidates and enrollees, oversee quality assurance, recruit and enroll HCBS-AMH providers, manage claims payment, and conduct program oversight.
The HCBS-AMH program is anticipated to serve a maximum of 106 people at any
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 41 point in time.78 In order to receive services, these individuals must demonstrate that HCBS-AMH will help them maintain stability, improve functioning, prevent relapse to an acute inpatient level of care, and maintain residence in the community. Eligibility will be determined by an individual assessment and history of extended inpatient psychiatric commitments. DSHS anticipates that many of these individuals will have a history of unstable housing/homelessness, co-occurring physical illness, cognitive-related issues, and low/no family support.
HCBS-AMH services will be individualized so that participants will receive the specific support they need. This process will be facilitated through an individualized recovery plan (IRP). A recovery manager will be responsible for creating the IRP. A team, including the individual, will actively participate in the development of the IRP. The individual receiving services will have the ability to choose who will be a part of their recovery team. This may include significant others, friends, families, providers, and others to be on their team. DSHS will perform quality assurance reviews of IRPs to ensure the IRPs are individualized and to address goals and needs that were identified by the individual and an assessment. IRPs will be reviewed annually with the ability to be revised as needed between the annual reviews.
The following array of services will be provided through HCBS-AMH:79 · Adaptive aids · Community-based residential assistance services · Community psychiatric supports and treatment peer support · Employment assistance
The Texas Environment Texas The · Home delivered meals · Minor home modifications · Nursing · Recovery management · Rehabilitation service · Respite care (short term) · Substance abuse services · Transition assistance · Transportation services
In addition to these services, other state plan services will be provided as medically necessary and will be coordinated with the HCBS-AMH services. For more information about these services or HCBS-AMH, visit www.dshs.state.tx.us/mhsa/hcbs-amh/. Health and Human Service Commission Sunset Review
For the first time since 1999, the Health and Human Services Commission (HHSC), along with the state agencies regulated by HHSC (DSHS, DARS, DFPS and DADS), are under review by the Texas Legislature per requirement of the Texas Sunset Act. The Act, created in 1977, mandates the Sunset Advisory Commission, comprised of ten legislators and two public members, to periodically evaluate state agencies in order to determine that an agency’s functions are still needed and that they operate efficiently and effectively. Over the two-year Sunset reauthorization process, the Sunset Commission staff closely research the agencies, looking for needs, strengths and potential improvements. The Commission will report agency recommendations to the 84th Legislature. The Legislature will in turn make final determinations about
42 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas the agencies’ continuation or changes in agency structure and/or operation. Figure 6 details the sunset evaluation process and Figure 7 provides a general timeframe and sequence of events for the agencies up for review in 2015.
Figure 6. Sunset Evaluation Process The TexasEnvironment
Source: Sunset Advisory Commission. (2013). Sunset in Texas. Retrieved from https://www.sunset.texas.gov/public/uploads/files/ reports/Sunset%20in%20Texas%202013-2015.pdf
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 43 Figure 7. Sunset Evaluation Timeframe
September 2013 Agencies submit Self-Evaluation Reports.
October 2013 to January Sunset Commission conducts extensive research and analysis in order to 2015 evaluate agencies and prepare reports. Sunset Commission holds public hearings and makes decisions. February 2015 Sunset Commission submits reports to the 84th Legislature with recom- mendations on each agency under review. February 2015 to May 2015 84th Legislature considers reports and makes final determinations Source: Sunset Advisory Commission. (2013). Sunset in Texas. Retrieved from https://www.sunset.texas.gov/public/uploads/files/ reports/Sunset%20in%20Texas%202013-2015.pdf
For more information on the Sunset process and the Commission’s roles and responsibilities, visit https://www.sunset.texas.gov. To view the Commission’s agency recommendations on HHSC, DADS, DFPS, DSHS and DARS, visit page 318. Mental Health Workforce Shortages
People experiencing mental illness can achieve recovery and wellness when appropriate mental health services and supports are available. Through recovery, they can live meaningful, productive lives in their community. Recovery, however, does not happen in isolation. It may require treatment and support from family,
The Texas Environment Texas The friends and mental health professionals such as psychiatrists, licensed professional counselors, social workers, psychologists, psychiatric nurses or advance practice registered nurses, and certified peer-to-peer specialists and community health workers. These professionals have specialized education, training and skills to serve a broad range of mental, behavioral, emotional and psychosocial needs.80
The individual and societal benefits of achieving mental wellness are obvious. The economic value of providing appropriate mental health services can be measured in avoided costs to hospitals and criminal justice and juvenile justice systems and improved workplace productivity.81 The need for mental health services is high. Nationally, 46.4% of adults experience mental illness in their lifetime and 26.2% of adults experience mental illness annually. On an annual basis, 5.8% of adults in the United States experience a serious mental illness.82 Nationwide, only 39% of persons with mental illness receive needed mental health treatment.83
As of November 2013 and shown in Figure 8, 207 of Texas’ 254 counties in Texas were designated by the federal government as whole or partial Health Professional Shortage Areas for mental health.84 Factors contributing to the critical shortages include limited education opportunities, high turnover, an aging mental health workforce, insufficient diversity, low compensation and an inadequate reimbursement system.
44 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Figure 8. Federally Designated Mental Health Professional Shortage Areas as of November 2013 The TexasEnvironment
Source: Texas Department of State Health Services. (2014). The mental health workforce shortage in Texas. Retrieved from https://www. google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CB0QFjAA&url=https%3A%2F%2Fwww.dshs.state.tx. us%2Fmhsa%2Fannouncements%2FHB1023_Final.doc&ei=0c-pU-yVGIycqAad24HgAw&usg=AFQjCNHDpebUBePZuUQPG8KruBSg 43QTUA&bvm=bv.69620078,d.b2k
The information below provides an overview of the current workforce of mental health professionals and the challenges they face in providing services to a growing population with complex conditions. It includes strategies for addressing the problem and a discussion of future needs that must be addressed to ensure Texans have access to the mental health services they need.
WORKFORCE AVAILABILITY IN TEXAS
While the population in Texas has increased and become more diverse and health care needs have grown more complex, the As of November 2013, supply of mental health professionals has not kept pace.85 As of November 2013, 207 of Texas’ 254 counties in Texas were 207 of Texas’ 254 counties designated by the federal government as whole or partial Health Professional Shortage Areas for mental health.86 were designated by the Even when accounting for psychiatrists and other related professions such as clinical psychologists, psychiatric nurses, federal government as clinical social workers, licensed professional counselors, and family therapists, (often referred to as Core Mental Health whole or partial Health Professions) 23.3% of the 2013 Texas population lived in 199 different counties with mental health workforce shortages.87 Professional Shortage
Factors that contribute to and exacerbate the mental health Areas for mental health. workforce shortage in Texas include:88
· An aging workforce that is beginning to retire. · Recruitment and training challenges for mental health professionals.
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 45 · Lack of Texas mental health professional internship sites. · Inadequate pay and reimbursement rates in the public mental health system. · Lack of cultural and linguistic diversity in the workforce, causing a significant shortage of mental health providers with the knowledge, training and skills to serve people who speak languages other than English or are of racial or ethnic minority populations. · Increasing demand for behavioral health services.
Culturally competent and linguistically diverse mental health professionals are particularly difficult to access in Texas.89 As of 2013, 65.5% of all psychiatrists were white, 5.3% were African American, and 12.4% were Hispanic.90 A 2011 report by the Hogg Foundation for Mental Health and Methodist Healthcare Ministries states that “without cultural competency in treatment, recovery and wellness can remain unreachable for many people with mental illness.” The problem is especially apparent in Hispanic communities along the border, where residents juggle two languages and cultures. Urban areas like Houston and Dallas struggle to meet demands of a diverse population that often includes a large number of immigrants and minorities.
The supply of health professionals in rural and border areas is even lower than in urban and non-border areas. As of September 2013, there were 1,393 active licensed psychiatrists in Texas who were offering direct patient care. This ratio equals approximately 13,394 Texans per psychiatrist.91 However, psychiatrists are disproportionality located in metropolitan counties: Harris, Dallas, Tarrant, Bexar, and Travis. Non-metropolitan, border areas have a population of 126,821 persons
The Texas Environment Texas The per psychiatrist.92 The majority of rural Texas lacks psychiatrists, primary care physicians, pediatricians, obstetricians, gynecologists and other providers.93 The difficulty of recruiting doctors to rural areas means many people must often travel long distances for even basic health care services that could prevent more costly illnesses in the future.
BEHAVIORAL HEALTH PROFESSIONALS IN TEXAS
Mental health services in Texas are provided by a number of different mental health professionals including:94
· Psychiatrists · Psychologists · Social workers · Licensed professional counselors · Licensed marriage and family therapists · Psychiatric nurses · Licensed chemical dependency counselors · Peer support specialists · Promotores · Psychiatric rehabilitation providers · Pastoral counselors · Occupational therapists
For a description of the professions, including data on the numbers of professionals in the state, refer to the DSHS Mental Health Workforce Report at: https://www. dshs.state.tx.us/chs/hprc/
46 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas During the 83rd legislative session, Representative Burkett authored HB 1023. Passage of this bill indicated that the legislature recognized the need to address the mental health workforce shortage. HB 1023 required the Department of State Health Services to conduct a study and produce a report on the mental health workforce shortage in Texas. To view the full report, visit https://www.dshs.state.tx.us/chs/ hprc/ . Additionally, the Select Committee on Health Care Education and Training held a hearing in Houston in September 2014. The recommendations developed by this committee will be made available to the 84th Legislature.
At the request of the Department of State Health Services, in February 2014 the Hogg Foundation for Mental Health presented workforce recommendations to the Statewide Health Coordinating Council in response to HB 1023. These recommendations can be found on the foundation’s website at http://www.hogg.utexas.edu/uploads/ documents/MH%20Workforce%20Recommendations_031213-1.docx. Texas Mental Health Code
In 2010, a report released by the state Continuity of Care Task Force recommended The TexasEnvironment an overhaul of the Texas Mental Health Code that delineates rules for both voluntary and involuntary mental health commitments in Texas. No major changes to the code have been made since 1985 and many provisions in the current code are outdated, obsolete, or contradictory.
In 2011, the Hogg Foundation for Mental Health awarded a grant to Texas Appleseed to study and make recommendations on changes needed to the Mental Health Code. Psychiatrist/attorney Dr. Susan Stone was the lead researcher, facilitator and coordinator of the grant. A comprehensive and inclusive process was used to garner input from a vast number of stakeholders across Texas. Dr. Stone facilitated approximately 45 public meetings around the state to gather information and recommendations for change. Stakeholders attending the meetings included individuals living with mental illness, family members, law enforcement, mental health advocates, judicial representatives, lawyers, administrators, hospital executives and more. The forums were held throughout Texas with an emphasis on identifying differences in urban and rural areas. A report,Recommendations for Updating the Mental Health Code: A response to decades of dramatic changes in Texas’ mental health system, was developed. As a result of this report and the information gathered throughout the process, a number of legislative initiatives were proposed during the 83rd legislative session. While some significant changes were proposed, there was no comprehensive omnibus bill filed to amend the mental health code and only few changes actually made it through the legislative process. The Texas Appleseed report can be found at http://www.texasappleseed.net/index. php?option=com_docman&task=doc_download&gid=855&Itemid=. HB 3793 – Mental Health Advisory Panel
HB 3793 (Coleman), passed by the 83rd Legislature, has a number of elements related to increasing mental health service in Texas, including the creation of an advisory panel that will assess the needs, access, and availability of services in Texas, with an additional request to assess the forensic population in order to reduce the number of persons with mental health disorders entering the criminal justice system. The advisory panel will oversee the development of a state hospital allocation plan
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 47 for voluntary civil commitments and forensic commitments. The legislation also asks DSHS to develop a procedure for raising awareness of alternate options to incarceration for persons with mental health disorders. DSHS will collaborate with the advisory panel to develop a framework and plan to improve mental health services and to allocate voluntary and forensic outpatient and inpatient services. The plan is statutorily required to address the following elements:95
(1) Determine the needs for outpatient mental health services of the two groups of patients. (2) Determine the minimum number of beds that the state hospital system must maintain to adequately serve the two groups of patients. (3) Create a statewide plan for the allocation of sufficient funds meeting the outpatient mental health service needs and for the maintenance of beds by the state hospitals two groups of patients (4) Create a process to address and develop, without adverse impact to local service areas, the accessibility and availability of sufficient outpatient mental health services and beds provided by the state hospitals to the two groups of patients based on the success of contractual outcomes with mental health service providers and facilities (under Sections 533.034 and 533.052 of the Health and Safety Code)
An initial plan was released in January 2014 and implementation will begin no later than August 31, 2014. In December 2014, DSHS must produce a report for the legislature and governor that includes an updated plan, the status of the implementation, and the impact of the plan on the delivery of services. The Texas Environment Texas The Addressing the Mental Health Needs of Individuals with Intellectual and Other Developmental Disabilities (IDD)
It has been estimated that the rate of mental health conditions for individuals with intellectual disabilities is two to three times higher than for the general population.96 Research findings have varied widely with prevalence rates for co-morbidity of IDD and mental health conditions ranging from 13.9% to 75.2%.97 The variation in prevalence rates is likely due to lack of consistency regarding diagnostic definitions and assessment instruments, small sample sizes, lack of studies using non-IDD comparison groups and overuse of administrative samples, level of disability (IQ) and type of disability.98 For individuals with autism spectrum disorder (ASD) the numbers appear to be more defined, with a 2011 study of 4,343children with ASD finding the psychiatric co-morbidity rate by age 16 to be 49%.99
Individuals with IDD exhibiting challenging behaviors often do not receive state-of- the-art mental health treatment; their care is often focused on managing behaviors and promoting compliance. Professionals, caregivers and family members who are accustomed to seeing their client or loved one through the lens of the disability can misinterpret behaviors that are in fact the result of mental illness, distress, past trauma or possibly an unidentified acute medical condition.
When challenging behaviors are attributed solely to the disability, opportunities for recovery are missed It is not uncommon, however, for professionals and other caregivers to fail to look beyond the disability and assess for possible mental
48 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas health conditions. Cultures of care in both residential and community or family settings have historically had a similar goal of reducing maladaptive behaviors by removing antecedents and replacing undesirable behavior with behaviors deemed “appropriate.” While behavior supports and services can be effective in addressing challenging behaviors, if underlying mental health conditions are not addressed, the likelihood of positive outcomes is greatly reduced.100
Some steps have been taken to begin drawing attention to this important issue, but much work is still needed to create meaningful systems change. In June 2014, the House Human Services Committee held a public hearing on an interim charge to address crisis intervention needs of people with IDD. As a result of that hearing, the Department of State Health Services is researching options for basic mental health/IDD training for direct support providers. Additionally, the Department of Aging and Disability Services (DADS) has conducted a number of trainings across the state on trauma-informed care for individuals with IDD. Also, in partnership with DADS, the Hogg Foundation for Mental Health recently completed a two-year project providing trauma-informed care training and technical assistance at two state supported living centers in an attempt to reduce the use of restraint. The The TexasEnvironment foundation is currently partnering with the National Child Traumatic Stress Network to develop a toolkit to be used for training providers and families on trauma-informed care for children with IDD. Boarding Homes
A boarding home is a business that provides basic care, such as meals and transportation, to at least three residents who have a disability and/or are elderly, where the residents are unrelated to the owner. A point in time study commissioned by HHSC in 2008 found 854 boarding homes throughout Texas.101 However, this number is likely to be greatly underestimated because homes can be difficult As a result of the severe to find and locate due to the lack of regulation or licensing in many parts of the state. Many people with serious behavioral shortage of affordable health conditions have limited income and finding affordable 102 housing can be a challenge. As a result of the severe shortage housing throughout Texas, of affordable housing throughout Texas, many times the only viable option for people with behavioral health conditions is many times the only to reside in a boarding home. In most cases, a resident’s Social Security stipend funds their stay in a boarding home. The same viable option for people 2008 study mentioned above found that 29% of boarding home residents in Texas had a mental health condition. This was not a with behavioral health comprehensive survey, however, and may under-represent the percentage of individuals living in boarding homes who have a conditions is to reside in a mental illness.103 boarding home. While boarding homes offer an alternative to homelessness and some homes provide safe and affordable living quarters for their residents, others offer poor living conditions and have been found to engage in abusive and exploitative behavior.104 During the 81st Legislative Session in 2009, HB 216 (Menendez) directed HHSC to develop and publish state model standards for the operation of boarding home facilities. Additionally, the Hogg Foundation for Mental Health awarded a grant to
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 49 Mental Health America (MHA) of Texas and six affiliate chapters to work with policy makers in the development of new state regulatory standards for boarding homes.105 Those model standards define boarding homes as facilities that:106
· Furnish, in one or more buildings, lodging to three or more persons with disabilities or elderly persons who are unrelated to the owner of the establishment by blood or marriage. · Provide community meals, light housework, meal preparation, transportation, grocery shopping, money management, laundry services, or assistance with self- administration of medication but do not provide personal care services to those persons.
The full boarding home model standards are available at http://www.hhsc.state. tx.us/BoardingHouseModelStandards.pdf.
The legislation, however, did not require cities to implement the model standards. Consequently many problems with this type of housing continue to exist. The grant also supported Mental Health America of Texas to work with city and county public officials to develop and establish boarding home regulations on a local level. The most substantial impact of this work with city and county public officials occurred in the greater Dallas area, Tarrant County, and Southwestern Texas (Beaumont area).
In June 2012, an affiliate chapter of MHA of Texas, MHA of Greater Dallas, had a significant impact in the unanimous passing of a city ordinance that implements
The Texas Environment Texas The boarding home standards in accordance with HHSC’s Texas Boarding Home Model Standards.107 Additionally, in June 2013, MHA Houston helped pass a city ordinance regulating boarding homes for the first time in Houston. Even though boarding home model standards are not mandated across the state, in the past few years some cities, including El Paso, Dallas, DeSoto, Brenham, San Antonio and Houston, have passed ordinances to require standards for boarding homes.108
Subsequently, in 2013, the Hogg Foundation for Mental Health funded MHA of Greater Dallas to create a website that summarized its efforts to improve the quality of boarding homes, provides tools and resources pertaining to regulating boarding homes, and provides a list of boarding homes in the city of Dallas. MHA of Greater Dallas continues to help cities in the greater Dallas community pass boarding home regulations, and in February 2014 the city of DeSoto passed boarding home regulations.109 MHA of Greater Dallas’s website about boarding homes can be found at www.boardinghome.org.
In 2013, the 83rd Legislature took steps toward improving the availability of housing information for people with mental health by passing HB 1191 (Burkett, Zedler). HB 1191 requires HHSC to add information about housing options for mental health consumers, including boarding homes, on the Texas Information and Referral Network Site, the state’s 2-1-1 website. The website’s mission is to assist Texans with obtaining necessary health and human services. Prior to this bill, this information was not available through the website. This bill provides a central location for mental health consumers to locate appropriate housing. HB 1191 requires the website to include definitions of the different types of housing, a searchable listing of available housing, and an explanation of the general populations served with the specific type of housing. This bill intends to further assist mental health consumers to reach
50 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas appropriate resources. The information about housing options for mental health is intended to be updated on the 2-1-1 website by September of 2014. However, the lack of statewide regulation for boarding homes has made it difficult for HHSC to compile a comprehensive and accurate list of boarding homes throughout the entire state. Therefore, a list of available boarding homes will not be available with the initial implementation of HB 1191. Peer Support Services
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.”110 According to research sponsored by SAMHSA to assess the effectiveness of peer support services, “peers are individuals with histories of successfully living with serious mental illness who, in turn support others with serious mental illness.”111 Adding peers to traditional services or having them deliver structured curriculum has shown promising outcomes, although more rigorous effectiveness research is needed.112 The TexasEnvironment
Certified peer specialists have both lived experience and have achieved the relevant education and examination requirements for certification. Peer support services generally fall into three categories:
· 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. · Activities that are delivered as part of a [recovery] team that may include non- peers (for example, an assertive community treatment team). · Traditional activities that are delivered in a way that is informed by a peer’s personal recovery experience (case management, information and referral, etc.).113
Texas has undergone a thorough process to develop certification requirements for mental health peer specialists and substance use recovery specialists. Via Hope is the organization sanctioned by the Department of State Health Services (DSHS) to certify peer specialists and is jointly funded by DSHS and the Hogg Foundation for Mental Health. Substance use recovery specialist certification is provided by the Texas Certification Board of Addiction Professionals. There are currently more than 500 certified mental health peer specialists and over 300 certified recovery specialists in Texas.
Mental health peer support services are currently being provided at all 39 local mental health authorities and a number of state psychiatric hospitals. Peer substance use recovery services are often offered at halfway houses, addiction centers and substance use rehab facilities. Due to current reimbursement rules however, the services provided by mental health peer specialists and recovery specialists are only reimbursable through Medicaid when offered at the local mental health authorities, reducing opportunities for recovery for those seeking treatment through other entities.
Peer specialists assist individuals experiencing mental illness or substance use conditions by helping them focus on recovery, wellness, self-direction, responsibility
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 51 and independent living. 114 Peer and recovery specialists play an important role in supporting individuals experiencing mental health/substance use conditions who are working toward recovery. According to one study conducted in 2008, peer support services include services to promote hope, socialization, recovery, self- advocacy, development of natural supports and maintenance of community living skills.115 The inclusion of peer support services in the service array increases the likelihood of recovery which reduces the high costs associated with people cycling through emergency rooms, county and city jails and state mental health facilities.116 Youth Empowerment Services (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, intended to reduce Medicaid psychiatric hospital expenses and out-of-home placement for children with serious emotional disturbance. A full range of Medicaid services and non-traditional services and family supports are available to create an intensive, comprehensive and individualized child and family plan of care.
The YES Waiver was developed in part to help reduce the need for parental relinquishment, in which parents are forced to give up custody of their children in order to obtain intensive behavioral health services that are not otherwise available or that families cannot afford. The waiver disregards parental income and deems children to be financially eligible if they meet the same eligibility standards for psychiatric institutions. The Texas Environment Texas The The Texas Department of State Health Services (DSHS) and the Texas Health and Human Services Commission (HHSC) submitted the YES Waiver proposal to the federal Centers for Medicare and Medicaid Services (CMS) in June 2008 and received approval in February 2009. In April 2010, pilots began in Bexar and Travis Counties, expanding to Tarrant County in July 2012. The waiver was renewed in April 2013 authorizing expansion of YES waiver services to Harris, Brazoria, Fort Bend and Galveston counties in February 2014 and Cameron, Hidalgo and Willacy counties in June 2014.117
DSHS contracts with the local mental health authorities (LMHAs) in the aforementioned counties to manage YES waiver services in each of these respective service regions. The LMHAs then contract with community service providers to ensure all needed services are available. The waiver is authorized to serve up to 400 youth at any time (100 per county). As of August 2014, 373 youth were enrolled in the YES waiver .118
Further expansion of the YES Waiver is anticipated, as Rider 80 in SB 1 of the 83rd Legislature directs HHSC and DSHS to develop a plan for the statewide expansion of the waiver during the 2014/2015 biennium. YES Waiver updates and information are available at www.dshs.state.tx.us/mhsa/yes/. Trauma-Informed Care
Trauma-informed care (TIC) is an organized treatment framework and strengths- based delivery approach that incorporates understanding, recognizing and appropriately responding to the emotional impact of trauma. TIC emphasizes
52 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas physical, physiological and emotional safety for everyone involved in treatment and works to empower trauma survivors to rebuild a sense of control over their own life.
A trauma-informed system is one in which all the components of a service system are evaluated and reframed with an understanding of the role that trauma and violence play in the lives of people seeking behavioral health services.
In recent years, TIC has grown as an evidence-based method and national movement. For example, SAMHSA’s National Center for Trauma Informed Care (NCTIC) has provided on-site training and technical assistance in order to develop and improve trauma-informed environments to a variety of health service agencies in all 50 states. Additionally, the National Council for Behavioral Health has held three national TIC learning communities from 2011-2013, with participation from over 120 organizations. The National Child Traumatic Stress Network (NCTSN) also serves as a national advocate for TIC, providing a collection of resources, research and expertise on TIC focusing on children and families.
In Texas, a number of TIC-based initiatives have been implemented. At the statutory The TexasEnvironment level, the Texas legislature has mandated TIC training for Child Protective Services staff and foster parents as well as specific juvenile justice workers. Additionally, the Department of Aging and Disability Services partnered with the Hogg Foundation for Mental Health on a two-year project to provide on-going TIC training and technical assistance at two state supported living centers for individuals with intellectual disabilities. An evaluation of the project indicates a decline in the use of restraints and a shift in how staff support the residents. Currently, the foundation is partnering with the NCTSN to develop a tool-kit to support trauma-informed care training for children with intellectual disabilities.
For additional information on TIC, see the Best Practices section Forensic Restoration of Competency Lawsuit
Competency restoration in the criminal justice system is the process used when people with mental illness or intellectual disabilities are charged with crimes but are deemed incompetent to stand trial because they lack the capacity to participate in their own defense. Before the legal process can continue the person must be restored to competency and be able to participate in his or her defense. Competency restoration generally takes place in state psychiatric hospitals and state supported living centers, although in recent years local mental health authorities and the legislature have made a significant commitment to providing competency restoration services in the community.
The number of inpatient forensic commitments has grown dramatically in recent years, but the number of available beds in state hospitals has not increased. Consequently, defendants may be held in local jails for an extended period, until a hospital bed is available. Defendants with a mental illness spend an average of 41 days in local jails, untreated and unable to go to court while waiting for a forensic bed at a state hospital.119 Meanwhile, increasing demand for forensic beds at state-operated psychiatric hospitals continues to reduce the number of beds available for civil commitments.
Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 53 In 2011, the 82nd Texas Legislature enacted HB 748 and HB 2725, limiting incarceration time while waiting for competency restoration to periods no longer than the maximum penalty for the crime charged. Such bills were efforts to ensure that the rights of individuals with mental illness were still protected even when charged with a criminal offense.
In 2007, Disability Rights Texas filed a lawsuit against the Department of State Health Services (DSHS) on behalf of individuals waiting in jail following a finding of incompetency. The case challenged the policy and practice of placing individuals found incompetent on a clearinghouse wait list due to lack of capacity in the state hospitals. In January 2012, a Travis County District Court judge ruled that a defendant found incompetent to stand trial cannot be held in jail more than 21 days before admission to a competency restoration program.120
The Department appealed and implementation of the order was stayed. However, the Department concurrently sought to increase bed capacity to comply with the 21 day ruling. DSHS has allocated additional forensic beds at the state hospitals and is contracting for civil beds in local communities in an attempt to facilitate transfer within 21 days and still maintain sufficient civil beds.121 Additionally, the state has expanded the number of outpatient competency restoration sites and is initiating a jail-based restoration program to reduce the number of people waiting for inpatient services. More information on Texas outpatient competency restoration services is provided in Best Practices.
The Texas Environment Texas The In May 2014, the Third Court of Appeals in Austin issued a decision overturning the 21 day ruling. The Court found that the plaintiffs “failed to demonstrate that the continued confinement of some individuals on the list who may be dangerous may be justified as the purpose of their confinement extends beyond restoring them to competency for trial.”122 The court characterized the case as a facial challenge to the clearinghouse wait list and found that, because some defendants may have been transferred to a state hospital for restorative treatment in a constitutionally permissible timeframe, the plaintiffs had not shown that the waiting list was unconstitutional as to every defendant.
The plaintiff requested a rehearing on the court’s decision, which was denied. While the lawsuit was pending, significant headway was made to ensure that individuals in need of restorative treatment are transferred within 21 days. While there is currently no requirement to transfer within a certain amount of time, the Department must continue to accept individuals for restorative treatment in a timely manner to avoid future liability. Counsel for the plaintiffs continues to closely monitor the timelines for transferring individuals to inpatient settings following a finding of incompetency to proceed.
54 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Public Behavioral Health Services in Texas 55 Legislative session, following session, following Legislative rd President’s New Freedom Commission on Mental Health Health on Mental Commission New Freedom President’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
“The mental health system is fragmented and in disarray—not from lack of from disarray—not and in is fragmented system health “The mental structural, underlying from but care, deliver of those who skill and commitment due to the are Many of the problems problems. organizational and financing direction, ‘layering without overall programs well-intentioned on’ of multiple, 123 or consistency.” coordination
Texas Department of Services (DSHS) Health Department State Texas Services (DFPS) and Protective of Department Family Texas in Texas the by A 2003 report behavioral agencies across in the Texas exist still problems these decade later, a Over coordination improve been made to efforts have recent although system, health 83 During the services. needed access to, of, and Health ServicesHealth nation as follows: across the health systems mental characterized Behavioral Public Public several national tragedies attributed to untreated mental health conditions, efforts mental health conditions, to untreated national tragediesseveral attributed and services were successful. health programs for behavioral funding to increase new and expanded of of a variety the creation enabled funds of critical The increase section. These following in the health programs discussed in detail behavioral expansion of the Youth state-wide campaign, awareness include a public programs and Human time Health of one full allocation (YES)Services Empowerment Waiver, mental health coordination to overseeing devoted Commission employee Services program in Harris pilot jail-diversion to help veterans, initiatives state-wide, changes managed to the With the many care. of Medicaid and expansion County, dedicated ensure that resources it is essential to system, health public behavioral through effective systems across services are maximized health to behavioral of services. that minimizes duplication coordination funding can health services and behavioral need and population, on the Depending agencies: following one of the any by be provided (HHSC) and Human Services Commission Health · · Public Behavioral Health Services in Texas 56 often more costly and less effective. schools, child protective services, and other social servicesettings whereservicesare jails, departments, hospital emergency adult and juvenile criminaljustice agencies, means that individuals with behavioral health needs are inadequatelyserved in limited fundingandaccess to community and preventive mental health services societal costs. Thehuman toll isimpossible to measure,buttheconsequencesof adequately fund behavioral health services results in substantial economic and for per capita mental health spending by astate mental health agency. Failure to Despite recent funding increases, Texas still sits near thebottom ofnationalrankings reduces thecost-effectiveness ofthelimitedfunds available toprovide criticalcare. coordinating propercare.Thislackofcoordinationnot onlycreatesconfusionbutalso providers, consumersandfamilymembersencounter problems receivingor With servicesdispersedacrosssomany agencies, even themost sophisticated Texas Veterans Commission (TVC) Texas HousingandCommunity Department of Affairs (TDHCA) Texas Education Agency (TEA) TexasDepartment(TJJD) JuvenileJustice Texas Criminal DepartmentJustice (TDCJ) of · · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Texas DepartmentAssistive andRehabilitative of Services(DARS) Texas DepartmentAging andDisabilityServices(DADS) of HHSC 57 72 72 72 73 73 73 68 69 71 64 62 63 73 75 60 62 59 127 126 The Texas Medicaid Medicaid The Texas 125 124
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 cts C a
Eligibility for Medicaid Services Medicaid for Eligibility Recipients ofMedicaid Demographics Medicaid Funding Funding Medicaid Children) and (Adults Programs Buy-In Medicaid (HIPP) Program Payment Premium Insurance Health Medicaid (TMHP) Partnership Healthcare and Medicaid Texas CHIP for Eligibility Costs and Utilization Enrollment, Federally Qualified Health Centers Health Qualified Federally State State Agency Medicaid SB 58 - Integration of Integration - 58 SB Services Health Behavioral Redesign Disability Intellectual/Developmental and Expansion Care Managed – 7 SB In 2011, 55% of the Medicaid population was female and 77% was under the ageand 77% was female of was population Medicaid 55% of the In 2011, recipients, 66% of all Medicaid for nearly account disabilities without 21. Children services. health-care on direct 33% of spending only they represent however For the 2014-2015 biennium, the HHSC budget is approximately 27 percent biennium, the HHSC is approximately budget the 2014-2015 For and Human Health while the budget state the entire billion) of $53.1 (over accounts for and DSHS, DARS DADS, DFPS, budget, comprised of HHSC, Services budget. entire state of the 39 percent approximately million) relied on out of 26.6 million (3.6 Texans in seven one roughly In 2013, each month. long-term services acute and for Medicaid Coordination of mental health and substance use services across agencies substance health and of mental Coordination Adequacyhealth services for behavioral of reimbursement rates with and coordination of 1115 initiatives Transformation waiver of 1115 Progress planning systems health mental recommendations of sunset Consideration Care the Affordable of Implementation Act managedcare Medicaid of services and expansion health of behavioral Integration agencies sharing between information governing and laws regulations Complex Children’s Health Insurance Program (CHIP) Program Insurance Health Children’s Measures ofQuality Health Behavioral Care Funding Funding Services Commission and Human Health Texas Environment Changing 64 Medicaid program caseload is projected to reach 4.2 million by 2015. by 4.2 million program caseload is projected to reach st F ast · · · F · · · · · · · Policy At A At A Glance: Services Commission: Services Texas Health and Human and Health Texas HHSC 58 Organiz · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 2011, these sites served 975,509 individuals. There are 70 FQHCs inTexas withmore than 300 sites delivering services. tional Chart 129 128 In HHSC 59 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 130 Department of State Health Services (DSHS) Health of State Department (DFPS) Services Protective and of Family Department (DADS) Services and Disability of Aging Department (DARS) Services and Rehabilitative of Assistive Department HHSC is div ided into 11 service regions displayed in Figure 10. HHSC and the HHSC Figure 10. in is div ided into 11 service regions displayed and Human Services to as the Health referred it are sometimes departments under 53,473 approximately the enterprise employed In FY 2013, (HHS) “enterprise.” million services to more than 3.4 and provided full-time and part-time employees Texans. Health and Human Services Enterprise Health 9. Figure Services Commission Services Commission (HHSC) Services Human and Health agency is the umbrella The Texas a handful of Program (CHIP), Insurance Health Children’s the Medicaid, overseeing departments: of four major operation and the programs, other · · · · Texas Health and Human and Health Texas HHSC 60 HHSC agencies. Figure 12shows thefunding sourcesfortheFY2014-2015HHSC budget. Transportation Program. (TANF), Supplemental Nutrition Assistance Program (SNAP), andtheMedical Program (CHIP), Disaster Assistance, Temporary Assistance forNeedyFamilies alsooperates the following programs: Medicaid,HHSC Children’s Health Insurance In addition to providing oversight for the health and humanservicesenterprises, state.tx.us/about_hhsc/Regions/ Source: Texas Health and Human Services Commission. (2014). Figure 10. Health andHumanServicesRegions Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas sub-agencies). appropriated toHealth and Human services (includingall funds toeachof the four In 2014 and2015, atotal of$77.6 billionofcombinedstate andfederalfunds were biennium. accounts forapproximately 39percentoftheentire state budget for the 2014-2015 budget whiletheHHSbudget, comprised of HHSC, DFPS, DADS, DARS andDSHS, budget is approximatelyThe HHSC 27percent(over $53.1 billion)oftheentirestate Funding requested for HHSC inFY2016requested and2017. forHHSC increase infunding granted fromthe2012-2013 biennium.Atotal of over $58billionis 132 TheFY2014-2015 bienniumappropriated funds included a14.2 percent 134 Figure 11below demonstrates thefunding appropriated toeachof the 131
Health and Human Services Regions. Retrieved from 133 http://www.hhsc. HHSC 61
Health and Human Services consolidated budget for fiscal years 2014- years fiscal for budget consolidated Services Human and Health Health and Human Services consolidated budget for fiscal years 2014- years fiscal for budget consolidated Services Human and 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 http://www.hhsc.state.tx.us/about_hhsc/finance/2014-2015.pdf http://www.hhsc.state.tx.us/about_hhsc/finance/2014-2015.pdf Source: Texas Health and Human Services Commission. (2012). (2012). Commission. Services Human and Health Texas Source: from Retrieved 2015. Figure 12. Methods of Financing 12. Figure Source: Texas Health and Human Services Commission. (2012). (2012). Commission. Services Human and Health Texas Source: from Retrieved 2015. HHS System Request by Agency Agency by Request System HHS 11. Figure HHSC 62 and SB7 (83 Services referred to as“phase one,” theflow asitchanges ofthefunding butdoesnot expand health authorities (LMHAs)to provide these services throughoutTexas. Thisis services. Initially, the health plans will primarily be contractingwiththelocalmental will contract with thevarious health plans tooversee deliveryHHSC of these the DSHS section. is availablemental health rehabilitative in services and targeted casemanagement careprograms is available inFigure on these specific managed 14. Adescription of disabilities and elderlyparticipants needing these services. information Additional that provides both acute and long term services and supportstopeoplewith services to eligible participants. STAR+PLUS isa careprogram statewide managed STAR isthe statewide care program that provides managed Medicaid acutecare state careprogramsSTAR managed and STAR+PLUS. conditions who areeligible to receive Medicaid benefits willbedelivered throughthe and mental health rehabilitative services for individuals withmentalhealth However, because of SB 58, effective September 1,2014, targeted casemanagement withLMHAs. of Medicaid care under aseparate payment arrangement managed Mental Health Authorities (LMHAs). These services have been provided outside services haveand targeted casemanagement historically beenlimitedto Local In Texas, the providers eligible to receive Medicaid reimbursement forrehabilitation SB 58 - The 83 period of significant change. The Health and Human Services Commission and the entire enterpriseareina Changing Environment Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas changes relate to the expansion of managed care asrequiredby relatetothe expansion of managed SB58(83 changes have already begun but will take years tobe fully implemented.Themost significant Following are briefdescriptions currently underway. ofmajor changes competition between health plansthat is expectedto result in higher quality services. and state monitoring, the members’ ability to switch somelevel of plansgenerates option plans if not to change satisfied. Inaddition tothecontractrequirements plans in each region. Once enrolled in aparticular health plan, membershave the Eligible individuals have a choice between at least two, andsometimes more,health capitated payment. required services andbears the financial riskiftheir actualcosts exceed the state payment made foreach member, every month. The healthplanmust provide all a capitated rate for each member enrolled. A capitatedrateisapredetermined administration of each member’s services. Thestate of Texas pays eachhealthplan provider network. The healthplan is thenresponsible for carecoordination and care organization)and is asked toidentify a primary care physician fromthat plan’s caresystem,In amanaged an eligible individual selects ahealthplan(managed Integr rd /Nelson). a tion of rd Legislature directed some major changes that Legislature directed somemajor changes Beha vior al He alth rd /Nelson) HHSC 63 and Disability al nsion xpa E 135 re re Ca ged pment al/Develo 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 Mana Design and implementation of a system of acute care and long-term services and of acute of a system implementation Design and disabilities developmental other and with intellectual for individuals supports (IDD). or more managedof one and implementation Development care capitation pilots with IDD. for people and supports term services of long for delivery to managed services care by waiver Living Home of the Texas Transition 2016. September to services waiver (ICF) and IDD Facility Care of Intermediate Transition 2020. managedthan September care no later a managedthrough care services acute care model, of all Medicaid Provision long term services and supports IDD receiving services to people with including in and individuals residing waiver a 1915(c) community-based through under disabilities Children with IDD. with people for care facilities intermediate acute receive continue to and may this requirement from the ageof 21 are exempt of the implementation until option delivery a fee-for-service through care services enroll in STAR+PLUS. elect to voluntarily may or below) Kids (see STAR and habilitation of attendant for delivery option effective cost of a Development program. STAR+PLUS through the services managedto all areas of the state. care program of the STAR+PLUS Expansion to managed services facility of nursing Transition of this care. Implementation March 2015. until has been postponed provision managed Kids capitated to provide care program STAR of the Establishment Develop two health home pilots. home pilots. two health Develop for people who are homeless and services groups to provide local Bring together use condition. a substance or illness mental have public reporting system. use treatment and substance a mental health Develop edesign R that is generatingof legislation a complex piece SB 7 was major service delivery changes in SB 7 impact Many programs. and changessystems across multiple the method disorders (IDD) and intellectual and development with individuals Individuals with IDD are delivered. and supports services long-term which through mental health condition. Therefore, experience a to likely more times are three of this mental health and wellness the improve in SB 7 will likely forth set legislation of the changes Some population. from SB 7 include: resulting · · · · · · · · · B 7 – – 7 SB · · · Intellectu the provider base and does not create an integrated system of care. system integrated an create not does and base the provider HHSC broaden the will this initiative phase two of plans for that has indicated changes to needed on systems focus and access to services, base, increase provider Health The Behavioral care services. and acute health behavioral integrate truly to recommendations SB 58 to make Advisory Integration created by Committee, HHSC phase two to help guide recommendations developed care, has on integrating of this initiative. also directed HHSCSB 58 to: HHSC departments. through multiplehealth and humanservices are alsodelivered toeligibleindividuals Medicaid behavioral health services, however, are overseenandadministered byHHSC. In Texas, theMedicaidstate planservices 64 utexas.edu/uploads/documents/83rd%20Lege%20Summary3.pdf. copy of the Hogg Foundation summary of the legislation can be foundat changes. Acopy ofthe legislation can befound online at In addition to themajor components described above, SB7 directs additional policy · · · · · · S cannot limit thenumber of eligible persons who canenrollintheprogram. services and cannot be placed on waiting lists. The federal government and states meaning that anyone meeting the eligibility criteria has a righttoreceive needed state plan amendments and Medicaid waivers. Medicaid isanentitlementprogram both the services offered andthe peopleeligible toreceive thoseservicesthrough provided and populations that must be served. States have theoption to expand disabilities. The federal government defines mandatoryservicesthatmust be primarily to childrenin low-income families, pregnant women,andpeople with It was createdasawayXIX ofthe Social Security Act. to provide healthcarebenefits Medicaid isajointly funded federal/state health care program authorizedinTitle Medicaid Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas disabilities by providing medical careand services. Medicaid guidelines areprimarily million low-income children, pregnant women, older adultsandwith isthedesignated state MedicaidHHSC agency. Texas t Development of quality-based payment systems. carecontracts.incentives inmanaged Development and implementation of outcome-based performance measuresand support for individuals with IDD. Subject to the availability of federal funds, development ofspecializedbehavior Expansion of housing support options for people with IDD. for resource allocation. the appropriatescope and duration of services to bedelivered aswellaprocess Development of a comprehensive functional assessment to beused determine relating to implementation of these changes. Establishment of multiple advisory committees to make recommendations until September 1, 2016. STAR+PLUS. Implementation of the STAR Kidsprogramhasbeenpostponed Medicaid benefitstochildrenwithdisabilities not voluntarily enrolledin a te Medic aid Agency apportioned to the states, including: though several important tasks are determined by the federal government,
· · · services. Setting the rate of payment for Determining the scope of services. by the federal government. minimum eligibility groups set forth Establishing eligibility beyond the Medicaid serves over three www.capitol.state.tx.us www.hogg. 136 . A 137
HHSC 65 http://www. The Texas Medicaid Texas The caseload is program 4.2 to reach projected million by 2015. Retrieved from from Retrieved Report. Self-Evaluation Sunset
139 Medicaid Program Responsibilities Program Medicaid services plan state Medicaid Texas the for supports and services long-term following the administers DADS program: Medicaid waivers: 1915(c) Medicaid and Assistance Living (CBA)-Community Alternatives -Community-Based (MDCP)- Program Children Dependent (CLASS)-Medically Services Support Community-Based and (DBMD)-Home Disabilities Multiple with Deaf-Blind (TxHmL) Living Home (HCS)-Texas Services programs Entitlement (PHC) Care Home -Primary (CAS) Services Attendant -Community (DAHS) Services Health Activity -Day Facilities Nursing or disabilities intellectual with individuals for Facilities Care Intermediate conditions related administers: DSHS Health Texas – (EPSDT) Treatment and Diagnosis Screening, Periodic and Early Steps children and women pregnant for management Case program care managed NorthSTAR waiver (YES) Services Empowerment Youth administers: DFPS Health) (STAR Systems Health Superior (FFCC) Program Children Care Foster Former Youth Care Foster Transitioning for Medicaid administers: DARS (ECI) Program Intervention Childhood Early impaired visually or blind are who children for management Case services rehabilitation Vocational 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 Medicaid program caseload is projected to program Medicaid The Texas 138 State Agency State Human and Health Commission Services Department ofAging (DADS) Disability and ofDepartment State (DSHS) Services Health ofDepartment Family Services Protective and Department of- Assis Rehabilitative and tive (DARS) Services . hhsc.state.tx.us/sunset/Evaluation-Report.shtml Source: Texas Health and Human Services Commission. (September, 2013) (September, Commission. Services Human and Health Texas Source: in Texas in established first was Program Medicaid The Texas 26.6 million out of (3.6 Texans one in seven roughly In 2013, 1967. services each long-term for acute and relied on Medicaid million) month. In Texas, the Medicaid state plan services are overseen and administered by HHSC. HHSC. by administered and are overseen plan services state the Medicaid In Texas, individualseligible to also delivered are however, services, health behavioral Medicaid chart (Figure The following departments. human services multiple health and through These services. Medicaid-funded offering programs various department details 13) agency in each respective will be elaborated services section in the guide. Agencies HHSC Across Programs Funded Medicaid 13. Figure reach 4.2 million by 2015. million by reach 4.2 Starting in the early 1990s, Texas Medicaid has been offered has been Medicaid Texas 1990s, in the early Starting HHSC 66 7 (83 care asof June 2013. million members(86percent)of the Medicaid population were enrolled in managed contracted network physicians and other healthcare specialists. Approximately 2.8 (MCOs) understate contract. Each MCO maintains a provider directoryof careorganizations Medicaid careservicesaredelivered through managed managed for delivering Medicaid services. care to include more services andpopulations, it has becometheprimary platform rate for each individual enrolled. Because ofrecent expansions ofMedicaid managed overseen by asingle provider organization with the state paying amonthlycapitated plan). Under theMedicaid care system, managed the overall careofanindividualis new to the program who have not yet care chosenor been assignedtoamanaged service delivered) isnow limited tovery fewMedicaid participants (e.g.individuals fee-for-service delivery option (providers receive payment based onthe unit of through two service models: fee-for-service care.Thetraditional and managed Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Figure 14. Texas Medicaid/CHIP Managed Care Programs NorthSTAR, STAR Health, CHIP andSTAR Kids. These programsinclude STAR (State of Texas Reform), STAR+PLUS, Access The following chartdescribesthesix Texas Medicaid/CHIPcareprograms. managed STAR+PLUS care program and thenew STAR managed careprogram. Kidsmanaged 1998) (start date: STAR+PLUS 1991) (start date: STAR Program rd Legislature, Nelson) that expands mandatory participation intheexisting STAR+PLUS March 1, 2015. expected to transition to Nursing facility services are Sept. 1, 2014. Services available statewide as of and targeted case management. ioral health rehabilitative services behav- includes the integration of Beginning September 1, 2014 also starting Sept. 1, 2014. Medicaid managed care program services through the STAR+PLUS services will receive basic acute care receiving Medicaid 1915(c) waiver and developmental disabilities Individuals with intellectual managed care system. long-term care services into the acute and Integrates delivery of Services available statewide. and targeted case management. ioral health rehabilitative services behav- includes the integration of Beginning September 1, 2014 also children and pregnant women. low-income families, non-disabled Provides acute care services for Description 140 Thisnumber is anticipated to grow ofSB with thepassage eligible for SSI and Medicaid. Voluntary for children 20 and under (acute care only). 1915(c) Medicaid waiver services receiving SSI; individuals receiving Mandatory for adults 21 or older age. through 20 years of Voluntary for SSI children age birth children. low income pregnant women and Mandatory for TANF Population; and Eligible Population 32.3% Outpatient or ED services: 0.7% tial hospitalization services: Intensive outpatient or par Inpatient services: 3.9% 8.7% Outpatient or ED services: 0.1% tial hospitalization services: Intensive outpatient or par Inpatient services: 0.3% (FY 2011) Mental Health Utilization - - HHSC 67 - - http://www. http://www. Mental Health Utilization Utilization Health Mental 2011) (FY Inpatient services: 0.5% services: Inpatient par or outpatient Intensive services: hospitalization tial 0.0% services: ED or Outpatient 78.1% Inpatient services: 7.0% services: Inpatient par or outpatient Intensive services: hospitalization tial 1.6% services: ED or Outpatient 9.4% 0.2% services: Inpatient professional or Outpatient 5.2% services: 0.2% services: ED N/A http://www.hhsc.state.tx.us/medicaid/ . Retrieved Retrieved . NorthSTAR Unit: Services Medicaid Eligible Population Eligible Mandatory for individuals who are are who individuals for Mandatory persons for and eligible Medicaid need in indigent medically deemed Must ofservices. health behavioral Ellis, of residents eligible be Dallas, and Rockwall, Navarro, Hunt, Collin, counties. Kaufman Children in the Department of Family ofDepartment the in Children Family conserva- Services Protective & protective child in youth torship; youth care; foster extended services care foster in previously 18-21 ages - Transition for Medicaid receive and youth care foster former Youth; ing 21-23 ages Uninsured children in families with families in children Uninsured Federal ofthe 200% under income Level. Poverty Mandatory for children with dis- with children for Mandatory Medicaid or SSI for eligible abilities services. waiver . Retrieved from from Retrieved CPS. at services medical to guide A – Health STAR . Retrieved from from Retrieved 2012-2016. strategy quality Care Managed Medicaid Retrieved from from Retrieved expansion. STAR+PLUS
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 Description Provides mental health and and health mental Provides the to services use substance Ellis, of residents eligible Dallas, and Rockwall Navarro, Hunt, Collin, behavioral a as counties Kaufman long and (Acute out. carve health by provided are services care term plans care managed Medicaid other NorthSTAR STAR+PLUS). STAR, (e.g. of direction the under is Depart- the ofment Services. Health State Provides integrated healthcare to healthcare integrated Provides provides Also care. foster in children to training and management case case- clinicians, caregivers, families, ofmembers and advocates workers, judiciary. the statewide. available Services Managed care program that program care Managed services care health acute provides in living children uninsured to income. low with families children to services provide Will When disabilities. with youth and will program this implemented, long and care acute both provide supports. and services term statewide. available be will Services - https://www.dshs.state.tx.us/mhsa/northstar/northstar.shtm Program NorthStar date: (start 1999) STARHealth date: (start 2008) Children’s Children’s Insur Health Program ance (CHIP) date: (start 1999) STARKids start (expected Sept. date: 2016) dfps.state.tx.us/Child_Protection/Medical_Services/guide-star.asp Medicaid Texas (2014). Organization Review Quality Eternal Texas & ofUniversity the at Florida, Policy Health Child for Institute from Retrieved Quality. in Healthcare Trends ofSummary EQRO Activities and Program: Insurance Health Children’s and Care Managed http://www.hhsc.state.tx.us/reports/2014/EQRO-Summary.pdf (CHIP) Program Insurance Health Children’s Texas request: Data 12). August, (2014, Commission. Services Human and Health Texas utilization health mental hhsc.state.tx.us/medicaid/about/QIS-1115.pdf (n.d.). Services. Protective & ofDepartment Family Texas Texas Health & Human Services Commission. (n.d.). (n.d.). Commission. Services Human & Health Texas from from Texas Department of State Health Services. ofDepartment Services. Health State Texas managed-care/mmc/starplus-expansion/ Sources: Commission.(n.d.) Services Human & Health Texas HHSC 68 FMAP of 58.69 percent. Medicaid program,Texas’ FMAP in 1998 was 62.28percent,compared to theFY14 an illustration ofTexas’ overall trend of decreasing federal portionoffundingforthe American Reinvestment inplace.As and Recovery but those fundsarenolonger Act, This decline was mitigated by three years ofenhanced federal funds dueto the the states’ average per capita income has increased relative to the nationalaverage. Texas’ rate of federal participation has beensteadily declining over thelast decade as inthe FMAP canresult in funding fluctuations ofmillions ofdollars.Small changes 40.70 and 41.31 percent of all costs respectively. rates for FYs 2013 and2014 are 59.30 and58.69 percent;thatis, thestate must pay the average state per capita income compared to the U.S. average. (FMAP), is determinedpercentage on anannual basis andisdependent primarily on The federal share of the Medicaid program, known as thefederalmedical assistance estimated torepresent26percent($24.8 billion)ofallstate expenditures. emotional disturbance. Total Medicaid expendituresforFY2011 atthestate level were services for children, youth,andadultslivingwithmentalhealthconditionsor serious Medicaid israpidlybecomingthelargest sourceoffundingpublicmentalhealth The federal and state government jointlyfundtheTexas Medicaid program.Nationally, MEDICAID FUNDING Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 142 Texas’ matching 141 HHSC 69
State Medicaid and CHIP income eligibility standards effective July 1, 2014. 1, July effective standards eligibility income CHIP and Medicaid State Family of 4 Family $3,577 $23,850 $31,720 $47,700 $95,400 Individual $1,750 $11,670 $15,521 $23,340 $46,680 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- Low-income parents, pregnant women and children. pregnant women parents, Low-income with disabilities. old and people 65 years over People recipients. Cash assistance Federal Federal Level Poverty 15% 100% 133% 200% 400% (2014). Services Medicaid & Medicare for Center Source: Retrieved from from Retrieved Eligibility-Levels-Table.pdf A common misperception is that being poor is sufficient to qualify for Medicaid. qualify for sufficient to poor is is that being misperception A common income and categorical meet must an individual for Medicaid, to be eligible However, requirements. category below are as shown Medicaid for each requirements eligibility The income 15. in Figure 2014 Levels: Income Annual & Texas in Coverage Subsidized 15. Figure ELIGIBILITY FOR MEDICAID SERVICES MEDICAID FOR ELIGIBILITY programs cash assistance of recipients to available only originally was Medicaid Supplemental and/or (TANF) Families for Needy Assistance such as Temporary the federal early 1990s, and late 1980s the during However, Income (SSI). Security of a broader population, the needs to meet the program expanded government de-linking people with disabilities, elderly and women, the pregnant including cash assistance. of receipt eligibility from Medicaid factors such as of a variety considers Texas eligibility, program In determining residency citizenship and state pregnancy, age,and family size, income disability, primary categories: the three covers Medicaid requirements. · · · HHSC CHIP-Eligibility-Levels-Table.pdf Forward-2014/Downloads/Medicaid-and- AffordableCareAct/Medicaid-Moving- Retrieved from http://www.medicaid.gov/ eligibility standards effective July 1, 2014. (2014). State MedicaidandCHIPincome Center forMedicare &MedicaidServices for anindividual).” poverty level($8,266annualincome thefederal does notexceed 74%of income Income (SSI)are onlyeligibleif disabilities receiving SocialSecurity 3).income forafamilyof People with federal poverty level($3,577annual the incomeisbelow15%of only if income level. Parents are eligible are noteligiblefor Medicaidat any “Currently in Texas, childlessadults 70 Figure 16. Medicaid-Funded Behavioral Health Services · · · · · · include: primary categories There are over 30different in Medicaid eligibilitycategories Texas. Someofthe Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Services Mental Health Service Type Certain working individualswithdisabilities. Individuals who aremedicallyneedy. Older adults and people with disabilities. Pregnant women with infants and children. Individuals receiving Supplemental Security Income (SSI). Individuals/families receiving Temporary Assistance forNeedyFamilies (TANF). Comprehensive community services for YES waiver participants (see DSHS section) Behavioral health services provided by a primary care physician Ancillary services required to diagnose or treat behavioral health conditions persistent mental illness or children with severe emotional disturbance Rehabilitative and targeted case management services for people with severe and Prescription medications Inpatient psychiatric hospitals for persons under 21 and those 65 and older Inpatient psychiatric care in a general acute hospital fessional counselors and licensed marriage and family therapists Therapy by psychiatrists, psychologists, licensed clinical social workers licensed pro- Mental health assessment and diagnosis Medicaid Behavioral Health Services: Figure 16 below. behavioral health services is provided in the A comprehensive description ofthe covered are described in the DSHS section. local mental health authorities. These services safety net servicesprovided through DSHS and Medicaidmanagement. also fundsmental health counseling, and medication Medicaid StatePlan, such aspsychiatric services, and substance useservices included in the and children, have access to mental health Eligible Medicaid recipients, including adults pregnant adults inthe Medicaid program is 0. program is thatthenumber of non-disabled, non- eligibility in theMedicaidthe role of categorical low-income parents. Ahelpfulstatistic todescribe individuals, suchaschildless adults orworking of Medicaid will continue to exclude many under the ACA nature means that the categorical Texas’ decisiontonot expand Medicaid as allowed HHSC 71
143 Retrieved from from Retrieved edition. ninth perspective, in CHIP and Medicaid Texas . Retrieved from from Retrieved edition. ninth perspective, in CHIP and Medicaid 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 Medicaid Behavioral Health Services: Health Behavioral Medicaid facilities state-licensed by counseling dependency chemical adolescent Outpatient diagnosis and Assessment therapy assisted Medication detoxification residential and Outpatient treatment and counseling Outpatient treatment Residential Service Type Service Use Substance Services Texas edition of Texas latest consult HHSC’s information regarding Medicaid, more For at as the “Pink Book”, available known , commonly and CHIP in Perspective Medicaid . http://www.txohc.org/PDFsPPs/Texas%20Medicaid_CHIP%20Pinkbook.2013.pdf Source: Texas Health and Human Services Commission. (2013). (2013). Commission. Services Human and Health Texas Source: . http://www.txohc.org/PDFsPPs/Texas%20Medicaid_CHIP%20Pinkbook.2013.pdf Source: Texas Health and Human Services Commission. (2013). (2013). Commission. Services Human and Health Texas Source: RECIPIENTS OF MEDICAID DEMOGRAPHICS receiving Medicaid of the individuals majority for the and children account Women was under and 77% was female population Medicaid of the 55% In 2011, benefits. for nearly 66% of all Medicaid account the agedisabilities without of 21. Children services. on direct health-care spending of only 33% represent but they recipients, only account for 25% of a disability or have who are elderly individuals In contrast, expenditures. estimated 58% of total over but represent population the Medicaid . http://www.txohc.org/PDFsPPs/Texas%20Medicaid_CHIP%20Pinkbook.2013.pdf Figure 17 below displays percentage of Medicaid populations by demographic populations by percentage displays of Medicaid below Figure 17 expenditures. corresponding category and their estimated 2011 Expenditures, and Beneficiaries Medicaid Texas 17. Figure HHSC 72 Children) Progr Medic insurance or the Medicaid Health InsurancePremium Payment Program(HIPP). on income,thenumberofpeopleinfamily, andaccessto employer-provided are requiredtopay monthlypremiums, co-pays ordeductibles. Cost-sharing is based 18oryounger,who is age aU.S. citizenorlegalresident,andnot married.Most families Medicaid buy-in forchildrenis available tofamilieswhohave achildwithdisability who are workingand who donot live in astate institution or nursinghome.TheTexas The Texas Medicaid buy-in programfor adults is available topersonswithadisability Medicaid program. premium. The health care services provided are the same asinthetraditional Participants must meet certainincome criteria and may berequiredtopay amonthly to enroll in Medicaid when their income levels exceed normaleligibilitylimits. The Texas Medicaid buy-in programs allow adults andchildrenwithdisabilities Medic There are 70 FQHCs inTexas withmore than 300 sites delivering services. Medicaid, or peoplewho are otherwise low-income anduninsuredor underinsured. comprehensive health care services for people with public health insurancesuchas FQHCs330 of the Public Health Services Act. play animportantrole in providing centers (FQHCs), which are health care entities that receive grants throughSection Many of the services listed inFigure 16 areprovided by federally qualified health Feder Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas is deemed costthen the policy effective. would spend in Medicaid payments,of insurance is lessthen what TMPH or HHSC and cost sharing forthe best covered policy by the recipient’s employer. If the cost payments are compared with thecost ofthe premiums, coinsurance,deductibles employer-provided policies must be considered cost effective. Past Medicaid In order to qualify for the program recipients must remainMedicaid eligible and actual Medicaid costs forthe Medicaid recipient. employer. TheTexas Medicaid andHealthcare Partnership (TMHP) establishes the eligible employees for payments for health insurance received throughtheir that covers the expenses of medical premiums. The programreimbursesMedicaid- The Health Insurance Premium Payment Program (HIPP) isaMedicaid program these sites served 975,509 individuals. health and substance use. integration of care for clientswith multiple chronic conditions, including mental to health homes orcomprehensive medicalhomes to improve thecoordinationand and publicly funded patients. Increasingly, FQHCs are transformingtheirpractices additional costs associated with provided comprehensive care toboth uninsured Medicaid and Medicare services. Thesereimbursements are designed to cover the receive enhancedreimbursements for providing services to individuals receiving While FQHCs receive grantfundingfrom the federal government, theyalso ally aid He aid Buy-In Progr am (HI PP) Qu alth alified He Insur 145 ams (Adults ance Premium P
alth Centers and a yment 144 In 2011, HHSC 73 (TM HP) ip h artners osts C re P are and hc alt This is partially a result of the ACA, which allows which allows ACA, of the a result This is partially tion 147 CHIP nd He and Utiliza 146 or aid f 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 Medic the CHIP population from 100 percent to 133 percent of the federal poverty level to level of the federal poverty 133 percent percent to from 100 population the CHIP into Medicaid. transition In 2011, the mean age population with 17 percent of the 10 years old, in CHIP was In 2011, years old. 6 and 14 age the between population of the and 61 percent of 5 below decade, the past over steadily increased have in CHIP levels enrollment Monthly 18). Recently, in 2013(Figure per month members more than 602,000 reaching children with 495,187 figures, dip in enrollment a noticeable there has been however, April 2014. in CHIP as of enrolled nrollment, Enrollment, CHIP is available for children aged 0–19 with income up to 200 percent of the federal with income agedfor children available CHIP is 0–19 of four) so that low-income family for a $47,700 of income (annual level poverty inpatient and outpatient mental including to health care, access can have children health insurance to provide developed was CHIP use services. and substance health for Medicaid, income or assets too much whose families had for children coverage or on or family insurance through employment access individual enough to but not based and co-payments enrollment fees with cost-sharing CHIP requires their own. income. on family Eligibility The Children’s Health Insurance Program (CHIP) was created in 1997 under Title created in 1997 under was (CHIP) Insurance Program Health The Children’s the Act. Security Social XXI of the funded by CHIP is jointly Medicaid, As with of a in CHIP requires approval State participation federal governments. and state CMS Services (CMS). While and Medicaid Medicare for the Centers by CHIP plan currently Texas programs, and CHIP Medicaid the both to combine states allows these programs separately. administers Children’s Health Insurance Program Program Insurance Health Children’s (CHIP) The Texas Medicaid and Healthcare Partnership (TMHP) is a coalition of companies is a coalition of (TMHP) Partnership and Healthcare Medicaid The Texas claims Medicaid HHSCwith contract under a single operating state’s the to carry out process not does TMHP system. fee-for-service the traditional, for process payments managed but does collect (MCOs), care organizations by services provided claims for and utilization of quality of for the evaluation MCOs to use data from encounter managed services. care the TMHP the lead contractor in billing, about improper of concerns As a result present, At to Services Computer Affiliated from Accenture. switched coalition to separate contracts HHSClargebreak the is planning to into smaller, contract medical care for disrupting without a vendor against action easier to take it make with Medicaid. people as Tex HHSC 74 file]. Retrieved from Figure 19. Legislative Appropriations Request FY 2016-2017: CHIP Services disenrollment by month. Retrieved from every year.Note: Data is from October of Source: Texas Health and Human Services Commission. (2014). CHIP enrollment, renewal and Figure 18. CHIPEnrollment administration. services; 19 percent on prescription drugs;and the remaining10percenton CHIP budget isspent on inpatient and outpatient hospital services and physician 2016-2017 LARpredictsadecline in funding. It isestimated that 71 percentofthe Although CHIP spending has experienced sporadic growth upuntil2013, theFY Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Source: Texas Health and Human Services Commission. (2014). http://www.hhsc.state.tx.us/LAR/2016-2017 148 http://www.hhsc.state.tx.us/research/CHIP/ChipDataTables.asp 2A. Summary base of request by strategy –84
th Regular Session [Data HHSC 75 53% 36% 48% 74% avail- Not able 19% 50% 66% 43% 71% 13% avail- Not able 2011 50% 36% 46% 72% 25% 19% 47% 58% 45% 72% 13% 10% 2010 Not available Not available Not 40% 67% (all 24% ages) available Not separately Not available Not available Not 40% 68% (all 21% ages) available Not separately Performance 2009 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 Antidepressant medication management within 3 within management medication Antidepressant dispensed) after visit (follow-up months 6 within management medication Antidepressant dispensed) after visit (follow-up months mental for hospitalization after care Follow-up days 7 within illness mental for hospitalization after care Follow-up days 30 within illness Adults - days 30 within Readmission Children/Adolescents - days 30 within Readmission After dispensing new medication to treat ADHD had ADHD to treat medication new dispensing After Phase) (Initiation days 30 within visit follow-up a ADHD treat to medication taking continuously After 9 within visits follow-up additional two least at had Phase) (Continuation months mental for hospitalization after care Follow-up days 7 within illness mental for hospitalization after care Follow-up days 30 within illness Adults - days 30 within Readmission Children/Adolescents - days 30 within Readmission Measure STAR+PLUS STAR Program Behavioral Health Quality of Quality Health Behavioral Care Measures to perform the Policy Health for Child Florida Institute the contracts with Texas Outcomes Managed Care programs. Medicaid Texas for the review quality external Data and Information Set Effectiveness Healthcare national are compared to The that HHSCbenchmarks or to available, when establishes. (HEDIS) standards, in to measure performance the country are used across HEDIS standards national services. health behavioral care, including areas of health important of care measures health quality behavioral and CHIP Medicaid for selected Statistics measures are health performance behavioral selected 20 and Figure are presented in 20. Figure in shown for Medicaid Measures Quality of Health Selected Behavioral Care 20. Figure and CHIP Programs HHSC 76 reports/2014/EQRO-Summary.pdf Program, EQRO summary activities of and trends in healthcare quality - FY 2011. Retrieved from http://www.hhsc.state.tx.us/ Institute for Child Health Policy Florida. at the University of (2014). – Annual chart book, FY 2008 . Retrieved from Institute for Child Health Policy Florida. at the University of (2009). careof report, FY 2010. Retrieved from Institute for Child Health Policy Florida. at the University of (September 26, 2011). care report – FY 2010. Retrieved from Institute for Child Health Policy Florida. at the University of (2012). Texas Medicaid Managed Care and STAR+PLUS, EQRO quality of – Annual chart book, FY 2008. Retrieved from Institute for Child Health Policy Florida. at the University of (2009). Annual chart book, FY 2008. Retrieved from Institute for Child Health Policy Florida. at the University of (2009). quality careof report - FY 2010. Retrieved from Sources: Institute for Child Health Policy Florida. at the University of (2011). Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Program STAR Health CHIP Measure only 5% STARof Health population) Readmission within 30 days - Adults (represents illness within 30 days Follow-up care after hospitalization for mental illness within 7 days Follow-up care after hospitalization for mental months (Continuation Phase) had at least two additional follow-up visits within 9 After continuously taking medication to treat ADHD a follow-up visit within 30 days (Initiation Phase) After dispensed new medication to treat ADHD had illness within 30 days Follow-up care after hospitalization for mental illness within 7 days Follow-up care after hospitalization for mental months (Continuation Phase) had at least two additional follow-up visits within 9 After continuously taking medication to treat ADHD a follow-up visit within 30 days (Initiation Phase) After dispensed new medication to treat ADHD had 149 http://www.hhsc.state.tx.us/reports/2012/ann-qual-care-rep-STAR+PLUS-fy2010.pdf http://www.hhsc.state.tx.us/reports/2012/ann-qual-care-rep-STAR-fy2010.pdf http://www.hhsc.state.tx.us/reports/2010/CareReportSTAR_FY08_0310.pdf http://www.hhsc.state.tx.us/reports/2010/Quality_Care_ReportFY08.pdf http://www.hhsc.state.tx.us/reports/2010/Annual_Quality_Care_FY08.pdf http://www.hhsc.state.tx.us/reports/2012/Care-Report-STAR-FY2010.pdf Texas Medicaid Managed Care and Children’s Health Insurance Texas Medicaid Managed Care STAR Quality Careof Measure – Texas Medicaid Managed Care STAR Health Quality Careof Measures Texas Medicaid Managed Care STAR+PLUS Quality Careof Measures Texas Medicaid Managed Care and STAR Program, EQRO Texas Medicaid STAR Health Program, EQRO quality 2009 Performance 28% 88% 61% 91% 83% Not available Not available Not available Not available 2010 28% 92% 70% 94% 89% 74% 45% 56% 45%
2011 able Not avail- 91% 69% 90% 86% 71% 43% 58% 43% DSHS 77 84 88 89 89 90 91 93 94 96 96 99 85 87 80 82 90 94 100 100 102 102 103 104 105 106 106 106 108 109 109 110 111 112 112 116 117 117 105 106 111 113 115 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
Costs and Utilization Service Adult Measures ofQuality Care Costs and Utilization Service Youth Measures ofQuality Care Costs and Utilization Services Crisis Measures ofQuality Care Costs and Utilization Service NorthSTAR Measures ofQuality Care 108 Funding Exclusion (IMD) Diseases Mental for Institutions Costs and Utilization Hospital State Rates Recidivism Medicaid 82 Funding Utilization System Waitlists Medically Indigent People People Indigent Medically Populations Priority Care Managed Medicaid Services Crisis Services NorthSTAR Local Mental Health Authorities Health Mental Local NorthSTAR Framework Recovery and Resilience Texas 105 Civil Forensic Maximum Security Maximum Hospitals State Hospitals Private and Community State-Funded State Psychiatric Inpatient Competency Restoration Restoration Competency Inpatient Psychiatric State Restoration Competency Outpatient Restoration Competency Jail-Based Access Access 116 Funding Services for Eligibility Populations Priority 88 Access Changing Environment Environment Changing Texas Department of Services Health Department State Texas Prevalence and Trends Providers Service Community Mental Health Services Health Mental Community Services Hospital Health Mental Inpatient Timeline of Timeline Initiatives Service Health Mental Types of Settings Inpatient Types Restoration Competency Addressing the Shortage of Public Inpatient Beds Inpatient ofShortage the Addressing Public Substance Use Services Use Substance At A At A Glance State Health Services: Health State Texas Department of Department Texas DSHS 78 · F · · · · · · · · · · · · · Policy Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · · · · ast F Texas enteredthe83 Reduction of restraint and seclusion in state hospitals and other settings Deteriorating inpatient physical plant witharchaic design Critical mentalhealth workforce shortage Statewide expansion of YESwaiver services Length of incarceration while waiting for competency restoration services Evaluation of jail-based competency restoration pilot forensic director Need for system wide coordination of forensic issues, perhapsthrougha DSHS and the need for forensicservices Inpatient capacity shortage care Integration of behavioral health services into managed and meaningful performance measures Accountability Funding for diversion servicestoprevent relinquishmentof children Expansion of peerspecialist/recovery coach support services care service delivery Increased access toquality community-based services through integratedhealth of behavioral healthcare in seven North Texas counties. NorthSTAR care carve-out program createdtoimprove isamanaged thedelivery centers. health authorities (LMHAs),commonly known as communitymentalhealth Public mental health services are primarily provided through 39localmental NorthSTAR program. substance abuse providers,were served by includingthe DSHS-funded percent) of the187,837 youth with chemical dependence andmedicalindigence In Texas during FY2013, 54,914 (3percent) of the 1,776,671 adultsand6,928 (4 health centers and NorthSTAR. communitymental serious emotional disturbances were served by DSHS-funded and NorthSTAR. Similarly, only47,086 (27 percent) of the175,137 childrenwith community mentalhealthcenters mental illness were served by DSHS-funded In FY2013, 156,642 (31percent) of the 499,389 adults withseriousandpersistent than was allotted inthe previous biennium. health services, nearly $350 million more was appropriated forFY2014 and2015 Realizing that transformative actions were imperative toexpandaccess mental spending, or $34.57 per resident. Promising Practices in Substance Use Treatment Services Disorders Co-occurring Psychiatric and Substance Use The Texas Recovery Initiative CareQuality of Measures Utilization and Costs
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M e c or f tan s on b u visi i S D a aniz Org DSHS 80 solely to access needed mental health services. Additionally, DSHSisfunding10 children relinquished to Department of Family and Protective Services (DFPS) to access intensive communitybehavioral services and decreasethenumberof expansion of thewavier will allow more youth with serious emotional disturbance and DSHS to expand the Youth waiver statewide. Empowerment The Services(YES) health projects. One notable legislative directive isRider80, which directsHHSC The additionalmajorlegislative actions are comprised of new and expanded mental for Medicaid populations. coordination of services and continuity of care as wellimprove healthoutcomes evaluation have of theintegrationisto streamline been conducted, the goal the to determine the full impact of SB 58until proper data collection andoutcome reimbursement to the localmental health authorities. Although it will bedifficult that limited the providerpayment arrangement network eligibleto receive Medicaid but have historically been delivered outside ofMedicaidcare undera managed are acore component of theservice array for people withseriousmentalillness, Medicaid caresystem managed by September 2014. These twoMedicaid services specifically psychosocial within rehabilitation andtargeted casemanagement, Texas’ health treatment. SB 58will integrate funding for key behavioral health services, SB 58 (Nelson) established a new strategy in Texas for thedelivery ofbehavioral behavioral health services for individuals with mental health conditions. the last session play apivotal rolein increasing the provision of and timelyaccessto necessary funds andthe approval of numerous behavioral healthinitiatives during ofthe state’smanagement behavioral healthcare system. Restoration of critically tothedeliveryThe 83rd Legislative and sessionbrought significant changes Changing Environment public behavioral health services. Services Division provides oversight, monitoring, and strategic directionforthese distributed across thestate’s 11health and human service regions. TheMHSA substance use services and hospital services, areprovided ineachofthe254counties Public behavioral health services, comprised ofcommunitymentalhealthservices, delivery system. Abuse ServicesDivision (MHSA) oversees the public behavioral health service substance use authority for Texas. Within DSHS, the Mental Health andSubstance Texas Departmentof State Health Services (DSHS) isthestate mentalhealthand State Health Services Texas Department of Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas service area. with NorthSTAR, care program in theNorthTexas the behavioral health managed 152 The division also manages activities associated Thedivision also manages DSHS 81
154 ) requires DSHS, in conjunction with DADS, to in conjunction with DADS, DSHS, ) requires rd 155 153 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 develop and implement a 10-year plan on the future of state hospitals and state hospitals and state state future of plan on the a 10-year and implement develop infrastructure operational needs, will outline This plan living centers. supported serving individuals in their community. for and methods capacity issues needs, and transitional inpatient settings within practices best will also include The plan to plan will be submitted The the community. to for individuals returning services 1, 2014. December by Board (LBB) Budget and Legislative the Governor state discussed in this section include are further that significant initiatives Other Another initiative that has increased opportunities for recovery for individuals for recovery opportunities has increased that initiative Another use of certified peer support is the health conditions behavioral experiencing the Centers practice by an evidence-based Deemed Texas. throughout specialists and Mental Abuse and the Substance (CMS) Services and Medicaid for Medicare individuals Services Administrationsupport programs allow peer (SAMHSA), Health of others in the recovery to aid training relevant and experience lived both who have self- wellness, on recovery, focusing by health conditions mental experiencing are a cost- support specialists Peer living. independent and responsibility direction, the frequency other more to reduce intervention of effective and clinically effective outcomes. and better costs in lower resulting services, and more expensive intensive has undergonecertification requirements for to develop a thorough process Texas is Via Hope specialists. use recovery substance and specialists health peer mental DSHS and the Hogg funded by and jointly DSHS by the organization sanctioned and certify peer specialists. educate to train, Health for Mental Foundation SB 1(83 83 of Rider Additionally, The implementation of the 1915(i) Home and Community Based Services (HCBS) Based Services Community and Home the 1915(i) of The implementation for adults with a HCBS program first be the will option amendment plan state DSHS, hospital stays. psychiatric state with lengthy health condition mental plan state for a 1915(i) approval federal is seeking HHSC, in coordination with and of 2014 the summer in place take plan will submission of the Formal amendment. contingenton Center for 2015, for November is anticipated program implementation Services (CMS) approval. and Medicaid Medicare beds in private residential treatment centers (RTCs) for youth at risk for parental risk for parental at youth for (RTCs) centers treatment residential private in beds access to inability (SED) and disturbance emotional severe to a due relinquishment allocated to funds were additional demand, to high Due services. RTC necessary placed with 20 13 children are currently There in FY 2014. 3 more beds support on the waitlist. children The session also directed the creation of a statewide mental health public awareness awareness health public mental of a statewide the creation also directed The session health and reduce the of behavioral to increase public understanding campaign The campaign targets use conditions. and substance mental health of stigma to demystify well as their support systems as adults (14-24) young and adolescents conditions throughout and substance mental health resources for and provide tactics such includes marketing 2014, June campaign, which began in The Texas. (speakyourmindtexas.org),as a website media on media and broadcast online more 2014, Spanish and English. As of August, in both radio available and television averaging for information and resources, individuals visited the website than 30,000 six of the 16 community 2014, as of August, Additionally, each week. visitors 5,000 to create local together stakeholders to bring in an effort were held conversations plans. action forums and DSHS previous biennium. than wasallotted inthe for FY 2014and2015 more wasappropriated nearly $350 million mental health services, expand access to were imperative to transformative actions Realizing that 82 · · · · In 2013, DSHS health strategies were funded by the following majorsources: Funding Trends and Prevalence expansion of crisisservice programs. Health Authorities (LMHAs),creation of ajail-based restoration pilot inDallas, and mental health services, expansion of thepriority populations served by LocalMental hospital infrastructure repairs, initiatives toeliminate wait lists forcommunity Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Other funds (9 percent). grant funding from SAMHSA). Federal funds(38percent) (including both Medicaid dollars fromCMSandblock revenue (36percent). State general Medicaid disproportionate share hospital program). $137,860,100 to theEMS-Trauma revenue dedicated account forthe general revenue dedicated (17 percent)(includes a one-timetransferof State general gains for FY 2014/2015. Every line item detailed in Figure21 received significant funding health system, with $1.7 billion from thestate revenue. general contains an unprecedented $2.6 billion for the public mental funding for behavioral health. The FY 2014–2015 DSHSbudget previous biennium. This increase put anendto a decadeof flat appropriated for FY2014 and 2015 than was allotted in the access to mental health services, nearly $350 million morewas Realizing that transformative actions were imperative toexpand attention to failures in thenation’s mental health system. and Aurora movie theater shootings in 2012 turned the country’s the national average of $103.53. capita mentalhealth spending, or $34.57per resident, well below Texas enteredthe83rd legislative session ranking 49th inper 158
157 TheSandy Hook Elementary 156 DSHS 83 $1,332,776,065 $79,971,620 $420,992,249 $150,011,076 $130,626,308 $110,829,717 $105,798,674 $324,546,421 FY 2017 FY Requested $1,322,776,075 $79,971,621 $420,992,251 $150,011,077 $130,626,310 $110,829,718 $105,798,676 $324,546,422 FY 2016 FY Requested Priorities. Policy Public for Center $1,306,901,402 $79,971,621 $419,788,110 $149,956,982 $119,228,465 $115,155,291 $108,430,662 $314,370,271 - Bud 2015 FY geted Retrieved Retrieved Request. Appropriations Legislative 2016-2017 FY $1,339,169,632 $77,675,356 $433,612,004 $157,893,764 $122,834,933 $106,716,332 $96,581,563 $343,855,680 - Esti 2014 FY mated $1,161,657,609 $67,501,308 $405,014,273 $136,191,615 $123,383,334 $84,006,025 $59,732,529 $285,828,525 FY 2013 FY Expended 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://forabettertexas.org/images/2013_10__PP_Budget_MentalHealth.pdf http://www.dshs.state.tx.us/budget/lar/default.aspx Total Mental Health Community Community Mental Health Hospitals Mental Health State Hospitals State Mental Health Substance Use, Prevention, Prevention, Use, Substance Intervention Treatment and NorthSTAR Behavioral Health Health Behavioral NorthSTAR Waiver Community Mental Health Health Mental Community Services Crisis Mental Health Services-Chil- Mental Health dren Mental Health Services-Adults Health Mental Budget Strategy Budget Source: Texas Department of State Health Services. (August 11, 2014). 2014). 11, (August ofDepartment Services. Health State Texas Source: from FY 2013 State Expenditures, FY 2014 – 2015 Appropriations and FY FY and Appropriations 2015 – 2014 FY Expenditures, State 2013 FY 22. Figure (all funds) Request Appropriations 2016-2017 Legislative and FY 2014/2015 expenditures for FY 2013 DSHS funds details figure The following strategy. budget by appropriations Source: Ligon, K. (October 21, 2013). Sizing up the 2014-2013 Texas Budget: Mental Health. Health. Mental Budget: Texas 2014-2013 the up Sizing 2013). 21, (October K. Ligon, Source: Retrieved from from Retrieved Texas Public Behavioral Health Spending: Annual Spending 2003- Spending Annual Spending: Health Behavioral Public Texas 21. Figure 2015 DSHS 84 mental health centers and NorthSTAR. community with serious emotional disturbances were served by DSHS-funded centers and NorthSTAR. Similarly, only 47,086 (27percent)of the 175,137 children communitymentalhealth persistent mental illness wereserved by DSHS-funded system. In FY2013, 156,642 (31percent) of the 499,389 adultswithseriousand mental health services than arecurrently being served in thepublic mental health As illustrated in Figure 23, there aremany more adultsandchildrenwhorequire driven byduring this period, and is largely increased utilization from adults. health services through these entities has increased by approximately 40 percent (LMHAs) and NorthSTAR. community mental health services in Texas through local mentalhealthauthorities From FY2008 through FY2013, roughly1.1 million adultsandchildren received System Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas mental health and substance abuse services [PowerPoint slides]. Source: Texas State Health Services. Department of (2014). Adults (FY 2013) Children(FY2013) Adults Figure 23. UnmetNeedsforCommunity MentalHealth Services being available and a smaller percentage ofpersons receiving services.being available andasmaller percentage unable to keep pace with the increased cost of services, resultinginfewerservices appropriations during the 83 While the amount of funding per person has increased asaresultofmentalhealth Utiliza tion The unduplicated number of personsprovided mental rd session, the previous decade ofstagnant fundingwas Presentation to senate health and human services committee: Overview 162 www.dshs.state.tx.us/legislative/default.shtm
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164 Recent legislative attempts have successfully addressed waitlist issues. Portions of Portions issues. waitlist successfully addressed have attempts legislative Recent the 83 by appropriated funding mental health the supplemental When LMHAs have exhausted their funding, non-Medicaid eligible individuals who eligible individuals non-Medicaid funding, their exhausted have When LMHAs are who individuals However, to a waitlist. added are services health require mental prohibits waitlists law federal because into services admitted be must on Medicaid on the while for Medicaid is approved if the individual Additionally, for Medicaid. All other services. into the individual to expedite 60 days LMHA has the waitlist, are Medicaid have not but do health services for mental who are eligible individuals are contacted every individuals These of capacity. due to lack the waitlist placed on mental there is no additional to ensure professional a mental health by 90 days intervention assessed and immediate is deterioration If clinical deterioration. health into services. be placed may the individual is required, itlists itlists Wa As a result of passed legislation, by the end of May 2014 these numbers decreased these 2014 May the end of by of passed legislation, As a result as of March Additionally, on waitlists. and zero children with 285 adults drastically, of care (LOC). level into an appropriate been moved adults had 1,435 2014, From FY 2009 to FY 2012, the number of adults on waitlists for community mental for of adults on waitlists number the to FY 2012, FY 2009 From number of monthly the average while 85 percent, by services increased health for community mental on waitlists Children remained constant. adults served due to a special period the same during percent 24 by decreased services health barrier to a significant remained still waitlists however in FY 2010; appropriation community mental by of adults served population the Like services. timely accessing has remained served of children number monthly the average services, health constant. funds adults and children requiring mental health services and children with special services and children with health requiring mental children and funds adults 92 Rider Additionally, 2012. May as of waitlist were on the who care needs health to eliminate million $48.2 over appropriated bill) 1 (appropriations in SB included also DSHS was services. mental health community adult and child for lists wait community health service and to expand Rider 85 through million $43 appropriated due to resource limitations are underserved who of individuals needs address the population and surgefor in demand demands of a growing the to address as well as services. lists. children were on the waiting adults and 241 7,947 end of FY 2013, the At DSHS 86 May 2014 Figure 25. Impact of Child Waiting List by Children Served – FY 2012 – FYTD mental health and substance abuse services [PowerPoint slides]. Retrieved from Source: Texas State Health Services. Department of (2014). 2014 Figure 24. Impact of Adult Waiting List by Adults Served – FY 2012 – FYTD May Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas mental health and substance abuse services [PowerPoint slides]. Retrieved from Source: Texas State Health Services. Department of (2014). Presentation to senate health and human services committee: Overview Presentation to senate health and human services committee: Overview www.dshs.state.tx.us/legislative/default.shtm www.dshs.state.tx.us/legislative/default.shtm
DSHS 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 The 80th Texas Legislature appropriates $82 million to address problems in the $82 million appropriates Legislature Texas The 80th were Funds system. delivery use crisis service and substance mental health state’s crisis services. to more effective access statewide to create intended OCR clients. its first serves pilot (OCR) restoration competency Outpatient been charged a crime with illness who have helps individuals with serious mental more rather than in communities own services in ther restoration to receive settings. restrictive and HHSC DSHS approves Services (CMS) Youth for Medicaid Center in flexibility greater (YES)Services allowing Empowerment proposal, waiver supports for youth with serious and services community-based of the funding Counties in Bexar and Travis began in programs Pilot disturbances. emotional counties Bend and Galveston Brazoria , Fort , Harris , 2012 in County Tarrant 2011, 2014. Hidalgo and Cameron, and Willacy counties in June, 2014 in February care of system of a recovery-oriented implementation statewide DSHS begins (ROSC)the ROSCof The initial elements initiative. in are developed initiative and mental use by substance persons affected that ensure to help communities of services and a continuous path to a continuum provided conditions are health recovery. a 1115 Transformation Waiver implement to approval a federal receives Texas agencies across through health infrastructure mental the state’s to transform solutions infrastructure and sustainable practical consumer-focused, “innovative, effectiveness.” mental health that hinder problems to systemic changes RDM, including a name change to to implementing system DSHS begins further emphasizes recovery- The system (TRR). Resiliency and Recovery Texas evidence-based practices. fidelity and focusing on of care system oriented DSHS begins roll out of the resiliencyroll out DSHS begins management disease and model (RDM) changeswhich created fundamental of services delivered and amount in the type relies on evidence- RDM model The conditions. health mental with to people consumer possible the best to obtain based practices and principles of recovery dollars. available maximize and outcomes 2007 · 2008 · 2009 · 2010 · 2011 · 2012 · Timeline of Timeline Service Health Mental Initiatives efforts to made sustained has DSHS decade, past the over limited funding Despite presented initiatives system major through delivery in service innovation implement a modern reflect a shift towards initiatives The following timeline below. in the in rooted person-centered, that are services emphasizes which system delivery access and improve institutionalization, to offer alternatives and resilience, recovery care. of continuum full a provide 2004 · DSHS 88 Figure 26. Subsidized Coverage in Texas & Annual Income Levels: 2014 children, pregnant women, older adults and people with disabilities. Medicaid covers acute healthcareand long-term servicesandsupportsforfamilies, who also meet other eligibility requirements (e.g.have categorical adisability). Medicaid isafederal and state funded program that serves low incomeindividuals Medic receive the appropriate level of careandsupport. to seek ways toimprove accesssothat individuals with mental healthconditions can delivery systems aretheprimarydeterminants of accessandquality. Texas continues Department’s priority populations (see below). Resources, eligibilityandservice conditions who areeligible for Medicaid, determined orfall under the to beindigent DSHS prioritizesaccessto services for persons with serious mentalhealth Access · 2014 · 2013 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Medicaid. On average, 3.6 million adult and2.6 million childTexas residentsareenrolled in Eligibility-Levels-Table.pdf Medicaid-Moving-Forward-2014/Downloads/Medicaid-and-CHIP- 2014. Retrieved from: State Medicaid and CHIP Income Eligibility Standards Effective July 1, Source: Center for Medicare & Medicaid Services (October 24, 2014). level (FPL) shown in Figure 26may qualify for Texas Medicaid. eligibility requirements and havecategorical an income lessthanthefederalpoverty U.S. citizens or legal permanent residents who live inTexas meet the necessary managed care(discussed in theService Providersmanaged section). The state hasno current 400% 200% 133% 100% 15% FPL management into Medicaid carebegins as ofSeptembermanagement managed 1,2014. The transitionofbehavioral health rehabilitative servicesandtargetedcase included in Medicaid care. managed Medicaid waiver, aswellexpanding the breadth ofbehavioral healthservices treatment capacity of alternatives toinstitutionalization, expansionofYES for mental health services and initiatives including housing services, expanded The 83rd Legislative sessionappropriates roughly $350 millionadditionalfunds 168 aid Most of these Texans will receive health services throughMedicaid http://www.medicaid.gov/AffordableCareAct/ $46,680 $23,340 $15,521 $11,670 $1,750 Individual $95,400 $47,700 $31,720 $23,850 $3,577 Family 4 of 167 166 Only insurance. access tohealth LMHAs wouldhave services servedby substance use mental health and individuals requiring medically indigent the majorityof theFPL,percent of to adultsup138 Medicaid coverage TexasIf expanded DSHS 89 174 Although If Texas expanded If Texas coverage Medicaid up to 138 to adults ofpercent the FPL, the majority of medically indigent individuals requiring and mental health substance use by services served LMHAs would have access to health insurance. 176
If 172 169 legislative session, amend the legislative rd
170 In an effort to reduce involvement in the criminal involvement to reduce In an effort
177 Medically indigentindividuals who Medically 178,179 171 tions Individuals whose adjusted income is at or below 200 percent percent 200 or below income is at adjusted whose Individuals 173 ) requires DSHS to improve the measurement and collection of the measurement and collection ) requires DSHS to improve rd ndigent People Indigent 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 lly ally As of January 2014, 143 of Texas’ 254 counties operated CIHCPs. 254 of Texas’ 143 2014, As of January 175 Health and Safety Code to expand treatment services provided by LMHAs to adults by services provided treatment to expand Code Safety and Health law. authorized by already not disorder health diagnosed mental with a Rider 58 of SB 1 (83 justice system and expand access to mental health services, LMHAs are now required LMHAs are now services, mental health access to and expand system justice following of the to manage DSHS adults and with any and adolescents children, by 27. in Figure listed diagnoses Within the first 30 days of rendering mental health services, a services, health rendering mental of 30 days first Within the ability of an individual’s assessment LMHA conducts a financial fee or no fee, depending on the monthly a maximum assesses for services and to pay income. individual’s meet the priority population criteria (explained below) are eligible (explained below) the priority population criteria meet DSHS-fundedto receive the DSHS system. through services Texas expanded Medicaid coverage to adults up to 138 percent of of percent up to 138 adults to coverage expanded Medicaid Texas indigentof medically the majority the FPL, requiring individuals LMHAs by services served use health and substance mental insurance. access to health would have HB 3793 (Coleman) and SB 7 (Nelson), from the 83 from the SB 7 (Nelson), and (Coleman) HB 3793 Priority Popula Priority The County Indigent Health Care Program (CIHCP) is one program offering services (CIHCP) Program Care IndigentThe County Health counties, services through health to individuals who are indigent.provides CIHCP eligible residents to the state throughout and public hospitals districts hospitals of the percent (depending on the county) 21-50 exceed whose income does not exceed household resources do not (FPG) and whose Guideline Poverty Federal $3,000. Medic Code, an indigent and Safety Health According to the Texas (2) has who: (1) possesses no property; person is “an individual support; and (3) is the patient’s for responsible no person legally support, patient’s of the costs for the the state unable to reimburse treatment.” maintenance and plans for expanding Medicaid coverage through the state-optional Affordable Care Care Affordable state-optional the through coverage Medicaid expanding for plans FPL who of the 100 percent below adults to provision Act (ACA) the Marketplace. through insurance access to have do not treatment services were not previously prohibited to the now expanded populations, expanded populations, the now to previously prohibited were not services treatment to adults with schizophrenia, bipolar of services the provision only ensured the law major depression. disorder and of the FPL are eligible for full funding of substance use services. Individuals whose use services. of substance for full funding eligible FPL are of the eligible for full funding of the FPL are of 150 percent below income is at or adjusted on a sliding fee basis. are assessed they services; otherwise, health mental other outcome data for medically indigentoutcome data for medically individuals and individuals enrolled in Medicaid. analysis on these two populations receivingDSHS will conduct a comparative study the final report on health services and submit a publically funded behavioral by December 1, 2014. Board (LBB) and Budget findings to the Legislative governor Only 166 167 Family of 4 Family $3,577 $23,850 $31,720 $47,700 $95,400 Individual $1,750 $11,670 $15,521 $23,340 $46,680 http://www.medicaid.gov/AffordableCareAct/ Most of these Texans will receive health services through Medicaid services through Medicaid health receive will these Texans of Most aid 168 The 83rd Legislative session appropriates roughly $350 million additional funds funds additional million $350 roughly appropriates session Legislative 83rd The expanded services, housing including and initiatives health services for mental YES expansion of to institutionalization, alternatives of capacity treatment services health breadth of behavioral the as well as expanding waiver, Medicaid managed care. in Medicaid included case services and targeted rehabilitative health behavioral The transition of 1, 2014. managedmanagementas of September care begins Medicaid into FPL FPL 15% 100% 133% 200% 400% managed care (discussed in the Service Providers section). The state has no current has no state section). The managedProviders in the Service care (discussed U.S. citizens or legal permanent residents who live in Texas meet the necessary necessary the meet in Texas who live residents permanent or legal citizens U.S. less than the federal poverty income an categoricaland have requirements eligibility Medicaid. for Texas qualify Figure 26 may in shown (FPL) level On average, 3.6 million adult and 2.6 million child Texas residents are enrolled in million child Texas adult and 2.6 million 3.6 On average, Medicaid. Medic income individuals low serves that funded program and state is a federal Medicaid a disability). categorical have requirements (e.g. eligibility other meet who also and supports for families, long-term services acute health care and covers Medicaid disabilities. people with adults and women, older pregnant children, 2014 Levels: Income Annual & Texas in Coverage Subsidized 26. Figure 2014). 24, (October Services Medicaid & Medicare for Center Source: 1, July Effective Standards Eligibility Income CHIP and Medicaid State from: Retrieved 2014. Medicaid-Moving-Forward-2014/Downloads/Medicaid-and-CHIP- Eligibility-Levels-Table.pdf 2013 · 2014 · Access mental health serious with persons for services access to DSHS prioritizes to be indigent the under or fall determined for Medicaid, who are eligible conditions eligibility and service Resources, (see below). populations priority Department’s continues Texas of access and quality. are the primary determinants systems delivery mental health conditions can with individuals access so that to improve ways to seek of care and support. level appropriate the receive DSHS 90 Service Providers Figure 27. LMHA Priroity Population Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas services fromanorganization undercontractwiththe state. In aMedicaidcare system, managed individuals getmost orall of theirMedicaid Medic · · · major service providers: Publicly funded mental health services inTexas are provided by thefollowing three for eachclient enrolledratherthanpaying theprovider afeefor each individual service. careorganization(MCO)andpays acapitatedrate(permember,a managed permonth) Children & Adolescents Children Adults Populations NorthSTAR Local Mental Health Authorities Medicaid Care Managed aid Mana the priority population criteria for mental health services. developmental disorder, intellectual disability or substance use do not meet autism,*Children and adolescents with a single diagnosis of pervasive serious emotional disturbance. Are enrolled in a school system’s special education program because of to psychiatric symptoms. a preferred living or child care environment disruption of due Are at risk of Have a serious functional impairment. the following criteria: one of serious emotional, behavioral or mental health conditions, and meet at least Children ages 3 through 17 who have a diagnosis mental of illness, exhibit Any other diagnosed mental health disorder specified Bulimia nervosa, anorexia nervosa, or other eating disorders not otherwise Delusional disorder Anxiety disorder Obsessive compulsive disorder Schizoaffective disorder, including bipolar and depressive types Post-traumatic stress disorder disorder Major depression, including single episode or recurrent major depressive Bipolar disorder Schizophrenia mental illness diagnosis of: Serious functional impairment (GAF less than 50) and severe and persistent Eligibility Criteria ged Care 180 The state contracts with Thestate contractswith DSHS 91 183 181 horities Aut h alt legislative session directed the integration of behavioral behavioral the integration of session directed legislative rd
l He al 182 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 Ment al State of Texas Access Reform (STAR) AccessReform (STAR) of Texas State +PLUS STAR HEALTH STAR (CHIP) Program Insurance Health Children’s Dental Medicaid Children’s CHIP and in 2016) Kids (starting STAR oc health and physical health services into Medicaid managed care. By September 1, managed September into Medicaid care. By services health and physical health management case health targeted mental and mental health rehabilitative 2014, Targeted case managed care benefit. Medicaid in the be included services must for Medicaid service coordination planning and face-to-face crisis managers provide Case managers also regularly health services. mental seeking individuals eligible services include crisis The mental health rehabilitative monitor service effectiveness. skills training and support services, training and medication services, intervention care. for acute programs and day services development Public mental health services are primarily provided through designated local primarily provided are services mental health Public as community mental health known commonly (LMHAs), health authorities mental or 39 community centers to provide oversees with and DSHS contracts centers. arrangehealth crisis and ongoingmental of community for the delivery services individuals with a priority indigentfor medically adults, adolescents and children, in specific residing Medicaid eligible for as those as well diagnosis population are designated 37 39 centers, Of the 28. in Figure below geographicareas shown service region. NorthSTAR in the providers as contracted and two serve LMHAs L HHSCoperational shift from fee-for- planning the for responsibility take will data collection and and to managedservices procedures, care, the evaluation HHSC specialty mental contracts for and monitor for will pay Additionally, analysis. HHSC between and collaboration Data exchange and DSHS will services. health policyits DSHS to continue for in order be crucial and planning role for Medicaid services. behavioral Additionalon managedinformation in the HHSCis available care programs section. 83 (Nelson) of the SB 58 The MCOs are responsible for creating a network of public and private providers providers private public and of a network for creating are responsible MCOs The a access to are able Medicaid receiving children and adults that to ensure authorization for service MCOs are responsible of services. variety comprehensive providers. service with and reimburse contract and directly include: Managedin Texas care programs · · · · · · DSHS 92 and services for mental health care. The LMHAs are required to plan,develop andcoordinatelocal policy, resources · · · As anauthority, LMHAs are responsible for: Health Committee. Retrieved from Source: Texas Department Stateof Health Services. (2013). Overview Publicof Mental Health System. Presentation to House Public Figure 28. LMHAsand39ServiceRegions Mapof Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas services when other providers areunavailable. LMHAs oftenfinditchallenging to external provider networks andserve asaprovider of last resort, providing direct involving state funds comply with pertinent state standards. Demonstrating that the services provided directly or throughsubcontractors treatment alternatives forindividualsrequiring mental healthservices. of service providers; and 2) recommending the most appropriate andavailable and the best useof public funds in: 1)creation and maintenanceofa network Considering community input, cost effectiveness, andcareissuestoensure choice are provided populations. in thelocal service area for indigent Allocation of fundsfrom DSHS to ensure mental health andsubstance useservices Lo www.dshs.state.tx.us/legislative/default.shtm c a L l
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DSHS 93 187 With the introduction of 186 In 2013, NorthSTAR recipients NorthSTAR In 2013, 188 DSHS oversees the quality of services provided of services provided the quality DSHS oversees 185 189 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 AR particularly in rural and Texas-Mexico border areas. Thus, LMHAs typically LMHAs Thus, areas. border Texas-Mexico in rural and particularly NorthSTAR, the state braided funding for mental health and substance use services funding for mental health and substance braided the state NorthSTAR, health a single public behavioral establishing thereby funding streams, across several found that the pooled funding system While evaluations of the NorthSTAR system. for maintaining multiple structures approach has resulted in fewer administrative it is difficult to compare for services, more money to be available allowing of care, systems structures. system differing due to the vastly traditional LMHAs with NorthSTAR to individuals and regularly provides both training and technical assistance to technical assistance and training both provides and regularly to individuals LMHAs. (with or without at the LMHA arrives eligible who is indigentA person or Medicaid is assessment and uniform diagnostic where a psychosocial, an appointment), is calculated. determination care (LOC) of a level process, this From completed. becomes eligible for the individual 4, 1 and LOC LOC LOC falls between If the discussed under the be further will distinctions The LOC health services. mental section. Services Health Mental Community development longerno are LMHAs responsible for network 2014, As of September targeted case services and rehabilitative mental health for Medicaid and payment management,included in the Medicaid services be that these 58 mandates as SB for the responsibility retains LMHA still the However, managed care system. as serving as the primary as well familiar with resources and being planning case management and targeted of rehabilitative in managed for people provider Traditional as Significant to serve with LMHAs contract MCOs care. Additionally, clients. for Medicaid-eligible (STPs) Providers ValueOptions, a private behavioral health organization, is the Medicaid Managedhealth organization, is the Medicaid behavioral a private ValueOptions, for service is therefore responsible region and the NorthSTAR Care Organization for managementutilization Local development, payment. and claims network delivery, for the NorthSTAR Authority Health Behavioral North Texas by is provided oversight local planning, has the same Authority Health Behavioral Texas service region. North provide LMHAs but does not policyother functions as resource development and services. health direct behavioral Medicaid-eligible residents in the service region are automatically enrolled in the region are in the service residents Medicaid-eligible mental health and substance with comprehensive program and provided NorthSTAR Medicaid recipients but who reside in the who are not Individuals use benefits. certain if they meet services NorthSTAR receive eligible to also be may service area federal 200 percent of the at or below income adjusted an clinical criteria and have insurance. health other and lack level poverty The NorthSTAR managed care carve-out program was created in 1999 in an effort to managedwas program care carve-out The NorthSTAR counties (Dallas, North Texas healthcare in seven of behavioral the delivery improve Ellis and Navarro). Kaufman, Collin, Hunt, Rockwall, hST Nort establish successful contracts for services, especially rehabilitation and other routine other and rehabilitation especially services, for contracts successful establish shortages workforce health mental in extensive to due in part services, outpatient Texas, providers. service as primary serve represented roughly 32 percent of the total population of Texas below 200 percent of below of Texas population of the total 32 percent roughly represented level. poverty the federal DSHS 94 4. 3. 2. 1. The TRRsystem isresponsible for: resilience to obtain the best possible outcomes and maximizeavailable funds. model relies on evidence-basedpractices (EBPs) and principles of recovery and person-, family- andcommunity-centered recovery-based approaches. TheTRR Texas andRecovery Resiliency (TRR)to further reflect the state’s commitmentto (RDM) to health system and DiseaseManagement from Resiliency name changed Texas In September andDiseaseManagement. 2012, Resiliency the Texas mental mental health services were delivered thatwas launched in2004underthename andRecovery.Resiliency Thisframework is anoutgrowth oftheshiftinhow public under which DSHSdelivers publicmental health services isknown asTexas services, practices and beliefs into the public mental healthsystem. Theframework with the recent national movement andrecovery-based to incorporate resiliency The DSHS vision statement of“Hope, Resilience and Recovery forEveryone” aligns Texas services and crisis services.ongoing The array of community mental health services for adultsand children includesboth Community Mental Health Services increase in numbers served over the seven-year period. in FY2013 in comparison to almost 48,000 in FY2006, resultingina54percent NorthSTAR was 506,646. Over 74,000 individuals received services from NorthSTAR In the third quarter of FY2013, theunique count of Medicaid enrolleesin Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas serve all eligible persons. NorthSTAR doesnot have a waiting list because, by contract,theMCOisrequiredto TRR level of care. describes the childand adolescent target population and servicesavailable at each recovery. Figure29describestheadult target populationandservices. Figure 32 and resilienceisbuilt, individuals will transition to lower LOCs, and eventually to continuum of mental health need. Theexpectation is thatasstrengths areidentified this model, the intensity of services is based on anindividual’s respective place onthe determine the appropriate level of care(LOC) and correspondingservices. Within Clinical needsidentified by auniform assessment (ANSAand CANS) areusedto Determining service cost Determining service Measuring outcomes clinical rendered and impacts of services Establishing ways utilization to manage service Strengths (CANS)) Needs &Strengths Assessment (ANSA)and &Adolescent Child Needs & Establishing through is who eligible auniform for assessment services (Adult R esilience 193
and 192 R ecovery Fr 190 Unlike the LMHAs, amework 191 DSHS 95 - All LOC 1M services + skills and skills + services 1M LOC All engage- development, training hous- supported activities, ment cognitive employment, and ing peer and therapy processing outpatient in Provided support. settings. office-based and +psychother services LOC-1 All services. apy Brief address to interventions prevent and crisis immediate the intensive more for need the services. management Pharmacological - manage case routine services, diagnostic psychiatric ment, Provided examination. interview office-based outpatient, in settings. All LOC-2 services + psycho- + services LOC-2 All services, rehabilitative social needs acute for programs day treatment. residential and in provided are Services and office-based outpatient settings. community-based Services - 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 - pres who population priority DSHS meet who Adults not do supports, social have ofrisk little ent harm, benefit can and intervention, intensive more require ofgoal The oflevel this to is care psychotherapy. from symptoms, reducing/stabilizing by recovery facilitate of deterioration prevent and functioning improve condition. person’s the ofsymptoms have who Adults depressive major little present who 50) than lower or at (GAF disorder oflevel a and supports have who ofrisk func- harm, service, intensive more require not does that tioning to is Goal psychotherapy. from benefit can who and oflevel improve - deteriora prevent and functioning goals. recovery support to and tion who population priority DSHS meet who Adults levels severe to moderate with system the entered is Goal ofrehabilitation. intensive require and need team-based a through recovery in adult support to symptoms, stabilize to individual Engages approach. skills, self-advocacy develop functioning, improve improvement sustain and support natural increase LOC. intensive more in made Target Population and Service Goal Service and Population Target of resolution is Goal crisis. in population General of avoidance and crisis the restrictive and intensive relapse. or intervention priority for definition DSHS the meet who Adults a maintained and attained have who population ongo- the for oflevel except treatment in recovery to ready are Individuals medications. for need ing of out transition system health mental public the if transition the make would and appropriate complement to Intended available. were resources the in available supports alternative and/or natural prevent to is Goal recovery. promote that community of deterioration ther medication through condition apy until access to psychiatric and pharmacological pharmacological and psychiatric to access until apy community. the in available are resources LOC-3: Intensive LOC-3: Services TRR Team with Approach LOC-2: Service Basic - Coun including seling LOC-1S: Services Basic Training) (Skills LOC-0: Services Crisis LOC-1M: Services Basic (Medication Management) Level of Care of Level Care (LOC) Texas Resiliency and Recovery Level of Care for Adults Adults for of Level Care Recovery and Resiliency Texas 29. Figure DSHS 96 Services.state.tx.us/mhsa/databook. FY 2013, fourth quarter [PowerPoint . slides] Retrieved from Note: Data are from each year’s fourth quarter. Source: Texas Department Stateof Health Services. (2013). Figure 30. Utilization/Cost for Adult Community Mental Health Services included in Figure30 below. The utilizationandcosts for adult community mental health servicesinTexas are ADULT SERVICE UTILIZATION AND COSTS www.dshs.state.tx.us/mhsa/trr/documents/ Source: Texas State Health Services. Department of (2012). Adult Utilization Management Guidelines-FY 2014. Retrieved from: Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Behavioral Health Databook, are provided in theFigure 31 below. Otherquality measures are reportedinthe Selected data from FY 2011 toFY2013 on common adult outcomemeasures QUALITY OFCARE MEASURES services. Average monthly number receiving community mental health Average cost of community mental health services per adult served. Average cost of tional Services LOC-5: Transi- Treatment (ACT) Community LOC-4: Assertive (LOC) CareLevel of obtain appropriate community-based services. into the appropriate LOC or assisting individual to preventing further crisis and engaging individual Goal is to assist individuals in maintaining stability, person in recovery from their home. within a mobile service delivery team to serve the services and merge clinical and rehabilitation staff nity level. Goal is to provide comprehensive array of atric hospital admissions at the state and/or commu- features, etc.) and have experienced multiple psychi- disorder, major depressive disorder with psychotic persistent mental illness (schizophrenia, bipolar Adults receiving ACT services have severe and Target Population and Service Goal available at http://www.dshs.state.tx.us/mhsa/databook/ http://www.the DepartmentofStateHealth FY 2011 76,325 $372 Services 90 days. need. LOC-5 is available for up to stay depend on individual of and service intensity and length LOC-5 is highly individualized behavioral therapy. cessing therapy and cognitive day programs + cognitive pro- All LOC-3 services not including Behavioral health data book, FY 2012 77,873 $366 FY 2013 79,611 $352 http:// DSHS 97 Performance Performance Contract Target 2013 FY 77% 98% 38% available Not Services FY 2013 79% 98% 38% 0.43% Briefthe address to interventions the prevent and crisis immediate services. intensive more for need LOC this in served Children/youth need occasional an have may management case routine for ongoing have not do but services ofoutside needs treatment services. related medication FY 2012 FY 81% 98% 37% 0.35% http://www.dshs.state.tx.us/mhsa/databook/ FY 2011 79% 98% 35% 0.38% Target Population and Service Goal Service and Population Target General child and adolescent population in crisis. crisis. in population adolescent and child General of resolution is Goal ofavoidance and crisis the relapse. or intervention restrictive and intensive Children and adolescents whose only identified identified only whose adolescents and Children Goal management. medication is need treatment child/youth’s the utilize and stability maintain to is identified and supports natural caregiver’s and/or based community to transition help to strengths if available. resources, and providers 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 Level of Care of Level Care (LOC) LOC-0: Services Crisis Percentage of services health mental community in adults Percentage - of assess days 14 within encounter service first receiving ment. of services health mental community in adults Percentage crisis. avoiding of services health mental community in adults Percentage year. per functioning acceptable or improved with of services health mental community in adults Percentage commu- or state a to days 180 in times more or 3 admitted hospital. psychiatric nity LOC-1: Medication Management Quality of Care Measures Quality of Care Note: Data for first three items are from each year’s fourth quarter. Source: Texas Department of State Health Services. (2013). (2013). Services. Health State of Department Texas Source: quarter. fourth year’s each from are items three first for Data Note: from Retrieved slides]. [PowerPoint quarter fourth 2013, FY book, data health Behavioral Ado- and for Children of Level Care and Recovery Resiliency Texas 32. Figure lescents
Selected Quality of Care Measures for Adults Receiving Community Community Receiving Adults for Measures of Quality Selected Care 31. Figure Services Health Mental DSHS 98 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Family Services LOC-4: Intensive Complex Services LOC-3: Targeted Services LOC-2: (LOC) CareLevel of caregiver through a team approach. build strengths and resiliency in the child/youth and or risk behaviors, improve overall functioning, and or death. Goal is to reduce or stabilize symptoms and/ residential treatment, or others, serious injury to self school, displacement from home, hospitalization, in—juvenile justice involvement, expulsion from symptoms may have resulted in—or are likely to result or emotional needs. These behaviors and/or mood home of placement as a result behavioralof and/ systems. out The child or youth is also likely at risk of significant involvement with multiple child-serving ioral and/or emotional treatment needs who have Children and adolescents who have identified behav- resiliency in the child/youth and caregiver. improve overall functioning, and build strengths and reduce or stabilize symptoms and/or risk behaviors, require multiple service interventions. Goal is to and/or life domain functioning impairments that risk behaviors also exhibit a moderate degree of behavioral and emotional treatment needs. May Children and adolescents who have identified building strengths in the child/youth and caregiver. mood symptoms or address behavioral needs while domain functioning needs. Goal is to improve In general, the child/youth will have low or no life needs in either emotional Children and adolescents must have identified Target Population and Service Goal or behavioral treatment. process. through the wraparound planning linkage to community resources identified by the caregiver and supports and strengths that are through building upon natural Caregiver resilience is fostered child/youth and caregiver. the support the complex needs of to consider flexible office hours to available.if Providers may need also be provided via telemedicine, community location. Services may setting, school, home, or other caregiver, including the office location for the child/youth and provided in the most convenient (wraparound). Services should be + intensive case management All services available in LOC-3 child/youth and caregiver. the support the complex needs of to consider flexible office hours to available.if Providers may need also be provided via telemedicine, community location. Services may setting, school, home, or other caregiver, including the office location for the child/youth and provided in the most convenient respite services. Services should be All services available in LOC-2 + available. if also be provided via telemedicine, community location. Services may setting, school, home, or other caregiver, including the office location for the child/youth and provided in the most convenient skills training. Services should be parent provided as a component of but individual skills training is also intervention for the child/youth when counseling is the primary training. The only exception occurs counseling or individual skills The targeted service is either Services DSHS 99
$383 17,878 FY 2013 FY Retrieved Retrieved $383 17,628 FY 2012 FY Services Behavioral health data book, book, data health Behavioral $357 18,017 FY 2011 FY All service available in LOC-4. LOC-4. in available service All of on placed is services Focus this as relationship dyad the context primary the is relationship primary These children. young for for stage the set relationship(s) behavior social-emotional future behavior. relationship future and the in provided be should Services the for location convenient most the including caregiver, and child Services home. or setting office telemed- via provided be also may if fidelity and ifavailable, icine, may Providers maintained. be can office/ flexible consider to need needs the support to hours service ofcaregiver. and child the the and individualized Highly oflevel and intensity service oflength vary to expected is stay Services need. individual on based management, case routine include interview diagnostic psychiatric pharmacological examination, training medication management, skills counseling, support, and development, and training family supports, partner family and group support parent training, activity. engagement - http://www.dshs.state.tx.us/mhsa/databook/ Target Population and Service Goal Service and Population Target Children ages 3-5 with identified behavioral and/or and/or behavioral identified with 3-5 ages Children young child may also The needs. emotional treatment of degree moderate a exhibit functioning domain life inter service multiple require that impairments symptoms, stabilize or reduce to is Goal ventions. and strengths build and functioning, overall improve caregiver. and child the in resiliency Intended to assist children and adolescents and adolescents and children assist to Intended preventing stability, maintaining in caregivers their child/ the engaging and events, crisis additional oflevel appropriate the into caregiver and youth communi- appropriate accessing in assisting or care services. ty-based 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.state.tx.us/mhsa/trr/documents/ Average cost ofcost Average served. adult per services health mental community Average monthly number receiving community mental health services. health mental community receiving number monthly Average LOC-YC: LOC-YC: Services Child Young Level of Care of Level Care (LOC) LOC-5: Transitional Transitional LOC-5: Services Retrieved from from Retrieved slides]. [PowerPoint quarter fourth 2013, FY Note: Data are from each year’s fourth quarter. Source: Texas Department of State Health Services. (2013). (2013). Services. Health ofState Department Texas Source: quarter. fourth year’s each from are Data Note: AND COSTS UTILIZATION SERVICE YOUTH community mental health services adolescent for child and The utilization and costs below. 33. included in Figure are in Texas Health Mental Community Adolescent and Child for Utilization/Cost 33. Figure Services ). Child & Adolescent Utilization Management Guidelines-FY 2014. 2014. Guidelines-FY Management Utilization Adolescent & Child (2012). ofDepartment Services. Health State Texas Source: from: DSHS 100 · The Texas Administrative Code defines a crisisassituationinwhich: Crisis health data book, FY 2013, fourth quarter [PowerPoint slides]. Retrieved from http://www.dshs.state.tx.us/mhsa/databook/ Note: Data for first two items are from each year’s fourth quarter. Source: Texas Department of State Health Services. (2013). in the Behavioral Health Databook, measures are provided in theFigure 34 below. Other quality measures are reported Selected data from FY 2011 toFY2013 on common child andadolescent outcome QUALITY OFCARE MEASURES Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Receiving Community MentalHealth Services Figure 34. Care SelectedQualityof Measures forChildren and Adolescents Health Services.state.tx.us/mhsa/databook. assessment. within 14 days of first service encounter health services receiving community mental and adolescents in Percentage children of psychiatric hospital. to a state or community more times in 180 days services admitted 3 or munity mental health and adolescents in com- Percentage children of Quality of CareQuality of Measures functioning per year. improved or acceptable health services with community mental and adolescents in Percentage children of behavior. improved school health services with in community mental Percentage children of self or others orisat risk ofseriousdeterioration of mentalor physical health. to Due to a mentalhealth condition, an individual presents animmediatedanger Services 77% 0.02% 37% 68% FY 2011 available at 80% 0.08% 38% 73% FY 2012 http://www.the DepartmentofState 78% 0.07% 38% 75% FY 2013 65% Not available 38% 71% 194 FY 2013 Contract Target Performance Behavioral DSHS 101 The 195 legislative appropriations bills. As As appropriations bills. legislative nd and 82 st Description and LMHAs 39 all week; per days seven day, per hours 24 Available by accredited are that hotlines crisis with contract or have NorthSTAR of Association (AAS) Suicidology American the they hotlines; crisis with conjunction in MCOT a operate LMHAs 39 All community the in location safe a or site crisis the at respond short- and care psychiatric emergency to access immediate Provide symptoms acute for treatment residential term psychiatric for treatment and ofobservation hours 23-48 Provide stabilization - resi safe staffed, clinically a in services crisis days 1-14 from Provide ofrisk some with individuals for setting dential selfto harm others or Texas Legislature appropriated $82 million to address problems million to address appropriated $82 Legislature 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 session, an additional $25 million was appropriated in FY 2014 to FY 2014 appropriated in $25 million was an additional session, th rd 196 As a result, 16 new crisis facilities were added and an additional three added crisis facilities were new 16 As a result, 197 An individual believes that he or she presents an immediate dangeran immediate she presents he or that believes An individual self to serious of at risk is health or physical mental her or that his or or others, deterioration. Crisis Hotline Services Hotline Crisis Teams Outreach Crisis Mobile (MCOT) (CSU) Units Stabilization Crisis Units Observation Extended Services Residential Crisis Service funds were intended to create statewide access to more effective crisis interventions interventions crisis to more effective access statewide to create intended funds were of levels Similar situations. health crisis to behavioral responses and to improve 81 in the were maintained funding During the 83 During the · 80 the In 2007, a result of increased funding, the number of persons using crisis intervention persons using crisis intervention number of funding, the of increased a result 80,000 in FY 2007 to over 31,000 from under dramatically, increased rehabilitation in FY 2011. in the state’s mental health and substance use crisis service delivery system. delivery crisis service use substance health and mental state’s in the crisis sites were enhanced. were crisis sites they are enrolled or not individuals whether to statewide Crisis services are available services: in ongoingthe following care and include Crisis Services 35. Figure improve crisis services across the state and enhance community-based psychiatric psychiatric community-based and enhance the state across crisis services improve emergency emergencyhospitalization, to as alternatives serve projects to services emergency observation include extended service projects Psychiatric or jails. rooms, LMHAs respite facilities. or crisis crisis residential units, stabilization crisis units, local need, on demonstrated dollars based for project competed and NorthSTAR emergency with collaboration justice rooms and the criminal cost-effectiveness, local project demonstrated design and overall clinical appropriateness, system, support. DSHS 102 Services.state.tx.us/mhsa/databook. FY 2013, fourth quarter [PowerPoint . slides] Retrieved from Note: Data are from each year’s fourth quarter. Source: Texas Department Stateof Health Services. (2013). Figure 36. Utilization/Cost for Adult Community Mental Health Services The utilizationandcosts for crisisservices are includedinFigure36 below. CRISIS SERVICES UTILIZATION AND COSTS State Health Services.Source: Department of (2010). Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Behavioral Health Databook, provided in the Figure 37 below. Other quality measuresarereportedinthe Selected data from FY 2011 toFY2013 on crisisservicesoutcomemeasures are QUALITY OFCARE MEASURES Average monthly number of persons receiving MH crisis services Average monthly number of Average monthly cost per person receiving MH crisis services Transitional Services ration Services Outpatient Competency Resto- in Hospital Setting Crisis Step-Down Stabilization Crisis Respite Services Service psychiatric hospitalizations care, involved in the criminal justice system, or experiencing multiple homeless, substance abuse treatment and primary health in need of temporary assistance and stability for up to 90 days; adults may be serious mental illness not linked with ongoing care; also provides Provides linkage between existing services and individuals with stabilization and participant training in courtroom skills and behavior burdens on jails and state psychiatric hospitals; provides psychiatric with mental illness involved in the legal system; reduces unnecessary Provides community competency restoration treatment to individuals setting with a psychiatrist on staff Provides from 3-10 days psychiatric of stabilization in a local hospital or others harm to self viduals with low risk of Provide from 8 hours up to 30 days short-term,of crisis care for indi- Description available at Crisis Services. Retrieved from http://www.dshs.state.tx.us/mhsa/databook/ http://www.the Department of StateHealth http://www.dshs.state.tx.us/mhsacsr/ FY 2011 5,529 $401 Behavioral health data book, FY 2012 5,667 $401 FY 2013 5,039 $459 DSHS 103 - mance Contract Target 2013 FY Perfor 98.3% 97.7% Child X X X X X X X X X X X X X X X X X FY 2013 FY 98% 98% Behavioral health data book, book, data health Behavioral Adult X X X X X X X X X X X X X X X X X X FY 2012 FY 98% 98% FY 2011 FY 99% 98% http://www.dshs.state.tx.us/mhsa/databook/ Services 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 AR Figure 38 lists NorthSTAR’s available mental health services. mental health available NorthSTAR’s lists Figure 38 198 Service Quality of Care Measures ofQuality Care Percentage of community in adolescents and children Percentage crisis. avoiding services health mental Percentage of services health mental community in adults Percentage crisis. avoiding Assessment Assessment Treatment planning Treatment Outpatient counseling (provided by LMSW, LPCs) Outpatient LMSW, by (provided counseling Psychology services Psychology Psychiatric services Psychiatric Crisis Services Crisis Medication training and support services support and training Medication Psychosocial rehabilitation services rehabilitation Psychosocial development and training Skill Employment related services related Employment Day program for acute needs acute for program Day Mental health, chemical dependency chemical commitment civil health, Mental Medication services:pharmacological management Medications New generation medications generation New Non-Medicaid laboratory laboratory Non-Medicaid work Inpatient hospitalizationDisease) Mental for Institution an not (is Inpatient Inpatient hospitalization (is an Institution for Mental Disease) Mental for Institution an (is hospitalization Inpatient NorthSTAR Mental Health Benefits Health Mental NorthSTAR 38. Figure NorthSTAR offers a comprehensive array of mental health services through a health services through of mental array a comprehensive offers NorthSTAR In members. to NorthSTAR of choices variety and offers a network broad provider model utilizes the TRR programing, NorthSTAR DSHS statewide with concurrence and adults in the priority adolescents to children, services mental health to deliver population. Note: Data are from each year’s fourth quarter. Source: Texas Department of State Health Services. (2013). (2013). Services. Health ofState Department Texas Source: quarter. fourth year’s each from are Data Note: hST Nort Retrieved from from Retrieved slides]. [PowerPoint quarter fourth 2013, FY Quality of Care Measures Measures of Quality Care 37. Figure DSHS 104 Figure 39. NorthSTAR Utilization of ServicesByPopulation provided by theNorthSTAR program. northstar/databook.shtm from Texas Department Stateof Health Services. (2013). Note: Data are from each year’s third quarter. counseling. individual counseling and group case management, medication management, members are primarily outpatient services. The top servicesutilizedinclude The most commonly utilized mental health services among adult NorthSTAR NORTHSTAR SERVICE UTILIZATION AND COSTS Retrieved from State Health Services.Source: Department of (2014). Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Source: Texas State Health Services. Department of (2014). Figure 40. FY 2013COSTS forNorthSTAR Services Early intervention Adult foster care Therapeutic foster care Personal care homes/ assisted living Residential treatment centers Intensive crisis residential services Supported Housing Respite Services Supported Employment Mental health case management Dollar per capita <200% FPL in service delivery area Dollars per capita in service delivery area Cost for overall mental health services Service Medicaid Indigent http://www.dshs.state.tx.us/mhsa/databook/ http://www.dshs.state.tx.us/mhsa/northstar/contract13-15/ 199 Thefollowing figures includethe utilizationandcosts ofservices 20,732 24,028 2011 Behavioral health data book, FY 2012, third quarter [PowerPoint slides]. Retrieved ValueOptions Contract and Appendices September 1, 2013 – August 31, 2015. NorthSTAR service trends. Retrieved from 21,153 22,251 2012 $95.55 $34.19 $131,092,179 FY 2013 X X X X X X X Adult http://www.dshs.state.tx.us/mhsa/ X X X X X X X X Child 23,964 23,143 2013 DSHS 105 FY 2013 FY 22% 37% 3% 13% FY 2012 FY 22% 36% 4% 18% http://www.ntbha.org/reports.aspx FY 2011 24% 38% 5% 17% Specific services include Specific 200 FY 2010 26% 39% 5% 10% Retrieved Retrieved 2013. Q3 Book, Data NorthSTAR 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 NorthSTAR enrollee receiving community services within 7 within services community receiving enrollee NorthSTAR observation 23-hour or services ER receiving after days NorthSTAR enrollees receiving community services within 7 within services community receiving enrollees NorthSTAR ofdays discharge Hospital Community NorthSTAR enrollees receiving Emergency or Crisis services Crisis or Emergency receiving enrollees NorthSTAR discharge Hospital ofCommunity days 30 within NorthSTAR enrollees receiving substance abuse residential residential abuse substance receiving enrollees NorthSTAR residential abuse substance to returned and treatment oftreatment year a with days >30 treatment diagnostics, structured therapeutic programming, liaison with appropriate courts liaison with programming, therapeutic structured diagnostics, and dischargeenforcement and law planning. inpatient comprehensive providing commitments of inpatient three types There are security. and maximum forensic civil, health services: mental Persons on civil commitments have symptoms of mental illness that result in being of mental illness that result symptoms civil commitments have on Persons emergencyfor 48-hour can be Civil commitments a danger or others. to themselves court-ordered mental or 90-day custody of protective orders 30-day detention, Civil Inpatient Mental Health Hospital Health Mental Inpatient Services community and private state, by are provided health services mental Inpatient crisis due to experiencing a psychiatric adults adolescents and to children, hospitals a period of time so that for necessary be may hospitalization Inpatient illness. mental or adjust to help accurate diagnosis, to provide monitored be closely can individuals an acute episode where during treatment intensive provide to medications, stabilize a person’s restore to assess or and/or worsens, temporarily mental illness a person’s trial. to stand competency health mental inpatient Code defines Administrative Texas 411 of the Chapter that includes medical in a hospital provided care as residential treatment activities and as well as therapeutic and social services, nursing services services, physician. treating the services ordered by psychological Source: Texas Department of State Health Services. (2013). (2013). Services. Health ofState Department Texas Source: QUALITY OF CARE MEASURES CARE OF QUALITY Results measures. and performance quality on multiple NorthSTAR DSHS monitors 41 below. Figure in are displayed measures for selected for NorthSTAR Measures Quality of Selected Care 41. Figure DSHS 106 forensic patients on a first come first serve basis. designated as forensic beds. Allother psychiatric beds are available eithertocivilor Only transitional forensic programs and forensic maximum securitybeds are The system handled over 22,000 casesin FY 2013. for persons residing in counties within a correspondingstate hospitalservicearea. allocation of state hospital resources to coordinate inpatient mentalhealthservices residential treatment facility for youth.Each LMHA and NorthSTAR receive an the nine state mental health hospitals displayed in Figure42 and onepsychiatric The State Hospital Services Section of the MHSA Divisionprovides oversight of S Types Inpatient Settings of and have been found NGRI. act, threat or attempt ofserious bodily injury and 3)patientswhohave beentotrial 2) forensic patients who have with a violent felony been charged offenseinvolving an civilly committed anddetermined to be manifestly by dangerous professionalstaff, Patients placed inmaximumsecurity commitments include: 1) persons whoare Maximum 103 individualsonthe forensic waitlist awaiting competency restoration services. determined to benot guiltyby reason ofinsanity (NGRI). InMay of2014 therewere been determined not tohave the capacity to stand trialor2)thepatienthasbeen 1) the patient has been admitted to ahospital by judicialorderbecause theyhave Patients on aforensic commitment fall intoone of the following two categories: Forensic of thisnaturecan either bevoluntary or involuntary onthepartof the patient. health services (which can beextended up to 12 monthsby thecourt). Commitments Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas to be no longer manifestlyto be no longer dangerous. individuals who transfer out ofmaximum security after theyhave beendetermined t a te Hospit Security als 203 Transitional forensic programs arealso available for 204
205 206 201 202
DSHS 107 . Retrieved Retrieved Services. Health ofState Department material: decision with report Staff 208 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 https://www.sunset.texas.gov/public/uploads/files/reports/DSHS%20Decision%20Material_0.pdf *This map excludes the Waco Center for Youth Center Waco the excludes *This map August). (2014, Commission. Advisory Sunset Source: meeting continuity of care in for achieving as responsible DSHS designates LMHAs of care, the state this continuum Within services. mental health need for a person’s health inpatient mental providing by people is to stabilize primary purpose hospital’s Managementhas a Utilization hospital Agreement with a state Each treatment. an individual seeking mental health screen LMHA to the requires LMHA which If the services. psychiatric requires inpatient if the individual to determine services is a need for inpatient psychiatric that there determine and assessment screening with available, treatment setting restrictive least the LMHA decides on the services, not the LMHA has When resort.” of last as the “provider hospitals considered state if the person determines physician a hospital the individual, and referred screened has an emergencystate for admission to the appropriate condition psychiatric coordinate alternative LMHA to to the a referral requires or if the person hospital services from from State Mental Health Hospitals: 2014* Hospitals: Health Mental State 42. Figure As displayed in Figure 43 below, there are a total of 2,503 beds across all bed types are a total there in Figure 43 below, As displayed inpatient the state-owned and adults among adolescents for children, available publicly funded beds located at excludes This number Texas. hospitals in psychiatric hospitals. and private community DSHS 108 biennium. Appropriations increased by over $52 million inthe83 7,974 full-time-equivalent (FTE) employees for state hospitals fortheFY2012 –2013 The 82 FUNDING Texas State Health Services. Department of (2012) Source: Texas State Health Services (2014, Department of May 19). Data Request: State mental health hospitals Texas, FY 2012 Figure 43. Number of Mental Health Beds, by Bed Types, at State Hospitals in Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas conditions, including medical attention, nursing care andrelated servicesfor inprovidingengaged diagnosis, treatment or care of personswithmentalhealth a hospital, nursing facility or other institution with morethan16bedsprimarily The IMD exclusion defines anIMDas inSection 1905 of theSocial Security Act between of22and64. the ages revenue is the primaryfunding source for stategeneral hospitalservicesforadults andeligible adults over 65.and younger the age Duetothisfederalrequirement, state whether 21 public orprivate, can only beused to serve childrenandadolescentsage Due to the IMDexclusion under current federal law, Medicaid fundingtohospitals, INSTITUTIONS FORMENTAL DISEASES(IMD)EXCLUSION state.tx.us/WorkArea/DownloadAsset.aspx?id=8589966342 employees toidentify possible instances of abuse orneglect. to provide directservices, andthe development of riskassessment protocols for employee drugtesting, specific trainingsand competency testing beforebeingable on all state hospital employees, volunteers and contractedserviceproviders, random state hospitals. Some of theseprotections include mandated FBIbackground checks (Nelson), funding has alsobeen allotted foradditional protections forpatientsat repairs and renovations, includingsuicide prevention renovation. UnderSB152 Of these appropriations, $30million has been allocated foressentialinfrastructure Session for theFY2014-2015 biennium. Total, all bed types Waco Center for Youth Terrell State Hospital San Antonio State Hospital Rusk State Hospital Rio Grande State Center North Texas State Hospital Kerrville State Hospital El Paso Psychiatric Center Big Spring State Hospital Austin State Hospital State Mental Health Hospitals nd Legislature appropriated approximately $783.4 millioninall funds and Mental Health State Hospitals Adolescents only Adults, adolescents and children Adults and adolescents Adults only Adults only Adults, adolescents and children Adults only Adults, adolescents and children Adults only Adults, adolescents and children Bed Type 209
[PowerPoint slides]. Retrieved from 210 rd Legislative Number of Beds Number of http://www.dshs. 2,503 288 302 365 640 202 200 299 78 55 74 DSHS 109
Investments in effective community- based services led to reduced need for expensive care. inpatient 211 212 Statewide Performance Indicators 1st quarter FY FY quarter 1st Indicators Performance Statewide Legislative session and Legislative th 213 FY 2013 FY 14,029 $16,192 $401 days 64 214 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.state.tx.us/mhreports/PIMHpub_2.shtm Total admissions Total person per cost Average day per bed per cost Average oflength Average stay As shown in Figure 44, more than 14,000 individuals were admitted to state hospitals to state were admitted individuals than 14,000 more 44, Figure in As shown per cost while the average $16,000 over was per person average cost The in FY 2013. 64 days. was of stay length The average $400. over just was day bed per RECIDIVISM RATES recidivism rates have inpatient hospital state decade, past the Over to a state percentage the readmitted of persons In FY 2001, decreased. rate had this same FY 2011, By percent. 9.1 was hospital within 30 days decrease coincides with this 45 shows, As Figure percent. to 6.9 decreased of as a result based treatments of community in availability an increase the 80 2007 during in services redesign the crisis Sources: Texas Department of State Health Services, State Hospitals Section. (2014). (2014). Section. Hospitals State ofDepartment Services, Health State Texas Sources: in the upsurge driver of hospital key is a commitments forensic of The increase typically longer intensive nature are of this as commitments spending, and more cost mental health for state stay the average length of In FY 2013, than civil commitments. for those found IST. and 135 days days 370 NGRI was ruled patients forensic hospital for civil commitments at discharge 49 days was stay length of the average In contrast, commitments. for voluntary 30 days and only Retrieved from from Retrieved 2014. Utilization and Costs for State Hospitals for State and Costs Utilization 44. Figure individuals under 22 years or over 64 years of age. The IMD exclusion policyage.of 64 years has IMD exclusion The or over years under 22 individuals the promote to intended was and in 1965 enacted was Medicaid since in place been did not the federal government and ensure that services of community expansion care. Consequently, psychiatric for inpatient responsibility assume financial to have be funded must services psychiatric inpatient public expand or to improve efforts general revenue. state by entirely almost COSTS AND UTILIZATION HOSPITAL STATE increased at state has steadily per patient average cost years, eight past In the from $11,912 in FY has increased served patient per average cost The yearly hospitals. that period. over 35 percent $4,280 or increasing by 2013, in FY $16,192 2006 to continued support in subsequent sessions. As part of the crisis service As sessions. in subsequent support continued transitional services of individuals receiving number the enhancement, individuals with serious allow These services considerably. increased multiple hospital admissions, already had have who may illness, mental crisis while transitioning after experiencing services of support 90 days into ongoing care. DSHS 110 Number of Beds Number of Figure 46. Contracted Community & Private Hospitals, Allocated Funds and hospitals, state allocated funds andthe number of hospital beds available. to individualswithintheir community. Figure46 displays contractedcommunity state but receive state funds in order toprovide mental healthinpatientservices forensic bed capacity. Community and private hospitals are not owned by the newly-built private psychiatric hospital operated by GEOCare,inorder to increase example, in 2011 DSHS began contracting with Montgomery CountyHospital, a community and private hospitals for additionalpsychiatric bedcapacity. For Due in part toneed for moreforensic beds, DSHS has enteredintocontractswith S Source: DSHS client assignment registration system. Retrieved from persons readmitted toastate psychiatric hospitalwithin30days. sitional servicesat DSHS-fundedcommunitycenterscompared topercent of Figure 45. personsaccessingcrisisoutpatient servicesandtran - Numberof Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Texas State Health Services. Department of (2014, May, 19). Personal communications: Community Hospitals Public Health Committee. Source: Texas Department Stateof Health Services. (2013). TOTAL MHMR of MHMR of Tarrant County Tropical South Texas Behavioral UTHSC-Tyler Center for Health Care Services Tri County MHMR Hill Country MHMR (Kerrville) Sunrise Canyon (Lubbock) Gulf Coast CenterGulf (Galveston) Harris County Montgomery County Community Hospital t a te-Funded Retrieved from C http://www.dshs.state.tx.us/legislative/default.shtm ommunity Overview of Overview the of Public Mental Health System. Presentation to the House http://www.dshs.state.tx.us/sa/_BHNB and Priv $74,603,096 $4,031,060 $2,208,250 $4,635,940 $5,520,625 $1,104,125 $2,357,120 $4,126,274 $3,726,006 $31,893,696 $15,000,000 Annual Funds a te Hospit 433 20 10 30 25 5 16 30 18 179 100 Beds Number of als DSHS 111 Because those 218 220 The average cost of The average cost 219 ompetency C tient In FY 2012, 12.3 percent of all commitments In FY 2012, 217 Inpa tric Individuals charged with violent felony offenses are committed offenses are committed Individuals charged felony violent with 216 Individuals determined to be incompetent, typically due to mental incompetent, be to determined Individuals 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 tion 215 a hia Psyc te a estor t commitments have a much longer average length of stay, the average daily census the average daily longer a much of stay, average length have commitments civil patients. that of nearly equaled patients for forensic In FY 2012, state-run psychiatric facilities provided a total of 940 forensic beds in of 940 total a provided facilities psychiatric state-run In FY 2012, reason of guilty by IST or not individuals found facilities for the 10 state eight of (NGRI). insanity S R Competency Restoration Competency be restored trial (IST) must stand to incompetent defendant found A criminal be considered to In order can continue. process legal the before to competency or with his to consult be able must trial, the defendant to stand competent of the legal understanding and factual a rational have and lawyer her defense proceedings. Placement Determination For Competency Restoration Programs Restoration Competency For Placement Determination 47. Figure illness or intellectual disability, may be placed in inpatient psychiatric facilities or inpatient psychiatric in be placed may disability, intellectual illness or a Figure 47 displays programs. restoration competency or jail-based outpatient placement As shown, program. in a specific for placement framework conceptual and safety clinical complexity individual’s on the be dependent can determination factors. additional also on other risk but to state-run psychiatric hospitals were for individuals found IST. for individuals hospitals were psychiatric to state-run to North Texas State Hospital’s Vernon Campus or Rusk State Hospital for inpatient for Rusk State Hospital Campus or Vernon Hospital’s State Texas to North services. restoration competency competency restoration in a state hospital is over $400 per day. hospital is over in a state restoration competency DSHS 112 The pilot is projected to provide 20 beds forrestoration purposes. Althoughnot in SanBernardino, California. Thepilot commenced on July 1, 2014 in Dallas, Texas. to Liberty Healthcare Corporation, the same corporation thatoperatedaprogram implement and operate the jail-based restoration pilot. Thecontractwas awarded Only one proposal was received inresponse to the DSHS request forproposals to less than the average cost of$50,520 for inpatient restoration inastate hospital. to provide restoration services through OCR in FY 2012 was $11,894percase,far commitments to state psychiatric hospitals. For the four pilot sites, theaveragecost DSHS developed OCR programs inresponse to the growing numberofforensic generally moreexpensive. making treatment more difficult and local taxpayers andoften have the result ofexacerbatingindividuals’mentalillness, individuals with mental illness toavoid jail stays, prolonged whicharecostly to misdemeanors and non-violent felony offenses. OCRprogramscanallow low-risk competency restoration with services that include education to people charged services, including mental health and substance use treatmentaswelllegal programs, servingtheir first clientsin 2008. OCR provides community-based In 2007, Texas initiated four outpatient competency restoration (OCR)pilot Outpa Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas local mental health authority(LMHA). rules for the pilot program developed through a contractwithprivatecontractoror convened in September of 2013 for thepurpose of establishing andpromulgating requirements upon failure torestore competency within60days. Aworkgroup was competency restoration or that the individual is unlikely to berestored, (3) program, (2) reporting requirements upon a psychiatrist’s determination of evaluations not later than the 21st day and55th day ofparticipation inthepilot for operating the pilot program, including: (1) requirement oftwofullpsychiatric facility or residentialcare facility for those services. Thebillset outconditions program for individualswhootherwise would becommitted toa mental health of competency restoration services in ajail-based competency restoration pilot SB 1475 (Duncan), enacted by the 83rd Texas Legislature, authorizes theprovision Jail-B 1,061 individuals. At the end of2013, there were 12 OCR sitesacross Texas thathadserved atotal of hospital bed. and eliminatingthe cost oftransporting an individual long distances toan available jails and local communities by reducing the length of timeindividualsremaininjail In addition to avoiding the high cost of hospitalization, OCRcan reduce costs to OCR pilot programs. allocation of $4million in FY2014 and FY 2015 tosupportcontinuationof existing in 2013 was $229. had felony offenses. Thecostaverage perday foroutpatient competency restoration likelihood of restoration. lengths of staythreshold. After that point, longer were not associatedwithgreater likelihood of restoration increased with greater lengthsofstay, uptoa21-week ased tient 222 223 C Roughly51%ofindividuals had misdemeanor offensesand49% A2014 study by theHogg Foundation found that a person’s C ompetency ompetency 224 Rider66of the 83 225
R R estor estor rd Legislative Sessiondirectedan a a tion tion 221
DSHS 113 In 230 Success Rate Success 45% restored 45% 58% restored or restored 58% with improved dropped* charges 75% restored 75% 226 Avg. Total Cost Total Avg. Individual per Served $17,514 $29,312 $50,520 Avg. Length of Length Avg. Stay 63 days 63 128 days 128 120 days 120 Cost Per Day Per Cost $278 $229 $421
227 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 2013) (FY 228 (San Bernadino, CA CA Bernadino, (San 229 Twice daily 1:1 sessions daily Twice sessions follow-up psychiatrist Weekly case reviews Weekly testing Psychological Daily groups State Psychiatric Hospital Psychiatric State Type of Program Type program, FY 2012) FY program, - Res Competency Jail-Based toration (FY 2012) (FY Outpatient Competency Competency Outpatient Restoration The forensic population’s use of state mental hospital resources has grown hospital resources has grown mental use of state population’s The forensic 37 percent in 2010. to in 2001 from 16 percent decade, past the over significantly Addressing the Shortage ofShortage the Addressing Public BedsInpatient *Percentage is for cumulative success rate for FY 2008-2013. FY for rate success cumulative for is *Percentage of cost and time additional the reflect not do programs jail-based and community- the for individual per cost and ofstay length **The services. restoration additional for hospital state the to transferred are and competence to restored not are who defendants treating Jails have traditionally not been therapeutic centers; however, with proper staffing staffing with proper however, centers; been therapeutic not traditionally have Jails receive inmates may health professionals, licensed mental numbers of ratios and hospital. As or state-run OCR than in an manner in a timelier treatment the needed at treatment OCR programs provide to date Texas 48 below, in Figure demonstrated competency Bernardino jail-based the San rates than and higher success costs lower as to the efficacy remaining questions are still there However, program. restoration the by be answered may that restoration competency rate of jail-based and success pilot. Texas based on programs restoration of competency three types the compares Figure 48 success rate. restoration and of stay length cost, Programs** Restoration Competency of Comparison 48. Figure · · · · · much information has been released as to the program features of the Texas pilot, the pilot, the Texas of features program as to the been released has information much features: model California comparable Healthcare’s Liberty the same period, the number of state hospital beds had not increased, resulting in beds had not hospital state number of period, the the same shortagecorresponding for patients with civil commitments and patients of beds for Since 2012, services. restoration competency commitments requiring with forensic DSHS state’s history. first timeinthe patients forthe surpassed civil hospitals mental health DSHS’s state represented in patients forensic of daily census average In 2014the 114 the DSHS State Hospital Admissions Clearinghouse waitlist,the DSHS State Hospital Admissions cappingthenumberof requiring all individualsfoundISTand in needofrestoration servicestobeplacedon In 2006, DSHS attempted toaddress this growing issue by implementingapolicy texas.gov/public/uploads/files/reports/DSHS%20Staff%20Report_1.pdf Source: Sunset Advisory Commission (2014). Department Stateof Health Services: Staff Report . Retrieved from Mental Health Hospitals2001-2014 Figure 49. DailyCensus Snapshot forCivilandForensic Commitments inState first time inthe state’s history. represented in DSHS’s state mental health hospitals surpassedcivilpatientsforthe As displayed in Figure49, in 2014 the average dailycensusofforensic patients populations with less severe mental health conditions. less capacity compared to state serve civilpatient hospitals and only generally relieving immense pressure onthe state hospital system, these facilitiesstill provide private, and university hospitals. Although this approach hasthepotential for DSHS has added approximately 200 state-funded beds in contractedcommunity, Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas admission into acompetency restoration program. deemed IST cannot be held inajail for morethan 21 days priorto incompetent tostand trial. The ruling initially stated that a defendant the DSHS clearinghouse waitlistwhich challenged for people found restoration capacity lawsuit filed by Disability Rights Texas in2007 In 2012, aTravis County District ruled on aforensic Court judge system. cycling backintothejudicial and likely contribute to re-offending and Constitution and are extremely detrimental to mentalhealthoutcomes and mental health services may violate speedy trial provisions in theU.S. longer for restorationlonger services. point that onaverage, 250patients were waiting in jailfor6monthsor state term,bed capacity was reducedtothe hospitalsaretypically longer on availability.became contingent Becauseforensic commitments at beds. Therefore,admission to oneof the 738designatedforensicbeds state hospital beds used for forensic commitments at 738state hospital 232 233 Delays inreceiving timely restoration 231 234
https://www.sunset. DSHS 115 . DSHS has . DSHS has 235 Major activities relating to substance use include the to substance relating Major activities legislature, $4.4 million in general million was revenue $4.4 legislature, rd 237 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 utilization of Victory Field by the adolescent patients will free space the adolescent Field by of Victory The utilization 236 appropriated to renovate Victory Field Campus at North Texas State Hospital- Texas North Campus at Field Victory to renovate appropriated adult forensic patients from forensic adolescent separate order to in Vernon patients. and increase capacity for adult forensic patients. Construction is scheduled to be Construction patients. adult forensic capacity for and increase 2016. of May the end by complete the a decision overturning issued in Austin of Appeals the Third Court 2014, In May court found that plaintiffs lawsuit. The Texas’ Rights in Disability order previous manner for every in an unconstitutional operates list that the demonstrate failed to was DSHS practice of maintaining the list that the court found While the detainee. be beyond a certain period would detention that it indicated unconstitutional, not unconstitutional. services include education, skills training for youth education, skills training for youth services include Prevention Abuse Substance Resource Centers Prevention and 11 coalition-building community and families, activities shown below. shown activities Substance Use Services Use Substance Services Administration Health and Mental According Abuse to the Substance issues. use with substance struggle 25 million Americans estimated an (SAMHSA), has the It challenges. emotional and behavioral in serious use can result Substance long-term usage can negatively and brain chemistry, individual’s to alter an potential and Continued and memory. processes thought mood, judgment, behavior, impact dependencyto chemical also lead use can and drug addiction. substance persistent effect on the individual, family and the a significant abuse has substance Ultimately, health disorders. mental and exacerbate create both and can community the State as Services Division serves Commissioner of the MHSA The Assistant abuse prevention, for substance in Texas (SSA) Authority Abuse Substance services for abuse substance provides DSHS treatment services. and intervention, treatment. to deliver providers with service contracts adults and youth and eligible for creating and implementing Services Division is also responsible The MSHA treatment services and defining optimal abuse policies regarding substance outcomes. Treatment (SAPIT) Program’s and Intervention, Prevention, Abuse The Substance use prevention, substance and services for supports primary goal is to provide treatment. and intervention, As a result of the ruling, DSHS added 40 maximum security beds to North Texas Texas to North beds security maximum 40 DSHS added of the ruling, result As a to beds forensic security 60 non-maximum converted and (NTSH) Hospital State additional 60 converted DSHS also (RSH). Rusk State Hospital security at maximum (SASH) to State Hospital Antonio and San at NTSH, RSH beds civil commitment for civil 60 new beds as well as purchased forensic beds security non-maximum the LMHAs through hospitals private psychiatric from commitments also created a 30-bed long-term psychiatric treatment unit housed at the University at the University housed unit treatment long-term psychiatric a 30-bed also created Tyler. Center at Science Health of Texas 83 during the Additionally, DSHS NorthSTAR program. including the abuse providers, funded substance were servedbyDSHS- and medicalindigence chemical dependence the 187,837youthwith 6,928 (4percent) of 1,776,671 adultsand the (3 percent) of FY 2013, 54,914 In Texasduring 116 Access state to carry outthese goals. reduce youth access to tobacco, and maintaining the infrastructure throughoutthe cessation efforts, eliminatingtobacco-related healthdisparities, supportingeffortsto problems. Theprogram focuses onprevention of tobacco initiation, supporting Tobacco Prevention andControl the community. individuals continuing the recovery process asthey transition fromtreatmentinto Recovery arebeingpiloted SupportServices inFY2014 andprovide supportto programs. Afulllist of services provided is shown inFigure50. across the continuum of need.These services include both inpatient and outpatient Treatment services are evidence-based, holistic, and emphasizecoordinationofcare systems to understand appropriate substance treatmentneeds. use or dependency Substance Abuse Treatment addressesthe client’s psychosocial andfamilial persons at highriskof developing substance use problems. outreach, and special initiatives such as therural border intervention programfor for persons with HIV, specialized female services such aspregnant/postpartum appropriate services. services include testing andcasemanagement Additional for individualsseeking treatment. Referrals are made for treatment and other and referral services (OSAR). Thisprogram serves asthefirst pointofcontact Substance Abuse Intervention includesoutreach, screening, assessment that serve(PRCs) as regional information clearing houses. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Board (LBB). DSHS iscurrently serving an average of9,306 individualsmonthly, treatment delivery system beyond the level established by theLegislative Budget attempted toaddress these concerns by expanding the capacityofsubstance use sufficient toaddress need, creating significantbarriers totreatment. DSHShas 239 substance abuse providers, including the NorthSTAR program. were served bydependence and medical indigence DSHS-funded adults and 6,928 (4percent) of the 187,837 youth with chemical In Texas during FY2013, 54,914 (3percent) of the 1,776,671 treatment rate. only increasedby 4 percent, indicating a decline in the overall this same 10-year period, however, substance use treatment 12andoverthe populationaged increased by 11 percent; during treatment receive services. Nationally, between 2001 and 2011 Only a small portion of individuals requiring substance abuse The level ofpublic funding for substance use services isnot Funding over substance usepriorities. and aperception that mental health priorities take precedence ofsubstanceshortages abuse providers, waiting lists for services This discrepancy inutilization and need couldbe due to Thisdiscrepancy 238 works to reduce tobacco-relatedhealth
240
DSHS 117 Use 241 session, session, rd ance Subst
242 and tric 243 tions Services or f 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 Pregnant, intravenous substance users users substance intravenous Pregnant, users substance Pregnant drug users Intravenous hia Psyc o-occurring C time. the same at in persons occur use commonly illness and substance Mental criteria for (and soon DSM-5) DSM-IV-R who meet aged youth 13-17 Additionally, Adults agedfor treatment services. are eligible abuse or dependence 18-21 substance program dependent on the individual’s a youth treatment to admitted be also may and behavior. experiences, needs, Three populations receive priority for admission to substance use services before all before use services to substance for admission priority receive Three populations of priority: order following are in the They others. 1. 2. 3. a Popul Priority Disorders For individuals who are not Medicaid eligible, substance use program providers are use program providers eligible, substance Medicaid individuals who are not For of individuals who seek DSHS-fundedrequired to conduct a financial assessment 200 percent of income is at or below Individuals whose adjusted use services. substance If adjusted use services. are eligible for fully funded substance level the federal poverty individuals will be assessed a fee on a sliding scale. income is greater than 200 percent, Eligibility to outpatient access have Adultsare on Medicaid use disorders who substance with counseling, and medication assisted detoxification, services (assessment, ambulatory and specialized detoxification (treatment, services as well as residential therapy) HHSC this free of cost. for women) services evaluating whether is currently Continuation of funding the cost. to offset savings benefit enough Medicaid generates will be contingent program results. evaluation on Medicaid for this exceeding the LBB’s target goal of 8,851 individuals per month. individuals goal target of 8,851 the LBB’s exceeding 83 million in the $25 over by increased was use funding Substance including nearly $11 million to increase provider reimbursement rates for substance rates for substance reimbursement provider million to increase nearly $11 including the service into providers competitive new and to attract in an attempt use services will hopefully incentivize providers service competitive of The introduction system. rates. and recovery treatment, quality, higher service to create an appropriation of $10 million the legislature approved Additionally, due custody are in DFPS whose children for parents service capacity additional assessment and screening, include Services issues. abuse substance to parental intervention pregnant and postpartum in the eligibility expanded services, treatment program. The goalintervention fatherhood of this establish programs and a newly of children in DFPS the number reduce are to services expanded and investment the average 2014, August As of to treatment. access parents’ expediting care by 2014, as of as of June and 1,448, roughly was this initiative through served monthly services. use trained in substance had been CPS caseworkers 1,851 approximately DSHS treatment. support dualdiagnosis and policiesthat need forinterventions demonstrates the these comorbidities high prevalence of illness.mental The occurring diagnosed percent hadaco- use disorder, 42 adults withsubstance Nationally, among 118 Figure 50. Available SubstanceUseServices Through DSHS adults and youth. The following figure lists substance use servicesDSHS makes available toeligible Services diagnosed mental illness. Nationally, amongadults with substance use disorder, 42percenthadaco-occurring Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Screening Services Assessment Referral Residential intensive Residential Residential intensive (specialized female) Residential intensive Residential intensive (women and children) (women and Residential intensive Residential supportive Residential Residential supportive (specialized female) (specialized supportive Residential Residential supportive (women and children) (women and Residential supportive Outpatient services Outpatient HIV residential detox Ambulatory (specialized female) detox Ambulatory detox (specializedResidential female) detox Residential facilities for thisspecialty service. substance use treatment facilities and 160residential treatment the primary condition. DSHS contracts with 488 outpatient services, wherein both disorders aretreated in conjunctionas Abuse Disorder(COPSD) Services isto provide coordinated disorders. ofCo-occurring Psychiatric Thegoal and Substance health services forthe simultaneous treatment of co-occurring DSHS supportsthe integration of substance use andmental · · · individuals were served through COPSD programs. disorders, thefollowing scenarios shouldbe considered: relationship of co-occurringpsychiatric and substance abuse support dual diagnosistreatment. When examining the demonstrates the need for interventions and policies that independent common risk factors Drug abuse and mental illness canbe results of other Mental illnesscanlead to drugabuse Drug abuse can leadto mental illness 244 Thehigh prevalence of these comorbidities Adults Service X X X X X X X X X X X X X X X
Av 246 ail InFY2013, 4,081 able to able able to Youth able Service X X X X X X X X X X 247 245
Av ail - DSHS 119 - ail Av
2013 492,925 $15 167,032 $60 31,303 $1,617 9,806 X X X X X X X X X X X able Youth to Service 2012 468,054 $16 141,299 $71 31,206 $1,582 9,034 able to ail Av
2011 468,054 $16 123,914 $89 31,627 $1,617 8,193 X X X X X X X X Service Adults 2010 409,585 $19 128,281 $97 42,194 $1,888 10,347 Substance Abuse Treatment Contract Performance Measure Report – FY 2014. FY – Report Measure Performance Contract Treatment Abuse Substance 2009 366,810 $20 180,586 $64 41,348 $1,827 10,948 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 Number per served year Avg. cost per cost Avg. year per adult Number per served year* Cost per adult per Cost year** per Number per Number year Cost per adult per Cost year per http://www.dshs.state.tx.us/mhsa/prs/ Co-occurringsubstancepsychiatric & use Conditions Opioid substitutiontherapy Group Individual Adolescentsupport counseling Family support Family consultation Psychiatrist Outpatient(specializedservices female) Group Female Individual Services Prevention Prevention program Intervention programs Treatment Treatment programs Number on Number for list wait the use substance treatment** Source: Texas Department of State Health Services (2013). (2013). Services Health ofState Department Texas Source: from Retrieved AND COSTS UTILIZATION use services. of substance costs utilization and the show two figures The following for children. Figure 52 adults; information for details Figure 51 Substance Use Services Adult for and Costs Utilization 51. Figure DSHS 120 mhsa/databook/ (October 7, 2010). [PowerPoint slides]. Retrieved from Sources: Texas Department Stateof Health Services. (October 11, 2013). ***Total entered on waiting list by following substance abuse programs: COPSD, Detox, Methadone, Outpatient and Residential. to reporting should continue to cause the numbers served to increase, scale. thereby reducing the cost per client due to economies of program instructed providers to try their best to provide staff unduplicated client counts, resulting in another dip. **Improvements intervention services to try their best to provide DSHS with client counts, which inadvertently led to duplication. Then, in FY 2010, *The spike in number served in FY DSHS-funded substance abuse 2009 is due to instruction from program to providers of staff Figure 52. Utilization andCosts for Youth SubstanceUseServices from Texas State Health Services. Department of (2010). Retrieved from Sources: Texas Department Stateof Health Services. (2013). Detox, Methadone, Outpatient and Residential. ***Total adults entered on waiting list by following substance abuse programs: COPSD, of D to cause the numbers served to increase, thereby reducing the cost per client due to economies scale of as seen from FY 2010-2013. reporting in CMBHS, clients served in the HIV Early such Intervention as (HEI) the program,automated calculation of should continue program instructed providers to try their best to provide staff unduplicated client counts, resulting in another dip. **Improvements to intervention services to try their best to provide DSHS with client counts, which inadvertently led to duplication. Then, in FY 2010, *The spike in number served in FY DSHS-funded substance abuse 2009 is due to instruction from program to providers of staff Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas gram Prevention pro- programs Intervention grams Treatment pro- treatment*** substance use the wait list for Number on http://www.dshs.state.tx.us/mhsa/databook/ http://www.dshs.state.tx.us/mhsa/databook/ Behavioral health data book, FY 2010, fourth quarter [PowerPoint slides]. Retrieved from per year Number served per year* Number served youth per year Avg. cost per Number per year per year** Cost per youth per year Cost per youth http://www.dshs.state.tx.us/mhsa/databook/ Behavioral health data book, FY 2010, fourth quarter [PowerPoint slides]. Retrieved 1,300,834 2009 81,878 $21 6,302 $43 $2,910 612 Behavioral health data book, FY 2013, fourth quarter [PowerPoint slides]. 1,516,959 2010 33,962 $18 5,804 $93 $3,569 809 Behavioral health data book, FY 2013, fourth quarter and Texas State Health Services. Department of 1,843,263 2011 26,519 $14 5,418 $127 $3,713 753 1,920,024 2012 58,903 $14 4,886 $55 $3,645 512 http://www.dshs.state.tx.us/ 1,939,809 2013 68,977 $13 4,848 $44 $3,246 438 DSHS 121 100% 59% 90% 52% FY 2013 FY 2013 52% 90% 75% 99% 100% 56% 89% 53% FY 2012 FY 2012 52% 89% 77% 99% http://www.dshs.state.tx.us/ http://www.dshs.state.tx.us/ 100% 52% 89% 56% FY 2011 FY FY 2011 FY 54% 89% 83% 99% and Texas Department of State Health Services. ofDepartment Services. Health State Texas and and Texas Department of State Health Services. ofDepartment Services. Health State Texas and 98% 57% 85% 58% FY 2010 FY FY 2010 FY 55% 83% 91% 97% Behavioral health data book, FY 2012, fourth quarter fourth 2012, FY book, data health Behavioral Behavioral health data book, FY 2012, fourth quarter fourth 2012, FY book, data health Behavioral 98% 62% 86% 63% FY 2009 FY FY 2009 FY 63% 85% 93% 96% http://www.dshs.state.tx.us/mhsa/databook/ http://www.dshs.state.tx.us/mhsa/databook/ http://www.dshs.state.tx.us/mhsa/databook/ http://www.dshs.state.tx.us/mhsa/databook/ 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 [PowerPoint slides]. Retrieved from from Retrieved slides]. [PowerPoint quarter fourth 2010, FY book, data health Behavioral [PowerPoint slides]. Retrieved from from Retrieved slides]. [PowerPoint quarter fourth 2010, FY book, data health Behavioral Percentage of use substance completing youth Percentage year per programs treatment of use substance completing youth Percentage at abstinence reporting programs treatment year per follow-up of use substance completing youth Percentage status school positive with programs treatment year per follow-up at of use substance completing youth Percentage year per re-arrested not programs treatment Percentage of use substance completing adults Percentage year per re-arrested not programs treatment Percentage of completing adults unemployed Percentage gaining programs treatment use substance year per follow-up at employment Percentage of use substance completing adults Percentage at abstinence reporting programs treatment year per follow-up Percentage of use substance completing adults Percentage year per programs treatment Sources: Texas Department of State Health Services. (October 10, 2013). 2013). 10, (October Services. Health ofState Department Texas Sources: from Retrieved slides]. [PowerPoint 2010). 7, (October Selected Quality of Care Measures for Youth Substance Use Services Youth for Measures Selected Quality of Care 54. Figure Sources: Texas Department of State Health Services. (October 10, 2013). 2013). 10, (October Services. Health ofState Department Texas Sources: from Retrieved . slides] [PowerPoint 2010). 7, (October QUALITY OF CARE MEASURES CARE OF QUALITY on the TRR areas based in several and performance quality DSHS monitors on a regular tracked measures representative show figures The following framework. basis. Use Services Adult Substance for Measures of Selected Quality Care 53. Figure mhsa/databook/ mhsa/databook/ DSHS 122 Tre use disorder. resources are available to supportindividuals in their recovery from asubstance of theTexasThe goal Recovery Initiative (TRI)isto ensure that needed servicesand THE TEXAS RECOVERY INITIATIVE Promising Pr Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · · · · frameworkinlocalmunicipalitiesacrossthestate by: the ROSC skills.management DSHSiscurrentlyassisting communitiesstatewide withinitiating enhance individual’s strengths andfunctioningwhilebuildingresiliencerecovery vital totherecovery process. servicesaimto By providing continual support,ROSC governmental, nonprofit andfaith-basedentities, toprovide acontinuumofcare of communitypartnerships and collaborations, includingthosewithfederalandlocal needs andchosenpathway to recovery. Thisframeworkunderscoresthesignificance person-centered, self-directedanddesignedtoreadilyadjust tomeet theindividual’s framework, which coordinatesmultiplesystems, services, andsupportsthatare Recovery assistance is provided through theRecovery OrientedSystem ofCare(ROSC) individuals receiving servicestotake responsibility for theirown recovery. multi-disciplinary and use coordinated treatment plans whichallow forthe In order for adelivery system tobe recovery-oriented, it must be person-centered, comprehensive, recovery-oriented models ofcare for individualsseekingtreatment. stakeholder input for creating evidence based procedures in order toimplement Assisting withdevelopment andtraining of recovery coaches. Health Institute. aweek-long educationaltrack on recoveryAdding during the Texas Behavioral meetings. community Participating in person and viateleconferencing in local ROSC concept. regarding the ROSC Providing telephone and emailtechnical assistance to localcommunities for achieving recovery. them with the development of the initial phase ofthis systems approach change Conducting on-site informational trainings to organize communities, assisting a tment 248 Thepurposeofthe multi-phase TRI istogatherinformationand a ctices in Subst ance Use 249 DFPS 123 126 127 128 134 134 135 142 132 132 135 137 138 139 141 147 126 132 135 142 145 125
At A At A Glance
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 cts C a Lesbian, Gay, Bisexual, Transgender, Queer Youth Youth Queer Transgender, Bisexual, Gay, Lesbian, Parental Relinquishment ofCustody Relinquishment Parental Courts Specialty System Response Alternative ofCare System Foster Care Redesign Redesign Care Foster Health) (STAR System Health Superior (FFCC) Program Children Care Foster Former Services Residential Institutional System CPS the in Fatalities Child Disproportionality Medications Psychotropic Care Trauma-Informed Restraint and Seclusion 258,996 children were allegedchildren were statewide. of abuse victims 258,996 Implementation and expansion of the Foster Care Redesign Project. Care Redesign of the Foster expansion and Implementation mental health services. to obtain children of relinquishment Parental system. the CPS fatalities within of child Prevention care. trauma-informed of implementation System-wide system. in the CPS youth minority of Disproportionality Addressingof LGBTQ youth. the needs mental health concerns. youth with transitioning services for Support in the CPS investigative System Response the Alternative the usage of Tracking process. of protective and provision abuse/ neglect of elder identification Improving services. care youth. of foster usage medication the psychotropic to monitor Continuing techniques. restraint seclusion and to alternatives Implementing Environment Changing Texas Department of Family and Protective Services and Protective of Department Family Texas Services Health Mental Accessing Issues Continuing (PEI) Intervention Early and Prevention (APS) Services Protective Adult Licensing Care Child st F ast F In FY 2013: · Policy · · · · · · · · · · · Services: Services: Family and Protective Protective and Family Texas Department of Department Texas DFPS 124 · · Organiz quished to state custody for thepurpose of accessing mental health services. that in 2001, morethan 12,700 children in the United Stateswerevoluntarily relin- A frequently cited study by the U.S. Office(GAO) estimated General Accounting · · · · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Revised Chie Off 16,676 childrenwerein the Texas foster care system (excluding kinship care). Of this number, 17,022 children were removed from their homes. from abuse and neglect in Texas. represented 80 percentofthe child fatalities three and younger Children aged There were 156 confirmed childabuse orneglect relatedfatalities. occurred” on preponderanceofevidence, staffas, concludedthatabuseorneglect “based There were 100,861 childreninconfirmed investigations (confirmed isdefined CPS completed 160,240 investigations of abuse or neglect. and ProtectiveServices Ide Cen Ope i Department ofFamily Oper cer O n Co C f Mana Information tral r tity
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2 8 & 7 0 5 DFPS 125 258 Investigates allegations of child abuse/neglect ofchild allegations Investigates retain to strives CPS accordingly. responds and also but conditions, home safe in children for system care foster the manages and oversees home unsafe from removed are who children environments. health mental on outreach community Provides services. wellness other and and neglect, ofallegations Investigates abuse, of exploitation dis- with people and adults older investi- at-home conducting entails This abilities. public the educates also APS facilities. and gations prevention. abuse adult on safety ensure to system childcare the Regulates Educates met. are regulations statewide other and child- and childcare on communities and parents facilities. care 257 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 Prevention and Early Intervention (PEI): Intervention Early and Prevention (APS): Services Protective Adult (CCL): Licensing Care Child Child Protective Services (CPS): Services Protective Child DFPS is divided into the same 11 regions as HHSC, each with a regional headquarters. each with a regional headquarters. as HHSC, 11 regions same into the DFPS is divided on pagesee Figure 10 Please for a map. 60 in the 2017 for and $1,599,149,665 2016 for $1,588,538,142 DFPS requested and 2017. 2016 for Fiscal Years Requests Appropriations Legislative Services Family and Protective Protective and Family agency is the state (DFPS) Services and Protective Family of The Department and adults with persons, elderly of children, the safety for ensuring responsible vulnerable populations by to these services and supports DFPS provides disabilities. exploitation. and neglect, of abuse, the likelihood to reduce attempting divisions: of four DFPS is comprised Texas Department of Department Texas DFPS 126 it would take over the duties previously administered by Providence Services Corp. state’s foster caresystem in counties in North and West Texas. DFPS announced that Services Corp. hadbeen managing and providing services for1,100childreninthe Corp. voluntarily terminatedits contract with the state on August 1,2014. Providence Corp., which began its contracton February 1, 2013. However, Providence Services The state’s initialFoster Care Redesign contract was awarded toProvidence Services a quantitative analysis and trackthe performance of theleadredesigncontractor. and research center at the University of Chicago,policy has been directedtoconduct delivery of careis tobetter coordinate services for families. contracts and acompilationofservice providers. The state’s instreamlining goal the comes from a singlecontinuum rather than through the distribution of multiple Additionally, theFoster Care Redesign will restructure service delivery sothatcare cost-per-care amounts. encouraging children’s transitionto lower service levels andreductionsin average- not tie payment to a child’s service level but instead topositive outcomes, thereby a childto be moved to a lower authorized service level. Theredesignhowever, does Operation, or Residential Treatment Center), which didnot create incentives for placement type (Child Placement Agency, Shelter, Emergency GeneralResidential was linked to achild’s moderate, specialized, or intensive) and service level (basic, based fundingtoperformance-based funding. Under theprevioussystem, payment of the FosterOne of the biggest changes from services- Care Redesign is the change · · · of theFosterThe goals Care Redesign include the following: placement settings. improve the outcomes for children and familieswhile using theleast restrictive foster care system, DFPS embarked on aFoster Care Redesign projectin2010 to In anefforttoreduce negative outcomes(including mortality)forchildreninthe could alsoexacerbate mental health conditions.childcare arrangements to aggravate mental health conditions. Furthermore, in the lackof permanency disconnected, uncoordinated, and otherwise unstable foster caresystem islikely entering the foster care system have suffered traumaticexperiences, and a Foster care is pertinent to mental health discussions because many oftheyouth Foster Changing Environment Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas placed far away fromhome for thepurposes of accessing services. of servicesfor fosterrange careyouth, thus eliminating the risk that a childwillbe catchment areaswill providea single source continuum contractor in geographic a Reduce the number of timeschildren move between foster homes. Improve the quality of care andoutcomes for children and youth. siblings. Keep childrenandyouth closer tohome and connected to their communitiesand Care R 260 edesign 261 259 Underthenewsystem, 262 Chapin Hall, a DFPS 127
266 State child welfare child welfare State in 19 states officials and county juvenile in justice officials 30 counties who to responded surveys estimated 2001, in FY that in their parents jurisdictions placed over 12,700 mostly children— adolescent males— into the child or juvenile welfare justice systems so these children that could receive mental health services. The second The second 264
265 This pilot will serve Erath, will serve This pilot 263 Custody
269 Relinquishment can also irreparably can also Relinquishment 268 ment o f ment elinquish 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 al 267 Texas legislature addressed parental relinquishment in Texas, most most relinquishment in Texas, legislature addressed parental Texas rd arent These children have serious mental health conditions and their treatment is often is treatment and their conditions health serious mental These children have Some parents have treatment. residential temporary need for due to the expensive making it insurance altogether, others lack coverage while insurance insufficient These services. health mental costly and often to afford needed difficult their children in order to of relinquish custody parents to can force circumstances treatment. health mental necessary obtain justice juvenile and county states officials in 19 child welfare State estimated that in surveys to who responded counties 30 officials in 12,700 children— placed over jurisdictions in their parents FY 2001, or juvenile child welfare adolescent males—into the mostly mental health could receive these children so that systems justice services. damage the child-family bond and result in insecure attachment of damageattachment in insecure bond and result child-family the caregivers. or other to parents the child stage will provide service to an additional seven metropolitan areas in Texas in areas in Texas metropolitan seven to an additional service provide stage will Denton counties. Dallas and among others, which spans, 3, Region notably through the passage of Senate Bill 44 (Zaffirini). In addition to ordering 44 (Zaffirini). In addition to Bill passage of Senate through the notably SB 44 also in the state, relinquishment reports on parental and data investigations relinquishment. One option to parental options of alternative calls for a series which would allow conservatorships, use of joint is the the legislature by espoused The emotional turmoil resulting from the decision to relinquish to relinquish from the decision resulting turmoil The emotional may Parents and children. parents both affects custody parental surrounding and powerlessness of humiliation feelings experience their relinquishment. P Accounting General that estimated (GAO) Office U.S. the by study cited A frequently were voluntarily States in the United 12,700 children than more in 2001, services. accessing mental health purpose of for the custody to state relinquished The second pilot program for the Foster Care Redesign was contracted to begin on to begin contracted was Care Redesign Foster for the program pilot second The organization a nonprofit project is this for contractor selected The 1, 2014. January Worth. Fort of Services Child and Family called ACH In addition to the trauma it causes parents and children, parental and children, it causes parents the trauma to In addition mental critically needed to obtain of custody relinquishment When challenge an additional services creates health for parents. under these state child to the of their relinquish custody parents parental to accept “refused have are deemed to they circumstances, The parents’ of neglect. considered a form which is responsibility,” registry. child abuse/neglect Texas to the then added names are employment parents’ future for serious consequences This can have as abusive the parent labels relinquishment Parental opportunities. typically have who these are parents in reality, when or neglectful of their children health and safety for the possible done everything and families. The 83 Hood, Johnson, Tarrant, Palo Pinto, Somervell, and Parker counties. and Parker Somervell, Pinto, Palo Tarrant, Johnson, Hood, DFPS 128 at the local andcounty level, for example in SanAntonioandHarris County. wouldhear CPS cases.where a designated judge This solutionhasbeenexplored difficulties faced byyouth inthe CPS system isthe establishment ofaCPS court as needed. An alternate solution that seeks to alleviate the waiting periodand CPS works with regional and district courts toobtain court orders forremovals, ultimate authority on whathappens to the child andwhereheorshegoes. environment and must betaken intostate custody, the judiciary serves asthe Once CPS makes adetermination that achildisunsafe in hisorherhome Specialty Residential Treatment Centers (see DSHS section). the Youth waiver and additionalfundingfor13bedsat Empowerment Services (YES) towards reducinginstances ofparental relinquishment included the expansionof addition was relinquishmentformental health services. Other legislative action removed from the child abuse andneglect registry if thesolereasonbehindtheir neglect registry. Parents may also petition the family court to have theirnames how to keep the names of parents who relinquish custody offthechildabuseand theCouncil on Children and Familiesalso charged to make recommendationson parents to continue sharing in major decisions affecting theirchild’s life. Thebill Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas counties they cover inTexas: and to be inthefield. Figure55 below illustrates thelocationofCPScourtsand between hearings, thereby providing themwith more timetocheckuponclients Centralizing all CPS hearings inone location could reduce caseworkers’ travel time quickly. Underthe current system, CPS cases are heardat county or district courts. more Specialty courts can ease thebacklog of cases and achieve permanency C ourts 270
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C C rt g n rt rt u u s re h o P P P P e P e P P P o o h t N C C C C R C C C C 4 Bra So C So Ea N N T Retrieved from from Retrieved Program. Courts Specialty 14). April (2014, Online. Courts Texas Source: Child Protection Courts and Covered Regions Covered and Courts Child Protection 55. Figure DFPS 130 depression and suicide), promiscuity, andcriminal behavior. traumatized youth is athigherrisk of substance abuse, mentalhealth issues (suchas behavioral problems. Nearly half of youth in childwelfare have clinically significant emotional or need for psychiatric intervention for foster from 60–80 percent. care youthrange this number, 17,022 childrenwereremoved from their homes. children have ahigherincidence of physical andbehavioral healthproblems. a lifetime; adults who experience significant childhood abuseandfamilydiscordas preponderance of evidence, staff concluded thatabuse orneglect occurred”). 100,861 children inconfirmedinvestigations “basedon (confirmedisdefined as, In FY2013, 258,996 children statewide victims of abuse.There were were alleged assessments are repeated if achildenters the foster caresystem. and make referrals for behavioral health needs assessmentsasnecessary. These During an investigation, a CPSworker willscreen the child’s behavioral health cognizant of thepotential mental health needs ofchildrenandyouthinfoster care. health and substance population. use conditions than children in thegeneral Children in CPSnationally and inTexas areatgreater risk for trauma-related mental chronic neglecthas a profoundeffect onchildren. Trauma inflicted by experiencing(physical, psychological, orsexual)violence and transitioningyouth. interacts with children at three stages: investigating abuse allegations, placingyouth, care system, and successfullytransitioning youth out oftheCPSsystem. Thus, CPS youth in need,removing children from unsafe environments, managingthefoster allegations of childabuse and neglect, providing at-home servicesforfamiliesand Child Protective Services (CPS) isresponsible for responding toandinvestigating Child Protective Services Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 16,676 childrenwerein the Texas foster care system. A childisplaced in foster care afterother options have beenexhausted. InFY2013, action to terminate parental rights. based protective services, acourtpetition to remove achildfromthehome,orlegal not safe, then the caseworker initiates protective services. Thiscouldincludefamily- safety of the children in thehome. If thecaseworker determines that the childrenare whether a childhasbeen abused or neglected and whether there isathreattothe CPS investigates abuse and neglect allegations and makes adetermination of 278 Figure 56 illustrates the CPSinvestigation process upon receipt ofanallegation: residential group facility. in agroup foster home, an individual foster home, another facility, state agency ora provide care, CPSisgiven temporary legal custody. CPSthenplacesthechildeither to remain in hisorher home andthere are noappropriatefamilyorfriends who can Professionalswhocome into contact with these children must thereforebe 276 Ratesof behavioral problems, developmental delays, and 272 Theeffectsoftraumacanlast 281 Whenit is unsafe for the child 274 280
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277, DFPS 131 https://www. . Retrieved from from Retrieved 2013. Book Data and Report 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 dfps.state.tx.us/documents/about/Data_Books_and_Annual_Reports/2013/FY2013_AnnualRpt_Databook.pdf Source: Texas Department of Family and Protective Services. (2014). (2014). Services. Protective and ofDepartment Family Texas Source: Process Investigation CPS 56. Figure DFPS 132 specialists, dentists, vision services, and more. foster care child with access toprimary care physicians, behavioral healthclinicians, care children. Figure 57 for anoverview of existing health insurance programs for former foster covered underMTFCY aslong as they meet MTFCY incomerequirements. See — willbetransitioned to FFCC. Youth orFormer (MTFCY) Foster CareinHigher Education Program(FFCHE) from one of theexisting insurance plans — Effective January 2014, Former Foster Care Children receivinghealthcareservices medical coverage. services provided by each of these plans vary, although theyboth provide integrated two FFCC oftheapplicant: STAR insuranceplansbasedonage andSTAR Health. The insurance plans, FFCC has no asset, income, or educationalrequirements. Thereare former foster of 26. carechildren under the age Unlike Medicaid orother foster care Care ChildrenProgram (FFCC) provides extended healthinsurancecoverage to coverage. As acomponent of the ACA effective January 1,2014, the Former Foster Many foster out of thefoster children who age care system losehealthinsurance Former Foster · · · · · in STAR Health. 22, andformer foster youth receiving transitional Medicaid services) wereenrolled In FY2013, 31,834 children (including those inkinship care, foster youthuptoage health care forchildren in thefoster care system. program is statewide and was designedto better coordinateandimprove accessto delivery model. Superior Health the STAR Plan manages Health program. The careorganization with primary care and behavioral health services using a managed In 2008, the STAR Health program was created toprovide childreninfoster care Superior He Accessing Mental Health Services Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas by Superior include: Depression Disease Management Program. Depression Disease Management Detoxification services. Rehabilitation skills training. Psychological testing (including screening, assessment, anddiagnosis). Psychiatric services. 282 285 STAR Health operates a healthcare model thatprovides each 284 alth Care System (ST 286 Thosewho do not qualifyforFFCC will still be Children Progr Medicaid forTransitioningFoster Care 283 AR He Behavioral healthservices offered alth) am (FF CC) DFPS 133
http://www. 287 Retrieved from from Retrieved http://www.dads.state.tx.us/ - Require Other or Income ments Have countable income ofincome countable Have less ofthe 400% to equal or than Limit Income Poverty Federal (FPIL). of resources countable Have less $10,000. to equal or than programs medical other all Meet - citizen as such criteria eligibility eligibility. alien or ship Have income at or below $3,955 $3,955 below or at income Have individual. an for month per No asset, income, or educational or income, asset, No requirements. - - Retrieved from from Retrieved - Medicaid for Former Foster Care Youth. Youth. Care Foster Former for Medicaid Texas Works Handbook. Handbook. Works Texas Eligibility vatorship or voluntary agency voluntary or vatorship 18th their on conservatorship birthday. institution an in enrolled Be ofin located education higher Texas. cover health adequate have Not HHSC. by defined as age Be age 21 through 23. through 21 age Be conser state’s any in been Have ship at age 18 or older. older. or 18 age at ship health adequate have not Do coverage. Are age 18 up to 21 to up 18 age Are non-cit- qualified or citizen U.S. A izen. conservator Texas ofout Aged Anyone who has aged out ofout aged has who Anyone fos- Unaccompanied the or care ter Resettlement Minor Refugee at Texas ofstate the in Program older. or 18 age 26. to up 18 ages Are funded federally Received ofout aged they when Medicaid care. foster eligibil- Medicaid other all Meet citizen- U.S as such criteria ity residence. and status, alien ship, 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 Name Plan Former Foster Care in Higher in Care Foster Former to [Prior (FFCHE) Education FFCC] into integration Medicaid for Transitioning Foster Foster Transitioning for Medicaid those [For (MTFCY) Youth Care FFCC] for ineligible Former Foster Care Children Children Care Foster Former (FFCC) Program With the implementation of the FFCC plan, a larger number of former foster care a larger care plan, foster number of former FFCC the of implementation With the children in foster Many age up to insurance coverage health of 26. have adults will Some of health conditions. mental or other of trauma care experience instances left after they have children even care foster impact former conditions may these in the than young adults likely are more care alumni Foster system. the welfare keeping in finding and to struggle generalpublic assistance, to rely on population and mental health concerns. risk for physical be at high home, and to a stable Source: Texas Human Health and Services Commission. (2014, May). May). (2014, Commission. Services and Health Human Texas Source: onevoicetexas.org/2014%20HHSC%20Presentation.pdf (n.d.). Commission. Services and Health Human Texas Source: handbooks/texasworks/F/100/100.htm Health Insurance Programs for Former Foster Care Children Care Foster for Former Programs Insurance Health 57. Figure Thus, retaining health insurance for former foster care children for a longer period former foster insurance for health retaining Thus, access to the better that they have ensuring by outcomes can lead to better of time DFPS 134 Exchange iftheyhave sufficient resourcesor may stillqualifyfor Medicaid. not qualify for FFCC may purchase health insurance through theHealth Insurance There areatotal inthestate, of253licensedGROs andalmost 80oftheseareRTCs. exclusively for children with emotional disturbances. residential treatment centers (RTC). AnRTC provides careand treatment services sheltersin which children may beplacedforupto 30 days,childcare, emergency and are licensed by DFPSand include long-term residential facilitiesproviding basic provides of18years. residentialservicesfor13or more children up totheage GROs other GROs. August 2013, 1,508childrenwereliving in RTCs and 1,353 children wereplacedin cost effective inthe longrunas it reducesthe needfor long-term servicesand involvement, and the development of support systems. as differentialresponse, placean emphasis onfamily strengthening, parental with less serious casesof abuse and neglect. ARS, also known atthenationallevel allegations. Indoingso, CPSwillprovide a non-adversarial meansof dealing Response System (ARS) adapts the typical CPS process toaddresslow-risk investigation and provide services to more families in need.The Alternative The CPS Alternative ResponseSystem aimsto ameliorate thestress ofa CPS Alterna with a relative. placing a childinfoster care, thecourt is required to considertemporaryplacement children in thecustody of thestate are placed in congregatecarefacilities. Priorto While the state recognizes that it is preferred that childrengrow up infamilies, some Institutional wellbeing. mental health careservices and supports necessary fortheirrecovery and long-term Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas worker satisfaction. outcomes related to child safety, communityinvolvement, family engagement, and Research has found that ARS ordifferential response systems lead tomore positive · · · · · 121 GROs provide121 GROs treatmentservices for children with emotional disorders. state.tx.us/Child_Care/Search_Texas_Child_Care/ppFacilitySearchResidential.asp aged out of Texasaged foster care andhave since moved to another state. out of the foster care system in another state are ineligible,asthosewhohave have access to post-care health services. ThoseoriginallyfromTexas whohave aged There are two groups of youngadults previously in CPSconservatorship that may not by the following features: residential operations (GRO) facility.residential operations (GRO) placed in a foster home with foster parents, afoster family grouphome, or ageneral Encourages collaboration with families.Encourages Connects families with appropriate service providers. Won’t perpetrator designate an alleged in these cases. Does not declare aformal finding ofabuse orneglect. Conducts assessments, not investigations. 288
294 tive 290 For alist of child-care operationsinthe state visit Ifthisoption isnot available orappropriate,thechildmay be 297 R Despite higher initial investment, thisapproachismore esponse R 296 esidential 291 A GRO is acongregate carefacilitythat AGRO System Services 295 TheARSischaracterized https://www.dfps. 289 Thosewhodo 293 Asof 292
DFPS 135
303 Children aged Children and younger three 80 represented ofpercent the child abuse from fatalities Texas and neglect in 2013. in FY legislature, is an rd Child
305 304
System 301 CPS Implementation of this framework has resulted in of this framework has resulted Implementation 299 300 re Ca
lities in the in alities ARS engages parents, prompts them to identify their strengths, and and strengths, their to identify them prompts engages ARS parents, 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 298 a There are currently eight communities in Texas that have implemented that have Texas in eight communities currently There are 302 this framework and serve families from the following counties: Travis County, Fort Fort County, counties: Travis the following families from this framework and serve Floyd, and Lamb, and surrounding counties, Tarrant Harris County, Paso, El Worth, County. and Crosby Swisher, Castro, Palmer, Bailey, Dickens, Hale, Briscoe, Motley, interagency consortium that aims to improve the delivery of mental health services of mental interagencythe delivery to improve that aims consortium services throughout of care system the expanding by in Texas for high-needs youth the state. lower findings of delinquent behavior, lower caregiver strain, increase in protective strain, increase in protective caregiver lower findings of delinquent behavior, lower cultural needs. to more attention and factors, The Texas System of Care Consortium expects to have a total of nine communities in of nine communities a total to have expects Consortium of Care System The Texas 2017. by in place of Care framework the System with Texas Children agedChildren and younger three of the 80 percent represented in FY 2013. in Texas and neglect child fatalities from abuse Continuing Issues Continuing F Child The Texas System of Care Consortium, established during the 83 during the established Consortium, of Care System The Texas System of Care refers to an organizational framework that is strength-based and is strength-based that framework to an organizational refers of Care System needs is coordinated across support intensive for youth with Care collaborative. children can families so that and organizations, public private and agencies, the services they need. accessing them from that prevent the barriers overcome cultural and linguistic family’s her and his or to a youth sensitive This framework is of care framework delivers A system health needs. as their mental as well preferences system, justice the juvenile hospitals, into reduce entrances and supports to services system. child welfare and the ystem of System intervention. connects them to community service providers to reduce the risk of behavior that is that behavior the risk of to reduce service providers community to them connects Slated for development. physical and emotional, social, cognitive, to a child’s harmful to be fully implemented is expected this program 2014, beginning September rollout three years. in two to statewide fatalities continue to occur in the Texas child welfare system, as system, child welfare the Texas to occur in continue fatalities Human Services hearing and Health Senate a Texas discussed in provide Figure 59 below Figure 58 and 2014. 20, February held on in FY 2013: in Texas the child fatalities on details DFPS 136 visits, identifyrisks, and intervene appropriately. Figure 59. Confirmed Child Fatalities Due to Abuse or Neglect dfps.state.tx.us/About_DFPS/Legislative_Presentations/DFPS/ Source: Senate Health and Human Services Committee. (2014, February 20). Figure 58. ChildMortalities in Texas Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas CPS. In 2013, 46 percent of familieswith child fatalities had priorinvolvement with Source: Senate Health andHumanServicesCommittee. (2014, February 20). Interim Charges for DFPS. Retrieved fromwww.dfps.state.tx.us higher than the recommended 17cases per caseworkers. to vulnerable children. The current average caseload is32cases, significantly caseworkers would allow themtobe more effective andtoprovide needed attention 306 HighcaseloadsforCPS workers may lead to failures conduct routine Interim Charges for DFPS. Retrieved from https://www. 307,
308,
309 310 Lower caseloadsforCPS Moreover, youthsee DFPS 137
315 In 2012, In 2012, 311 320 DFPS passed new regulations designed to new regulations designed DFPS passed 316 However, turnover rates in some CPS regions were CPS regions in some rates turnover However, 312
314
Lower-tenured workers require more supervision and require more supervision workers Lower-tenured 317 313 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 steps were put in place to protect and provide more oversight of more oversight provide and protect in place to were put These steps 318 A number of theories have offered explanations for disproportionality offered have of theories A number
319 Parent and family risk. and Parent social factors. risk and other neighborhood and Poverty policyof child welfare The impact color. on children of workers. child welfare Racial bias among An additional interview of a family member not living in the home. not member of a family interview An additional other and/or school employees, clergy, additional interviews of neighbors, Two members. community parents. Interviewsof foster children of all adult household and review of parents of foster relationships An assessment of personal finances. two agency enforcement law past home for the to the foster calls of any Review years. as an person designated any checks for and background of identity Verification emergency caregiver. within the child welfare system including: system child welfare within the enforce stricter monitoring of foster care homes, effective September 1, 2014. These 1, 2014. September effective homes, care monitoring of foster stricter enforce rules require: new safety training, so turnover among caseworkers affects the department’s overall efficiencyoverall the department’s affects among caseworkers so turnover training, cases. and timeliness with · · · · · · AgenciesChild Placing monitor more closely changesto will also be expected in the and family frequent visitors, divorces, marriages, job losses, such as home, foster additions. · · · · Texas children in the CPS of profile and racial the ethnic breaks down Figure 60 system: Since 2004, CPS has been striving to reduce the disproportionate representation of to reduce been striving CPS has Since 2004, in the CPS children and youth represented American African American and Native system. ality portion Dispro In FY 2012, two children died from abuse/neglect while in foster care placement. care in foster while from abuse/neglect died children two In FY 2012, high turnover in caseworkers, reducing the likelihood that they have a reliable and and a reliable they have that likelihood the reducing in caseworkers, turnover high are in they while occurring not abuse is and that neglect ensuring advocate consistent care. foster foster creates for turnover high caseworker that to the instability In addition a quarter Almost within CPS. cohesion rates also diminish retention low children, within a year. CPS employment of agency percent) leave (24.1 employees foster care children to prevent child fatalities. fatalities. child prevent children to care foster CPS hired 1,704 caseworkers. CPS hired to 8. rose number this In FY 2013, as high as 34.3 percent. as high as 34.3 DFPS substance abuse. depression, and suicide, for attempting more at risk were significantly adulthood and health issues in mental chance of had agreater family rejection experiencing who reported LGBTQ youth 138 the needs of LGBTQ youth inthe state’s foster care system. heterosexual peers. show that LGBTQ former foster care youth areless financially stable than their youth in thefoster care system continues upon their exit,asnational studies However, the NationalResourceCenterforYouth Development reportsthatLGBTQ it isdifficultto determine theactualnumberofLGBTQyouthinfoster care system. suicide. mental healthconditionssuchasdepression,substance abuse,andheightenedriskof The stigma associatedwith LGBTQ identitymakes thispopulationmorevulnerableto LESBIAN, GAY, BISEXUAL, TRANSGENDER, QUEER YOUTH dfps.state.tx.us/documents/about/Data_Books_and_Annual_Reports/2013/Combined13.pdf Source: Texas Family Department of and Protective Services. (2014). Figure 60. Disproportionality intheCPSSystem Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas and inclusive environments within the foster care system. youth are freefrom harassment and abuse, have equalaccesstosafe, supporting, 321
Due to a lack of reporting and the fact that sexual orientation is self-identified, Due toalackofreportingandthefactthatsexualorientationisself-identified, risk forattempting suicide, depression,andsubstance abuse. chance ofmentalhealthissuesinadulthoodandweresignificantlymoreat LGBTQ youthwhoreportedexperiencingfamilyrejectionhadagreater coming out. reported sufferingphysical violenceatthehandsofafamilymemberafter Additionally, onestudy foundthatover 30percentofLGBTQyouth youth representanywhere from5–10 percent ofyouthinfoster care. toward identity. their sexual orientationorgender away fromtheir foster placements as a resultofencounteringhostility youth who wereplaced in foster care endedup being removed orran by the Urban Justice Center revealed that up to 78percentofLGBTQ family that is understanding andresponsive totheir needs. Astudy may receive unfairtreatment, and may have difficulty findinga foster identity,or gender andthusmay face higherrates of harassment, because of negative social attitudes towards their sexual orientation LGBTQ foster youth may bemore at riskfornegative outcomes their safety risksandentranceintothefoster caresystem. essential forpromoting thewell-beingofLGBTQchildrenandreducing policies for youth in the foster care system should ensure that these 327 Thereare currently no policies in Texas specificallyaddressing 324 For thisreason,increasingfamilyandcaregiver supportis 2013 Annual Report and Data Book. Retrieved from 326
Disparity for LGBTQ 325 Supportive 323
http://www. 322
DFPS 139 A 328 In many instances, non- instances, In many 335 One research study showed that nationally nationally that study showed One research of 10 percent foster kids received a powerful antipsychotic medications, subset of side with significant psychotropics children. in effects In FY 2012, almost 32.5 percent of percent 32.5 almost In FY 2012, 329
336 However, children’s symptoms of trauma may of trauma may symptoms children’s However, tions 334 a 332, 333 Medic Usage of psychotropic Usage of psychotropic 330 One research study showed that nationally 10 percent of foster foster percent of that nationally 10 showed One research 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 331 In state fiscal year 2011, a total of about $42,000,000 was paid out for was paid out $42,000,000 of about a total fiscal year 2011, In state kids received antipsychotic medications, a powerful subset of psychotropics with of psychotropics subset a powerful medications, antipsychotic kids received in children. effects side significant medications may also result in long- also may medications physical stunted as such term effects development. Psychotropic medication prescriptions reached a peak in 2004, when almost in 2004, when almost reached a peak prescriptions medication Psychotropic medication. In on a psychotropic care were in foster of all children 42 percent for foster prescriptions medication psychotropic of rates to the alarming response and federal state the at both on this issue spotlight media and the care children Utilization Parameters, Medication released Psychotropic 2005 Texas in level, of psychotropic for prescriptions and requirements standards which established is to encourage The goal clinically appropriate and of the parameters medications. in Figure 61, psychotropic As shown medications. usage of psychotropic informed 30 percent over a little In 2011, thereafter. declined steadily prescriptions medication medications. psychotropic were prescribed care in foster of children pharmacological alternatives could successfully help children with their behavioral children with their behavioral help could successfully alternatives pharmacological to are costly prescriptions medication psychotropic Additionally, issues. health the state. care clients. foster drugs to psychotropic 2011 report by the U.S. Government Accountability that in (GAO) showed Office Government U.S. the by report 2011 4.5 rates 2.7 to at drugs psychotropic care were prescribed children in foster Texas care. foster in not than children times higher be misinterpreted as deliberate problematic behavior. problematic as deliberate be misinterpreted Children in foster care have undergoneexperience neglect and, as a result, abuse and have care in foster Children consequences are one of the health conditions Mental degrees of trauma. several experiences. traumatic arising from Foster children are disproportionately treated for their behavioral health needs with health needs with their behavioral for treated are disproportionately children Foster behavior). and emotions, mind, the affect (drugs that medications psychotropic pic otro h Psyc Texans in foster care were prescribed at least one psychotropic medication (see medication psychotropic one at least prescribed care were foster in Texans prescription that high psychotropic points out GAO report The below). Figure 61 nevertheless, states; on behalf of action indicate improper necessarily not rates do of the prescription regulate better to a series of steps has undertaken Texas care children. for foster medications psychotropic but mental disorders, in treating can be effective medications Psychotropic always are not medications psychotropic Even or necessary. appropriate clinically health mental in treating effective when medications psychotropic conditions, potentially and significant also carry including side effects, long-lasting appetite, decreased/increased trembling, of risk increased nausea, and headaches, suicidal thinking. DFPS 140 · · · · · · verbally or inwriting: the definition ofinformed consent, the following elementsmust beprovided either for psychotropic medicationsforchildren/youth in state custody. Inorderto meet H.B. 915 also clarified whatconstitutes informed consent withrespect toconsent The 83 texastribune.org/2013/01/29/interactive-foster-children-prescribed-high-doses/# Source: Aaronson, B. (2013, January 29). Rate Fosterof Kids on Psychotropic Drugs Falls . Figure 61. Psychotropic Medication Prescriptions Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas kinship caregivers, andcertainDFPSstaff. right that is typically delegated to legal caregivers suchasfoster parents, relative and and older that they may petition the court to betheir own medicalconsenter, alegal for their input. Attorneys 16 ad litem are required to explicitlyinformyouthages children and youththe medical and mental health care theyarereceiving andtoask Guardians ad Litem and Attorneys adLitem are now required todiscusswith medication prescription process. created provisions to strengthen the roleof informed consentinthepsychotropic their child’s placement on psychotropic medication. Most notably however, H.B. 915 youth taking prescription medication, and the notification ofbiological parentsof creation of amedical consenter informational brochure, a youth transitionplanfor youth in theirown treatment. These include minor developments suchasthe monitoring of medication by implementing client-based approachesthatinvolve care youth. H.B. 915 (Kolkhorst) resulted innew policies anddutiestoimprove the Reasons for the proposed course of treatment. interventions to the medication, if any. Generally accepted alternative medications and non-pharmacological medications. Probable clinically significant side effectsandrisks associatedwiththe medications. Probable health and mental health consequences of not consenting to Beneficial effects onthatcondition expected frommedications. Specific conditionto betreated. rd Legislature revisited theissueof preventing overmedication offoster 337
The Texas Tribune. Retrieved from http://www. DFPS 141
338 Trauma-informed Trauma-informed the recognizes care of on effects trauma and the individual, that care provides is evidence-based to an and tailored It needs. individual’s a provides therefore non-pharmacological to healing approach reliance decreases that on psychotropic and medications placement increases stability.
339 re Ca ormed 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 uma-Inf ), DFPS should assist in the development of trauma-informed programs to development in the should assist ), DFPS a nd the extent resources are available for court-appointed special advocates, children’s children’s special advocates, for court-appointed are available resources the extent violence and domestic centers, mental health community local advocacy centers, managed care had Health STAR under providers mandated that 219 also S.B. shelters. training. care trauma-informed to offer Trauma-informed care recognizes the effects of trauma on the individual, and trauma on the individual, of effects recognizes the care Trauma-informed It therefore needs. to an individual’s and tailored that is evidence-based care provides reliance on that decreases to healing approach non-pharmacological a provides stability. placement and increases medications psychotropic Tr By involving medical consenters, the child, and the judiciary system, all actors are all actors system, judiciary the and child, the consenters, medical involving By for psychotropic consent Moreover, history. medical child’s of the abreast kept the measures The intention of discontinued. or be denied may medication of appropriate regulation and accountability improve 915 is to H.B. by implemented have means non-pharmacological that and to ensure prescriptions psychotropic overmedication. of the risk lessening thereby explored, properly been alarming addresses the for FY 2015 budget Obama’s President On a national level, The requested medications. on psychotropic children care foster rates of for medications of psychotropic curb the usage million to of $750 appropriation pursue non- to states allow funding to two-pronged: is youth care 1) it provided foster who states to incentives 2) provided care, and to mental health approaches medicinal prescriptions. reduce the psychotropic to those strategies implement successfully Even though Congress rejected the budget in May 2014, President Obama’s budget President Obama’s 2014, in May the budget rejected Congress though Even youth. care needs of foster the critical highlighted Awareness of an individual’s trauma-inducing experiences can experiences trauma-inducing of an individual’s Awareness within the scope of the occur that may re-traumatization avoid care foster the children in Many services. of traditional delivery of trauma stemming forms to multiple been exposed have system sexual abuse, violence, sexual, or emotional physical, from family the Understanding the home. from removal abuse, and substance coping a child’s insight into more provide can of trauma effects and developmental and tendencies, behavioral mechanisms, can care trauma-informed As a result, development. cognitive a better and caseworkers schools, parents, communities, provide them to approach traumatized children and provide grasp on how needed. and supported the services for trauma- the need Session recognized Legislative The 83rd 1356 S.B. (including of bills a series care and passed informed education on trauma to expand 460 – Deuell) S.B. Putte, de – Van and administrators, for educators, and trauma-informed care the Legislature session, In the previous staff. justice juvenile care trauma-informed DFPS to maintain its own authorized programs of similar the development in and to assist program 219 in S.B. As outlined permitted. as funding system welfare the child throughout (82 DFPS 142 resident youthwill bere-traumatized. may helpreduce thelikelihood that a to seclusionandrestraint techniques trauma. Thus, institutingalternatives techniques mayexacerbate their settings andseclusionrestraint is commonamongyouthinRTC Emotional andphysicaltrauma re-traumatized. and restraint techniques may helpreduce the likelihood that a residentyouthwillbe techniques may exacerbate their trauma. Thus, instituting alternatives toseclusion Costs and Availability in Texas Figure 62. Prevention andEarlyInterventionPrograms andServicestheir under PEI. provide servicesforyouth. Figure 62 lists thevarious programs and servicesprovided outreach efforts coordinatedthrough thisdivision addressnegative outcomes and child’s removal fromthe home, incarceration, and schooldropout. them to treatment to prevent negative outcomes such ashomelessness, poverty, a at riskofdeveloping mental health and behavioral health conditionsandlink have access to private providers. Additionally, these programs may identify youth as reducing disparities for low-income and minority populationswho may not address mentalhealth conditions by providing timely access to services, aswell delinquency. Community-based early intervention strategies andprogramscan This division partners with communities to prevent abuse, neglect, andjuvenile Prevention and Early Intervention (PEI) Seclusion Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Program Risk Youth(STAR) to At Services tion Program Descrip- run away. delinquent, orhave been truant or at home, have experience conflict up to age 17 who services to youth to offer short-term munity agencies Contracts withcom- 341
and R estr Services counseling. ual and family care, and individ - gency residential short-term emer counseling, intervention Family crisis aint in RTC settings andseclusion and restraint physical trauma iscommonamongyouth or chemical restraints. others; this may include physical, mechanical, believed to beatrisk of harming themselves or isolate (seclude) orhold (restrain) individuals techniques used by administrators and staff to restraint. Seclusion and restraint refers to training in reducing the useofseclusion and staff from RTCs across Texas have received decrease the riskof traumatization and injury, well-being and techniques that encourage In anefforttopromote behavioral management - ability Regional Avail- ties. All TexasCoun- Served Numbers 23,677 youth served = Average yearly 5,351 youth served = Average monthly 340 Emotional and 343 342 Programsand $255.16 served = cost per youth Average monthly Cost 344
DFPS 143 346 Total Expendi- Total 2012 FY in tures $716,847 = Cost Average per cost monthly = served family $334.79 Average monthly monthly Average year per cost $71.63 = served Annual youth youth Annual 16,767 = served number Annual offamilies 990 = served Numbers Numbers Served number Annual offamilies 1,736 served 345 Potter, Travis, Travis, Potter, Dallas, Nueces, Tarrant, El Paso, Galveston, Lubbock, Harris, Harris, Hidalgo, - McLen Bexar, nan. distrib- Funds com- to uted across munities Texas. Regional Avail- Regional ability - Communi - pro ty-based select in grams counties. Texas Respite, parent parent Respite, education, fatherhood parent services, leadership, visitation, home various and initia- special including tives, awareness public campaigns. Varies across across Varies communities include may but mentoring, youth-employ- programs, ment - prepara career alterna- and tion, recreational tive activities. Services across Vary communities include may but family outreach, interventions, promoting and net- support works. 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 Uses federal grant grant federal Uses develop to dollars local support and to partnerships commu- increase of awareness nity - preven existing services, tion com- strengthen - paren and munity involvement tal abuse child in efforts, prevention encourage and engage to families services. in Contracts with Contracts - organi community develop to zations - delin juvenile prevention quency zip in programs a have that codes ofincidence high crime. juvenile Funds communi- Funds programs ty-based to designed and stress alleviate parental promote competencies ofadoption and that behaviors ability the increase ofsuc- to families nurture cessfully and children their family toward work self-sufficiency. Program Descrip - Program tion - Communi Child ty-Based - Preven Abuse tion Community Community - Develop Youth ment Texas Families: Families: Texas and Together Safe Program DFPS 144 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas HIP). Project HOPES is intended to prevent child abuse and neglect for children (Project HOPES) and Project Help through Intervention andPrevention (Project child abuse: Project Health Outcomes through Prevention andEarlySupport In addition to the existing programs, two newinitiatives aredesignedtoprevent Program Adult Living Preparation for Services Network Statewide Youth Program Hotlines and Youth Texas Runaway services system. child protective departure from the stitute care for their foster youth in sub- Prepares older services. quency prevention juvenile delin- evidence-based grams that provide prevention pro- community-based wide networks of Supports state- tion Program Descrip- neglect. and abuse and quency, truancy, conflict, delin- including family situations variety of Callers raise a YOUTH). Hotline (1-800-98- and Texas Youth (1-888-580-HELP) Runaway Hotline toll-free Texasthe Volunteers operate management and money for the future health, planning transportation, housing and skills, job skills, interpersonal personal and life, such as lead a successful financial skills to social and with necessary provide youth Classes to drinking. usage, and activity, drug such as sexual risky behavior delinquency and prevent juvenile personal skills to to 17 social and and youth age 6 Teaches children Services and families. troubled youth and referrals to counseling tion, telephone Crisis interven- All DFPS Regions DFPS region. Available in each ability Regional Avail- availability. Widespread = 7,265 served in 2013 youth Number of = 4,384 youth served of Annual number Served Numbers calls = 7,462 2013 incoming 347 $253,372 ditures = 2013 Expen- 349 $532.63 per youth = Average cost served = $50.71 cost per youth Average monthly Cost 350 348 DFPS 145
The population of Texans Texans of population The aged 65 and older to reach is projected 3,029,847 in 2014 and 3,148,771 in 2015 and to continue is expected increase This increasing. in the elderly population a higher could indicate need for services in the future. 357 The strategy behind Project Project behind strategy The 351 Project HIP is a more targeted intervention intervention HIP is a more targeted Project 352
353 This increase in the elderly This increase The total of the completed in-home of the completed The total 355 All of these services help to protect the mental health and help to protect services All of these 356 354 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
358 69,383 completed in-home investigations. in-home completed 69,383 allegations. in-home validated 48,393 investigations. facilities completed 10,818 confirmed allegations. 1,373 strategy designed to increase protective factors and prevent child abuse; the target child abuse; the prevent and factors increase protective designed to strategy due terminated rights previously parental their had who have are families consumers a cause identified who died with who had a child families and neglect, to child abuse birth given or who have are pregnant who youth and foster or neglect, as child abuse months. four last within the HOPES is to encourage the development of protective factors that will reduce the the will reduce factors that is to encourageHOPES of protective the development neglect. and abuse of child likelihood and facility investigations in FY 2013 are enumerated below: enumerated are in FY 2013 investigations and facility · · · · percentage higher behind the reason One possible validated of in-home cases most facilities allegations is that validated allegations than in-home a involving validated than allegations more readily are thus and self-neglect involve perpetrator. The APS division investigates allegations of abuse, neglect, and exploitation of adults neglect, and exploitation of abuse, allegations division investigates The APS age regardless of aged in who are living disabilities with adults and of and older 65 Allegations facilities. or state-contracted in state-operated or settings residential caregivers, children, abuse by their adult parents by abuse of include self-neglect, other types of abuse, financial exploitation, and abuse, well as emotional as physical scope of APS is investigative the context, at-home In the or exploitation. neglect other types of exploitation In facilities however, exploitation. financial limited to be investigated. may Adult Protective Services (APS) Services Protective Adult 0 – 5 years old and contracts will be dispersed to select target counties (Potter, Webb, Webb, (Potter, counties select target to dispersed will be and contracts years old 0 – 5 El Paso). Travis, Hidalgo, Cameron, Ector, Gregg, population could indicate a higher need for services in the services for a higher need indicate could population abuse/ of in-home made reports 87,257 There were future. 22 percent of which were reported neglect of adults in FY 2013, personnel. medical by wellness of persons with disabilities and aging Texans. and aging Texans. with disabilities of persons wellness agedto older is projected and 65 The population of Texans and is expected in 2015 and 3,148,771 in 2014 reach 3,029,847 increasing. to continue Figure 63 illustrates the APS flow of a case once an allegation is received: allegation once an a case of APS flow the illustrates Figure 63 DFPS 146 general public about elder abuse via public outreach campaigns.general In addition to the investigations conducted by APS, thisdivisionalso educatesthe alerts law enforcement to the case. guardianship services. If the suspected abuse may constitute criminal conduct, DFPS services are referred to theDepartment of Aging andDisabilities Services (DADS) for care and services for victims ofabuse. Those who are incapableofconsentingto dfps.state.tx.us/documents/about/Data_Books_and_Annual_Reports/2013/Combined13.pdf Source: Texas Family Department of and Protective Services. (2014). Figure 63. APSInvestigation Process Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas do so. have been affirmative findingsofabuse or not, APSis not statutorilyauthorizedto affirmative finding. WhereasCPScan provide services regardless of whether there not have the capability or resources to provide supportsorservicesafteran ongoing serviceintervention but does If allegations are confirmed,APSprovides emergency 359 TheAPS division ofDFPS works with other state to coordinate agencies 2013 Annual Report and Data Book. Retrieved from
http://www. DFPS 147 https://www.dfps.state. Retrieved from from Retrieved It is therefore imperative that the that It is therefore imperative Children from birth through 13 years of age who ofage years 13 through birth from Children for homes childcare and centers childcare attend ofpart day. 24-hour the for residence own caregiver’s the in care Provide total The years. 13 through birth from children ofnumber time, given any at care in children caregiver, the to related children the including 12. exceed not must a hours 24 for ofage, years 17 through Children home own child’s the than other place a in day Texas. of State the across 361 Guide to Childcare in Texas. Texas. in Childcare to Guide In 2013, there were 21,980 daycare centers and homes centers and 21,980 daycare there were In 2013, 360 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 Day Care or Licensed Child Care Center Care Child Licensed or Care Day daycare group as known also cares day At-home home childcare Licensed a or homes care child Residential quality of that care is regulated to ensure healthy physical, mental, and emotional mental, and emotional physical, to ensure healthy is regulated care of that quality conditions and adverse of mental health onset the to prevent and development childhood experiences. The number of children living in regulated, residential childcare in Texas is residential childcare in Texas regulated, living in children of The number 41,420. approximately Source: Texas Department of Family and Protective Services. (n.d.). (n.d.). Services. Protective and ofDepartment Family Texas Source: tx.us/child_care/other_child_care_information/childcare_types.asp Child Care Licensing Care Child and childcare operations regulates (CCL) division Care Licensing The Child childcare RTCs), (including facilities childcare residential for permits approves reduces in Texas system childcare the Regulating daycares. and at-home centers, Figure 64 of communicable diseases. transmission abuse, and the of injury, the risk this department: by overseen childcare operations describes key below Texas in Operations Child Care 64. Figure in Texas, with a total capacity of 1,085,366. capacity a total with in Texas, DFPS 148 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas DADS 149 152 152 153 154 154 155 158 159 159 153 153 158 165 165 165 166 152 153 154 158 165 151
362
At A At A Glance 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 cts C
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People with Disabilities with People Texans Aging SB 7 SB 45 SB Centers Living Supported State Mexia and conferences waiver DADS at trainings care Trauma-informed 2013 Services Waiver to People Connecting in Authorities of Role Local Centers Living Supported State Medicaid 1915(c) Waiver Services Waiver 1915(c) Medicaid SB 1226 SB Angelo San at assistance technical and training planning, person-centered and care Trauma-informed Facilities Nursing Skilled Facilities Care Intermediate Community Services Non-Medicaid Program Guardianship Initiative Independence Promoting Program Person the Follows Money The rate of mental health conditions for people with IDD is two to three times for people health conditions of mental The rate varied widely with generalfor the higher than Research findings have population. health conditions ranging of IDD and mental co-morbidity rates for prevalence percent. to 75.2 percent from 13.9 may people with disabilities conditions among health rate of mental The higher Coordination of services between DADS and DSHS DADS between of services Coordination Accessincluding emergencycrisis services to respite behavior care, positive trauma-informed of implementation System-wide and person-centered practices supports centers supported living services in state psychiatric Improved services for community-based wait time Significant in SSLCs of restraint Reduction Addressingwith disabilities of individuals health needs the mental Texans Aging and Disabilities with People for of Conditions Health Behavioral Prevalence Texas Department of Aging and Disability Services Department Texas Environment Changing Conditions Health Behavioral Co-occurring Have Who Disabilities with People for Services and Programs Supports and Services Long-Term Community Supports and Services Long-Term Institutional Texans Aging and Disabilities with People for Programs Additional st F ast · · · · · · · · F · Policy Services: Services: Aging and Disability and Aging Texas Department of Department Texas DADS 150 Organiz · · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Januar O L egal S institutionalization, bullying, low self-esteem, and other factors. be due to psychological stress related to adisability, socialisolation,trauma, mental health diagnoses. at least one co-occurring mental health disorder and 41percenthadtwo or more indicates that for10-to 14-year-old children living with autism,70percenthad conditions in people with autismspectrum disorder (ASD). Recentresearch Over the past decade, evidence has shown ahigh prevalence of mental health likelihood of developing a mentalhealth condition. with IDD experienced at least one traumatic event in theirlifetime, increasingthe population. In one study,higher than the general nearly75percentofparticipants institutionalization, abandonment, bullying and other types oftraumaatrates and children with disabilities experience abuse, neglect, Adults A rganiza E dministr P nf Litiga olic S S S or er er er Rules er c vic vic vic y and emen vic tion y 2014 es es es a es tiv t e S tak eholder Rela C onsumer R S and S C tions urr onsumer R tional C P oga C C r of omplain omplain Mak Review In In er essional t tak tak e D vic ing igh e e ecision es igh t t ts ts/ G o Rela v ernmen tions C hief O t Inf T echnology Infr Managemen Managemen D Inf A har orma O O O eput pplic B S per per orma P astr usiness ec per r ojec a a urit c y IRM/ tion a tions uc tions er tions tion a t tur y ting e t t t V E olun C ngagemen ommunit t eer and C C and Ex en y on t and S C tional t tr on C er f on ac and tr T A t tr t O r or C ac ssistanc ernal A Review ust F uppor C ac T lien t S echnic v t Review onsumer ersigh anc und t t e tions al airs A t ssocia Rela Media tions t e C S ommissioner Ex ta S ec A uppor Managemen B C E O dministr oor duc utiv udget S S per er er dina a t S vic vic e and tional a tions er es es tion a vic tiv S t ta e es C t e L ommunic O mbudsman ong-t O c e erm C a tions C S hief F tr a A ar t ccoun O P egic O A and G e r ccess andG ogr Planning and 366 inancial C O Repor ommunit per c am B ting er r per an a tions ting usiness ts a tions r an y ts Chart
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tak y y t es t t e Q ualit P r y Initia ogr P G olic uar am O D S C O v ev er W ommunit y andP Regional dianship ersigh tiv per S elopmen uppor vic alk es a tions es t and r er ogr t y Inno t am P r ogr vation am S er Da Resear C vic Repor A ta A ommunit and O ccoun es C C C nalysis/ ch and on on ting v on tr tr tabilit ersigh ac ac tr t ts y ac 12 F y t 365 ts C SSL and Inno en acilities Inno t er f C A linic Cs vation or P ssistan al v Managemen a S olic tion IDD uppor U C tiliza ommunit y E t C W NF nr S Rules C A r aiv . P ollmen H UR Unit Q tion and ssur ommissioner f ospic t ualit W ers/P olic UR ed LivingC t Review aiv y S anc oor y A y e ers/ t UR er r e ogr dina dvisor/ vic am es t or en P or S t r P D ogr ers olic eput P olic am S ta y pecial A Independenc t O y andP e C C y C per Managemen O C oor oor S P P per omplianc C er r F r a linic ommissioner ojec ogr acilit dina dina dvisor f tions S vic a r pecial P tions omoting ams ts C al es y t t ors ors e oor e t or olic dina y t or A dministr O and C Regional O L W and O per C A 363, 364 O oc S aiv r omplianc ur per chit al S a er er S v Unit tions v ey a ti ec ersigh ur tions a ur tur c tion of v a v ey tion e ey al c es t S enior P A dvisor olic y E P nf r o C E E E C P vider Lic S or nf r nf nf er eden r ur c of A or or or ti emen v essional ssistan c c c ey and emen emen c Regula emen tialing a tion ensing t t t t t C t or ommissioner y S er vic and C D P ADC, ALF ev es olic NF andICF/IID elopmen urric and LSC y Rules , HCSSA ulum t P Lic C and C r o r Da NF eden vider Lic ensing and A Lic ta/Rec er tialing ti ensing c ensur or a tion ds e DADS 151 In the DADS section In the DADS the term of guide, this to is used “disability” to people with refer physical disabilities and people with intellectual and other developmental It disabilities. should be noted some mental that conditions can health constitute a disability under some program eligibility criteria and even legal protections though the term is not typically used when to people referring health with behavioral People conditions. living with mental prefer illness often not to be identified as having a disability while people with physical disabilities and people with intellectual and other developmental disabilities the prefer often terminology. 369 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 Post-traumatic stress has also been identified as a has stress Post-traumatic Research has also indicated an over-representation an over-representation has also indicated Research 368 367 of schizophrenia in people with IDD compared to the generalIDD compared to with of schizophrenia in people population. While trauma is not the only cause of mental health challenges of mental only cause the While trauma is not attention. and requires it is significant with disabilities, in people Adultsneglect, abuse, experience disabilities children with and types of trauma at rates higher abandonment, bullying and other institutionalization, Services Aging and Disability and Aging (DADS) Services Disability of Aging and Department The Texas and supports for services long-term providing is responsible for with and people disabilities with physical people aging Texans, (IDD). Long- disabilities developmental and other intellectual in their to remain help individuals and supports term services institutionalization. long-term avoid and communities needs have and support individuals with long-term service Many DADS years, In recent health conditions. mental co-occurring support the unique to addressing more attention has devoted Developmental behaviors. challenging with those needs of mental health existing can often overshadow disabilities and family caregivers Professionals, conditions. or medical through an individual to seeing are accustomed who members that behaviors can misinterpret disability of a primary the lens acute distress, conditions, mental health with be associated may trauma. medical conditions or past to focus with IDD continue for people of care systems Many without behaviors on controlling and managing challenging underlying mental for of the potential consideration adequate cause of the behavior. conditions as the or medical health of the development been has often of treatment The focus or the compliance management behavior plans to promote cases, both In behaviors. control the use of medications to the actual and not behavior the the treatment is targeting reduces This significantly condition. health or medical mental for recovery. opportunities two of the are and anxiety depression indicates that Research in people health conditions mental frequently identified most with IDD. Texas Department of Department Texas significant cause of mental health concerns in people with IDD. concerns in health cause of mental significant DADS population. needs amongthesenior substance usetreatment unmet mentalhealth and “silver tsunami”of anupcoming warned of Medicine the Instituteof A July 2012report by 152 level of disability (IQ) andtype of disability.level of disability (IQ) comparison groups, overuse ofadministrative samples (versus populationsamples), and assessmentinstruments, smallsample sizes, lack of studies usingnon-IDD prevalence rates is likely dueto lack ofconsistency regardingdiagnostic definitions indicates that forchildren living with autism, 10–14 yearsold, 70 percent had atleast conditions in people with autismspectrum disorder (ASD). Recentresearch Over the past decade, evidence has shown ahigh prevalence of mental health health conditions ranging from 13.9 percent to 75.2 percent. have varied widely with prevalence rates forco-morbidityof IDD and mental population.Researchfindings IDD istwoto three times higher than for thegeneral It hasbeenestimated that the rate ofmental health conditions forpeoplewith experience significant disparitiesin theirability toaccessneededservices. population,often higher risk of having mental health conditions than the general require accesstoquality mental health services. People withdisabilities, whileata Individuals with disabilities canexperience all types of mentalhealthconditionsand People with Aging Texansand Conditions for People with Disabilities Prevalence Behavioral Health of of developing a mental health condition. experienced at least one traumatic event in theirlifetime, increasingthelikelihood population. In onestudy,than the general nearly75 percent of participantswithIDD Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas self-esteem, andother factors. related to adisability, socialisolation, trauma, institutionalization, bullying,low conditions among people with disabilities may alsobe due topsychological stress but not withinDADS programs and facilities. trauma-informed care training inthe child welfare and thejuvenile justice systems, the impact of trauma on development and behavior andhave statutorily mandated Disabilities commonly depression, alcoholism or dementia-related has some form ofbehavioral health condition, most Approximately 20 percent of the current elderly population two or more mental health diagnoses. one co-occurringmental health disorder and 41percenthad use treatmentneeds among the senior population. “silver tsunami”ofunmet mentalhealth and substance report by theInstitute of Medicine warned of an upcoming and under-treated behavioral health conditions. A July 2012 Persons who are aging also experience under-recognized Aging 373, 374 373, Texans 370 Texas have policymakers recognized 372 Thehigherrateofmentalhealth 371 375 Thevariationin
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DADS 153 Texas Legislature and HHSC and Legislature Texas rd Older Texans meeting the medical the medical meeting Texans Older 378 An estimated two million seniors in the seniors in million two An estimated 377 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 leadership, departments are seeking new ways to provide more effective, appropriate more effective, provide to new ways are seeking departments leadership, of are descriptions Following need them. people who to the efficient services and cost changethe major some of place at DADS. taking initiatives United States have serious mental illness. mental serious have States United B 1226 SB as the desired outcome employment established competitive SB 1226 (Zaffirini) to Taskforce First Employment created the The bill with disabilities. for people for individuals employment competitive to promote efforts on their state advise the employers, self-advocates, comprised of force will be The task with disabilities. opportunities increase for individuals with in seeing interested and others providers settings. competitive in to find employment disabilities B 45 45 SB SB 45 (Zaffirini) required programs, waiver Medicaid the standardize In an effort to services in all employment supported and assistance of employment the inclusion increase This will waivers. home and community-based 1915(c) Medicaid of the meaningful integrated to obtain disabilities for individuals with opportunities employment. B 7 SB major changes7 (Nelson), in SB included of directives As a result are expected in to services and supports services and long-term acute care of both the delivery HHSC See the information on the for more detailed section with disabilities. people changes that will be development those under and being implemented currently the expanded of these changes involve Many years. few next in the operationalized The SB use of managedto people with disabilities. of services for the delivery care HHSC in the AdvisoryRedesign is assisting 7 IDD System and DADS Committee systems. delivery service of future development Foundation please visit the Hogg SB 7, summary of comprehensive a more For at http://www.hogg.utexas.edu/uploads/documents/83rd%20Lege%20 website Summary3.pdf Changing Environment Changing agencies enterprise, and human services (HHS) the health in case with other As is the and Health change.of significant period in a currently is the As discussed in DADS various the by (HHSC)Commission Services Human provided services many section, of a system through or will be provided, provided, either being are HHS departments managed programs. care 83 the from both of directives as a result Additionally, behavioral or psychiatric symptoms. or psychiatric behavioral criteria for nursing home services may be eligible for community-based services community-based for be eligible services may for nursing home criteria criteria. eligibility financial meet also if they DADS by funded DADS 154 Living a planning, tr are funded through various federal and state funding sources. through a variety of community-based and institution-based programs. Theservices co-occurring behavioral health conditions. Services and supportsareprovided with intellectualand other developmental disabilities, includingthosewhohave DADS serves persons who are aging,people with physical disabilities, and people Behavioral Health Conditions Disabilities Who Have Co-occurring Programs and Services for People with by people with IDD, including those conditions resultingfromtrauma. awareness of the need to recognize and treat mental healthconditions experienced and funded by the Hogg Foundation for Mental Health. This training helpedtobuild state during the summer of 2013. The training was conductedby Dr. Karyn Harvey trauma-informed care training at five regional waiver conferencesheldacrossthe intellectual disabilities and co-occurring mental health conditions, DADS included Recognizing the importanceof trauma-informed care forindividualswith w 2013 training and intheorganizational awareness of the impact of trauma onresidents. project indicates significantimprovements in thecultureofcareasaresult in how staff atthecenters relate toandsupport theresidents. Anevaluationofthe ofthistwo-yearThe goal projectwas toreducetheuseofrestraint andcreatechanges and MexiaAngelo State Supported Living Centers through agrant-fundedproject. to provide trauma-informed care training and technicalassistance ongoing at San From 2012 to 2014 theHogg Foundation for Mental Health partneredwithDADS Tr Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas below. health challenges. Some ofthe major community service programsare described provide neededservices to people with disabilities and co-occurringbehavioral services and supports not provided care.Many through managed of theseprograms DADS isresponsible for the administration and regulationofcommunity long-term Supports Community Long-Term Services and t aiver conferences a San Angelo uma-inf Tr Centers a uma-inf ormed c aining and ormed c Mexia and technic are and are tr S t a person-centered te ainings Supported al assist a t ance D ADS DADS 155 supported home living home supported care foster/companion home) (group living supervised support residential Behavioral Health Services Health Behavioral Medicaid to addition (in Provided services) plan state Case management Case social including support, Behavioral psychology and work including: assistance Residential o o o o Respite habilitation Day services Nursing services Employment employment Supported - Services iver iver Wa Individuals ofIndividuals intel- an with age any before diagnosed disability lectual score IQ an have Must 22. age and condition related a or 70 below have Must 75. below score IQ an qualify that limitations functional ser facility care intermediate for Eligibility eligibility financial meet Must vices. income including requirements SSI ofthe percent 300 to up limit of resources countable and limit no income Parental $2,000. than more considered. not is 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 1915(c) 1915(c) aid - Communi and Home (HCS) Services ty-based Program DADS administers the 1915(c) Medicaid home and community-based services waiver services waiver community-based and home 1915(c) Medicaid the administers DADS to individuals and services supports community provide designed to programs care facilities or intermediate facilities nursing care (i.e. for institutional eligible by people with disabilities of the institutionalization prevent These waivers (ICFs)). and supports. services community appropriate providing an services is not these waiver access to care, to institution-based As opposed Legislative list. has a significant interest currently each program and entitlement programs in these services receiving of people number the determine appropriations but ranges program from by for services varies time wait The slots). waiver (funded services are also waiver Medicaid receiving Individuals 10 years. more than three to use services. and substance health mental plan state Medicaid to receive eligible and services for three primary about eligibility information basic provides Figure 65 disabilities. developmental and other intellectual persons with for waivers Health-Related Eligibility and Behavioral Waiver Community-Based 65. Figure Services Disabilities Medic DADS 156 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Disabilities (DBMD) Deaf/Blind/Multiple (MDCP) Children’s Program Medically Dependent (TxHmL) Texas Home Living Services (CLASS) Assistance Supports and Community Living Program care facilities. meet eligibility for intermediate one or more other disabilities who Individuals with deaf-blindness and is not considered. more than $2,000. Parental income no limit and countable resources of limit up to 300 percent the of SSI requirements including income care. Must meet financial eligibility requirements for nursing facility who meet the medical necessity age Individuals under 21 years of financial eligibility for children. parental income when determining This is theonly waiver that considers no more than $2,000.resources of the SSI limit and countable of income limit up to 300 percent eligibility requirements including facility services. Must meet financial that qualify for intermediate care 75. Must have functional limitations related condition with an IQ below Individuals with an IQ below 70 or a Parental income is not considered. no more than $2,000.resources of the SSI limit and countable of income limit up to 300 percent eligibility requirements including facility services. Must meet financial that qualify for intermediate care Must have functional limitations ability to function in daily life. age 22 and affects the person’s tual disability that originated before mary disability other than intellec - any age with a pri- Individuals of Eligibility Supported employment Employment services Chore services Nursing services Assisted living Behavioral support services aids Residential habilitation adaptive Day habilitation Case management Supported employment Employment services Nursing services Flexible family support services Adaptive aids Respite Case management Habilitation Supported employment Employment services Day habilitation Respite Community support Behavioral support Specialized therapies Case management Supported employment Employment services Nursing services aquatic, music, recreational Specialized therapies such as Respite port services Psychological and behavioral sup- Habilitation Case management state plan services) Provided (in addition to Medicaid Behavioral Health Services DADS 157 http:// $ 1,302 $ $ 4,302 $ $ 1,429 $ $813 $ 3,723 $ $ 3,530 $ Est. Average Average Est. Cost Monthly Client per 2014 FY http://cfoweb.dads.state. http://www.dads.state.tx.us/ Behavioral Health Services Services Health Behavioral Medicaid to addition (in Provided services) plan state management Case response Emergency Nursing aids Adaptive living Assisted services assistance Personal care Respite meals delivered Home services assistance Transition services Employment employment Supported 6,040 480 27,575 Uses the HCS the Uses List Interest 50,035 Avg. Monthly Avg. List Interest 2014 FY 70,117 Retrieved from from Retrieved 2013. Guide Reference . Retrieved from from Retrieved . Request Appropriations Legislative 2016-2017 Retrieved from from Retrieved sheets. fact and FAQs Website
9,939 169 2,361 5,845 4,712 20,903 Est. Avg. Number Avg. Est. FY month per Served to limited (not 2014 behavioral with persons conditions) health Eligibility Individuals with disabilities over disabilities with Individuals of age the criteria the meet who 21 meet care.Must facility nursing for including eligibility financial percent 300 to up limit income of countable and limit SSI the of resources $2,000. than more no - 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 Community-based Alternatives Community-based (CBA) Program Deaf/Blind/Multiple Disabilities Deaf/Blind/Multiple (DBMD) Medically Dependent Children’s Children’s Dependent Medically (MDCP) Program Texas Home Living Waiver (TxHmL) Waiver Living Home Texas (TxHmL) Community Living Assistance and Assistance Living Community (CLASS) Services Support Home and Community-Based Community-Based and Home (HCS) Services Waiver Program Community-Based Alter Community-Based (CBA) natives services/faqs-fact/index.html and services/faqs-fact/index.html . http://www.dads.state.tx.us/providers/waiver_comparisons/LTSS-Waivers.pdf Texas Department of Aging and Disability Services. (n.d.). (n.d.). ofDepartment Services. Disability and Aging Texas Sources: Department of Aging and Disability Services. (2014). (2014). ofDepartment Services. Disability and Aging Sources: Figure 66 below shows the number of people receiving services in the waiver receiving services in the waiver of people the number shows below Figure 66 as of March 31, list interest on the number of individuals the 2014, in FY programs program. of each community-based the average cost and 2014 Waivers HCS for DADS and Costs Utilization 66. Figure Sources: Texas Department of Aging and Disability Services. (2013). (2013). Services. Disability and Aging ofDepartment Texas Sources: tx.us/ReferenceGuide/guides/FY13ReferenceGuide.pdf. cfoweb.dads.state.tx.us/lar/2016_17/volumeI.asp DADS 158 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · following: prior to admission toanursing facility. PASRR screeningisintendedtoidentifythe mandates Pre-admission Screening and Resident Review(PASRR) Level 1screening governmenta nursing home placement are identified andaddressed,thefederal In order to ensurethat the mental health needs ofindividualsbeing considered for professionals. health services areprovided by psychiatrists andother medical and behavioral health equipment, over-the-counter drugs andpersonal needs items. Skilledbehavioral Nursing facilitiesprovide room andboard, social services, medicalsuppliesand and long-termservices and supports. STAR+Plus, a Texas Medicaid care program that provides managed both acutecare conditions. Starting in March2015, nursing facility services willbeintegratedinto many individualsresiding in nursingfacilities also have co-occurringmentalhealth While nursingfacility eligibility criteria requires medical necessityforadmission, disabilities whose medicalconditionrequires skilled licensednursing services. Texas nursingfacilities provide institutional care for olderTexans andpeoplewith Skilled services is provided primarilythrough Medicaid. experience co-occurring behavioral health conditions. Funding fortheseresidential intermediate care facilities, state-operated orinlarge supported living centers often Persons with disabilities residinginnursing facilities, privatelyoperated Supports Institutional Long-Term Services and program. care facilities, state supportedliving centers and grouphomes undertheHCSwaiver wholive in institutionalless than 22 yearsofage settings includingintermediate lists. planning for individuals Local authorities are also responsible for permanency developing service plans, coordinating and providing services, andmaintaining wait responsibility for determining eligibility and enrollment,conductingassessments, living centers. Depending on the program, local authoritieshave varyinglevels of net services, intermediate care facilities, nursing facilities andstate supported intellectual and developmental disabilities, revenue safety- aswell as forgeneral point of entryfor many publicly-funded waiver programsforpersonswithphysical, The 39Texas local authorities, alsoreferred to ascommunitycenters, serve as the People to R ole of The appropriateness of placement in thenursing facility. disability (alsoknown as relatedconditions). Individuals who have amental illness, an intellectual disability oradevelopmental
Nursing F L oc Waiver al Authorities in a Services cilities C onnecting DADS 159 cilities a re F re Ca Centers 379 te
380 Living a Intermedi 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 orted Supported te a The eligibility for specialized services. for specialized eligibility The (PE) Evaluation PASRR in the nursing facilities the role of Eliminate that will party (LA) as the local authorities introducing by process determination the PE. complete nursing facility before to be identified specific, specialized services Require admission. is triggeredto local authorities that communication an automated Require a when Review is required. Resident ommunity ommunity t S 24-hour large that provide (SSLCs) are centers living supported State institutions must service that is a required treatment health Behavioral services. residential owned and and certified ICFs SSLCs are licensed The facilities. the by be provided SSLCs operate in 13 owned). are privately ICFs (community the state by operated Lubbock, Denton, El Paso, Corpus Christi, Brenham, Austin, Abilene, locations: Grande Rio San Angelo Rio Grande, Mexia, Richmond, and San Antonio. Lufkin, hospital, serving persons psychiatric a licensed inpatient also Center is State Individuals and mental illness. disabilities developmental with intellectual and financial and functional eligibility both meet must in an SSLC placement seeking requirements. Although the SSLC in these facilities. individuals reside 3,450 Approximately discussion related to any decade, the past over significantly has dropped population opposition. legislative with strong has been met of facilities or consolidation closure supported living of a state can direct closure legislature the Texas only In Texas, as the census in these aging facilities, deteriorating the and costs Due to fixed center. increase. costs per person the declines, facilities Intermediate care facilities (ICFs) services are optional services permitted in permitted services are optional services (ICFs) care facilities Intermediate services as to include ICF chooses state once a However, plans. state Medicaid to all those meeting become an entitlement services those benefit, a Medicaid services to provide can be licensed ICFs Community-based criteria. eligibility disabilities, developmental or other disabilities intellectual with to people residential facilities provide These as related conditions. referred to sometimes and are privately owned but living centers supported state to the similar services 160 beds; most over from six beds to size vary in ICF facilities Community operated. beds. or fewer with eight small, are ICFs community-based · to make Texas Services directed and Medicaid for Medicare Centers the In 2013, major changesprogram. Three included: changes to the PASRR · · · C DADS 160 Disabilities Figure 68. InstitutionalCare EligibilityandBehavioral Health-Related Services provided by institutional providers of DADS services. Figure 68 provides informationonthe eligibility requirements andthe services reports continue to identify significant deficiencies attheSSLCs.381 designed to reduceof the useof restraints. Despite the agreement,monitoring care, increasedaccessto psychological services, and improved andpractices policy consumers living inthem. The agreement included increased accesstopsychiatric conditions at SSLCs, DADS agreedto improve health, safety and quality ofcarefor As partof a 2009settlement agreement with the U.S. Department of Justice over Promoting Independence Advisory Committee. Source: Texas Department of Aging and Disability Services (2014, April 17). Promoting Independence Activity Report presented to the Figure 67. State Supported LivingCenter Census Data Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Nursing Facilities Program Census Total SSLC 2008 Sept. 4,769 Sept. 2009 4,532 nurse on a regular basis. a licensed requires the skills of Have a medical condition that Eligibility Sept. 2010 4,182 Sept. 2011 3,982 Sept. 2012 3,774 Specialized therapies/services. Skilled nursing. Medication management. Behavioral health services. PASRR (see above). vices that include: 24-hour residential care and ser services) (in addition to Medicaid state plan Behavioral Health Services Provided Sept. 2013 3,547 Feb. 2014 3,457 - DADS 161 - - http://cfoweb.dads.state. 24-hour residential care and ser and care residential 24-hour include: that vices services. nursing and Physician services. health Behavioral training. Skills therapies. Occupational employ- and programs Vocational ment. connections maintain to Services fami- their and residents between systems. support lies/natural Behavioral Health Services Provided Provided Services Health Behavioral plan state Medicaid to addition (in services) 24-hour residential care and ser and care residential 24-hour include: that vices services. Physician services. health Behavioral management. Medication Nursing. training. Skills speech and physical Occupational, therapies.; connections maintain to Services fami- their and residents between systems. support lies/natural - 382 Meet ICF/ID eligibility requirements. eligibility ICF/ID Meet - intellec profound or severe Have (1) disabilities, developmental and tual develop- and intellectual Have (2) OR medically be and disabilities mental and intellectual Have (3) OR fragile, behav- and disabilities developmental a Represent (4) OR challenges, ioral ofrisk substantial to injury physical selfothers. or provide to unable be adult, an As physical personal basic most the for needs. mined financially eligible for eligible financially mined Medicaid. Eligibility diagnosis ofa Have dis- intellectual of score IQ full-scale a with ability behavior adaptive an and 70 below deficits, extreme to mild with level or or of75 score IQ full-scale a Have by diagnosis primary a and below of physician licensed a related a 22 age before (manifest condition behavior adaptive an and years), deficits, extreme to mild with level or ofdiagnosis primary a Have a before (manifest condition related licensed a by diagnosed 22) age of regardless physician an and IQ mod- with level behavior adaptive AND deficits, extreme to erate benefit to able ofand need in Be provided treatment active the from - residen supervised 24-hour the in of setting tial ICF. an deter be or SSI for eligible Be 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 Intermediate Care Facilities Facilities Care Intermediate - Intellec with Individuals for Related and Disabilities tual Conditions Program Living Supported State Centers Source: Texas Department of Aging and Disability Services. (2013). Reference Guide 2013. Retrieved from from Retrieved 2013. Guide Reference (2013). Services. Disability and Aging ofDepartment Texas Source: . tx.us/ReferenceGuide/guides/FY13ReferenceGuide.pdf DADS 162 costs forbehavioral health servicesintheseprograms isnotavailable) Figure 70. Total Programs Cost of ServingIndividualswithDisabilities(Data on Figure 70 provides dataon total spending for the past three years. monthly cost trends. includes total spending, data on enrollees with behavioral healthconditions, and and institutional programs and services offered by DADS. Theinformationprovided The following tables provide some comparison data between thevariouscommunity each waiver program be cost neutral in theaggregate. need of the individual. The Center for Medicaid and Medicare Servicesrequires that per person costs within each program can alsovary greatly dependingon the level of programs. Whilethecosts shown above are averagecosts, itshouldbe noted that Average per person costs varygreatly between the DADS long-term services cfoweb.dads.state.tx.us/lar/2016_17/volumeI.asp Texas Department of Aging and Disability Services. (2014). 2016-2017 Legislative Appropriations Request. Retrieved from abilities Figure 69. Residential Utilization andCostsPrograms of forPersons withDis- client for nursing facilities, ICFs andstate supported living centersdescribedabove. Figure 69 shows theprojected number served and averagenet costs per month per Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas (CLASS) Supports and Services Assistance nity Living Commu- (CBA) alternatives nity-based Commu- Program State Supported Living Centers Intermediate Care Facilities Nursing Facilities Setting $202,065,579 $146,443,637 Expended 2013 $209,977,202 $155,249,965 Estimated 2014 Served per Month FY 2014 Number Estimated Average 3,439 5,227 55,915 $225,301,068 STAR+Plus) (Transferred to 0 Budgeted 2015 per Client FY 2014 Estimated Average Monthly Cost $ 16,034 $ 4,356 $ 3,390 $231,050,814 STAR+Plus) (Transferred to 0 2016 Requested $231,050,814 STAR+Plus) (Transferred to 0 2017 Requested http:// DADS 163 Requested Requested 2017 $968,625,479 $12,643,008 0 to (transfers kids) STAR $82,211,947 $282,570,235 $144,224,828* $682,860,733 Requested Requested 2016 $968,625,479 $12,643,008 $41,749,547 $82,211,947 $282,671,837 $145,040,486* $682,860,733 Budgeted 2015 Budgeted $977,566,068 $11,776,215 $44,001,299 $80,883,385 $281,011,219 $1,284,604,394* $679,774,904 . Estimated 2014 Estimated $885,501,250 $8,783,912 $40,486,431 $57,075,024 $280,912,477 $2,286,729,014 $677,050,452 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 2013 Expended $844,768,822 $7,690,746 $39,639,172 $48,462,288 $286,527,175 $2,257,033,016 $661,866,854 Program Home and Home - Commu nity-Based Services (HCS) Deaf-blind Deaf-blind multiple with disabilities (DBMD) Medically dependent children’s program (MDCP) Texas Home Texas Waiver Living (TxHmL) Intermediate Facilities Care Individ- for ID with uals (ICFsID) Nursing Facilities State State supported centers living (SSLCs) **The reduction in nursing facility payments is due to the transition of these services into managed care as of3/1/15. as care managed into services ofthese transition the to due is payments facility nursing in reduction **The Source: Texas Department of Aging and Disability Services. (2014). 2016-2017 Legislative Appropriations Request. Retrieved from from Retrieved Request. Appropriations Legislative 2016-2017 (2014). Services. Disability and Aging ofDepartment Texas Source: http://cfoweb.dads.state.tx.us/lar/2016_17/volumeI.asp DADS 164 Waiver andInstitutionalPrograms Figure 72. Program Cost Trends - Average MonthlyCost Per IndividualforDads various long-termservices and supports programs. Figure 72provides acomparison of the average monthly, perpersoncost forthe available. provided. The MDS data available for behavioral health diagnoses prior to FY 2013 is unreliable. Consequently only FY 2013 data is *Nursing facility counts only include individuals receiving full Medicaid daily care in order to match with the average monthly costs Source:Aging and Disability Services. Department of (2014, May 15). Data Request: People enrolled in DADS programs Health Diagnosis Figure 71. Percentage People of Enrolled inDadsPrograms withaBehavioral the Medicaid 1915(c) wavier programswith a co-occurringmentalhealthcondition. Figure 71 shows thetrends over the past three years ofthenumber individuals in Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Source:Aging and Disability Services. Department of (2014, May 15). Data Request: People enrolled in DADS programs Program CLASS CBA Program SSLCs Facilities* Nursing ICFsIID TxHmL MDCP DBMD HCS CLASS CBA SSLCs Nursing Facilities ICFsIID TxHmL MDCP DBMD HCS Enrolled 4,294 Available Not 6,500 2,557 6,394 156 20,829 4,954 28,874 $ 12,257 $ 3,181 $ 4,535 $ 4,083 $ 3,527 3,592 $ $ 1,564 FY2010 $ 664 $ 1,537 Diagnosis BH 2,468 able Not Avail- 2,630 685 2.138 16 7,644 1,105 4,747 FY2011 57.48 % able Not Avail- 40.46 % 26.79 % 33.44 % 10.26 % 36.70 % 22.31 % 16.44 % % $ 13,588 3,130 $ $ 4,495 $ 4,195 3,464 $ 3,444 $ $ 1,600 FY2011 $ 668 $ 1,491 FY2012 4,084 able Not Avail- 6,265 5,363 6,257 155 21,102 4,910 25,675 Enrolled 2,386 able Not Avail- 2,583 1,410 2,445 16 7,856 1,102 3,514 nosis BH Diag- 58.42 % able Not Avail- 41.23 % 26.29 % 39.08 % 10.32 % 37.23 % 22.44 % 13.69 % % $ 14,286 $ 3,228 $ 4,361 $ 4,175 $ 3,433 $ 3,502 $ 1,458 FY2012 $ 1,475 $ 799 799 $ FY2013 3,907 93,466 6,169 5,997 6,407 158 21,404 4,828 14,631 Enrolled 2,257 56,439 2,535 1,522 2,486 16 8,201 1,080 2,296 nosis BH Diag- $ 15,112 $ 3,275 $ 4,338 $ 4,256 $ 3,489 $ 3,610 $ 1,265 FY2013 $ 1,444 $ 870 870 $ 57.77 % 60.38 % 41.09 % 25.38 % 38.80 % 10.13 % 38.32 % 22.37 % 15.69 % % DADS 165
383
384 tive Initia am Services Independence aid 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 Progr anship ardi Incapacitated children upon reaching the age of 18 who have been in CPS the age reaching upon children Incapacitated of 18 who have conservatorship. the ages of 18-65 with a disability, or between adults ageIncapacitated 65 or older, an investigation (APS) following Services Adultby referred who were Protective other means of confirmed, and no was or exploitation abuse, neglect, in which is some indication the individual lacks and there is available the person protecting capacity. probate a court with program by to the directly referred individuals Incapacitated or rule. statute in established criteria under certain authority Adult Foster Care Adult Foster Services Attendant ManagedClient Personal ActivityServices (DAHS) Day Health and Emergency Response Care Family Meals Delivered Home with Disabilities Persons Special Services to Support Program and Family In-Home Services Community Disability Intellectual Promoting Promoting The purpose of the guardianship program under Human Resources Code Section under guardianship program the of The purpose to: guardianship services is to provide 161.101 · · · The Texas Promoting Independence Initiative began in January 2000 in direct in January began Initiative Independence Promoting The Texas in which the court , L.C. in Olmstead v. Court ruling Supreme to the U.S. response services for persons with community-based provide must states ruled that Gu when they cannot wellbeing individuals’ to protect is a legal method Guardianship person or entity who makes court-appointed A guardian is a themselves. protect important life capacity to make the who lacks an individual of on behalf decisions 2013 Commission in the Sunset to submitted self-evaluation The DADS decisions. receiving guardianship 913 individuals on average, were, there in 2012 that indicates individual. $432 per adult of cost an average monthly at from DADS services DADS administers several non-Medicaid funded programs providing direct long- direct programs providing funded non-Medicaid several administers DADS These include: with disabilities. to individuals and supports term services · · · · · · · · · services offered, please visit http:// and the these programs information on more For . cfoweb.dads.state.tx.us/ReferenceGuide/guides/FY13ReferenceGuide.pdf Additional Programs for People with People for Programs Additional Disabilities and Texans Aging Medic Non- DADS 166 nursing homeresidents. the Person program for including theMoneyFollows choice,communities of remain inorreturn totheir available tohelpindividuals supports area numberof Independence Initiative, thePromotingAs part of Person from lessthan one tomore than 100 years old. programranges services. have transitionedfrom nursing homes to community living withsupportsand country. Sincethe inception of theprogram in Texas, morethan21,300 individuals person model developed in Texas has been replicated in multiplestates aroundthe institutional care to be usedto provide community services. Themoney-follows-the- community-based services and supports by allowing the moneybeingusedfor living in nursing facilities to transition back to their communitieswith appropriate known as Money Follows thePerson. This program makes it possibleforpersons conditions, DADS participatesinafederally funded national demonstration program Among the many DADS initiatives impacting individuals withco-occurring Money Follows the Person Progr · · · · disabilities under thefollowing conditions: Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Money Follows thePerson program for nursing home residents. to help individuals remain in orreturn to theircommunities of choice,includingthe As partof the Promoting Independence Initiative, anumberofsupportsareavailable services. the state and the needs ofothers who arereceiving state-supported disability The placementcan be reasonably accommodated given theresourcesavailable to The affected person agreestoreceiving community-based services. appropriate. The state’s treatment professionals deem community-based placement to be The person would otherwise beentitled to institutional services. 386 The age span of individuals taking advantage of theMoney spanofindividuals taking advantage Follows Theage the 385
DSHS sectionformore information). in providingprimarily engaged mental health care (see facility or other institution of 17 beds ormore which is of 22through 64 yearsin a hospital,nursing the ages the use of Medicaid funding for individuals between of mental disease exclusion.” Thisexclusion prohibits project were denied by CMSdue to the“institutions address this gap through a BalancedIncentive Program individuals leaving state psychiatric facilities. Efforts to relocation services are not currently available to transition to community-based services. Similar available to assist nursing facility residents in their opportunities and communitytransition teams are In addition, statewide relocation assistance, housing am DARS 167 173 173 174 170 171 174 175 175 176 176 179 178 179 172 170 176 169
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Comparatively, the employment rate for persons with a disability was was a disability persons with rate for employment the Comparatively, cts C 387 a Program Overview Program Process Eligibility Services Expansion Eligibility Services Program Rehabilitation Vocational Eligibility for Services for Eligibility Costs and Utilization, Services, Independent Living Services Living Independent Process for Admission and Eligibility and Admission for Process Utilization Impaired Visually and Blind for Division Division for Rehabilitation Services Rehabilitation for Division Division ofDivision (DDS) Services Determination Disability 17.8 percent 17.8 In 2013, almost one-fifth (14,428) of the total individuals served by the Vocational by the individuals served the total of (14,428) one-fifth almost In 2013, were mental/ whose primary disabilities individuals were program Rehabilitation emotional/psychosocial. The national employment rate for the general population in 2012 was 63.9 63.9 was for the generalrate population in 2012 employment The national percent. that based on Council stated Investment Workforce Texas the by report A 2013 in disabilities individuals with number of second largest had the Texas data, 2011 the nation. Cost-sharing barriers for families seeking Early Childhood Intervention (ECI) Early Childhood Intervention seeking barriers for families Cost-sharing services services eligibility for ECI reduced Impact of Accountabilityrehabilitation services for vocational outcome-based for living with mental illness individuals living with mental illness individuals to support expertise needed Lack of Texas Department of Assistive and Rehabilitative Services ofAssistive and Rehabilitative Department Texas Services Intervention Childhood Early for Division st F ast · · · F Policy · · · · Services: Services: Assistive and Rehabilitative and Assistive o f le Tab Texas Department of Department Texas DARS 168 D AR S O rg Organiz · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas a D Infor n O i i r O v z e D e p c a m r i tor e spouse. is $721per eligible individual and $1,082 pereligible individual withaneligible The federal maximum monthly payment standard for SSIasof January 2014 s r t C e r i ati i o ati g M h c S
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395 397 Employment can help adults with Employment 396 393,394 DARS seeks to reduce the need for long-term support the need for long-term to reduce seeks DARS 392 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 from other public programs and services. The Early Childhood Intervention and and Childhood Intervention The Early programs and services. public from other special of are under DARS programs administered Rehabilitation Vocational The nurturing of a child’s for Texans. mental health of promotion to the relevance the future prevent can social development and behavioral, emotional, healthy conditions. health of mental development mental or behavioral health conditions obtain independence, become integrated into independence, become obtain conditions health or behavioral mental and general well-being. emotional, social, and achieve society, Division for Early Childhood Intervention Servicesstate and federally Division for Early Childhood Intervention : Offers and disabilities agesto children 3 who have 0 to statewide services funded delays. developmental Division for Rehabilitation Services: Administers to promote a series of programs peer via therapy, and self-sufficiencyindependence with disabilities for persons for transition services and services, advocacycounseling, support, employment with disabilities. students Services: Security disability Social Makes Determination Division for Disability who apply for Social Security disabilities with severe for Texans determinations Income. Security Insurance or Supplemental Disability their and or visually impaired persons blind Division for Blind Services: Assists include the Blindness by this division unique programs offered Two families. Cole Rehabilitation and the Criss Program, and Treatment Screening Education, independent living that provides residential facility (CCRC),Center Austin-based an blindness. with visual impairments and are living who for Texans training in their Leigslative for 2017 and $611,047,309 for 2016 $634,725,654 requested DARS and 2017. 2016 for Fiscal Years Request Appropriations Rehabilitative Services Rehabilitative of Assistive and “in works (DARS) Services Rehabilitative and of Assistive Department The Texas who have and families with children with disabilities with Texans partnership their full to enable and their lives the quality of to improve delays developmental in society.” participation Texas Department Texas The agencydivisions: of four service consists DARS 170 levels, as well astosupport projected caseload increases. the 83rd Legislature approved the ECI budget to continuecurrentservice revenue funds arerequired to drawgeneral down federal funding.In2013, budget forECIinFY2013 was $128,836,309 and $150,256,901 inFY2014 early intervention program for infants and toddlers ages 0 to 3.early intervention program for infants and toddlers ages Part Cisa federal grant program that assists states in operating astatewide ECI isauthorized by Part C oftheIndividuals with Disabilities EducationAct; needs children,andcounterenvironmental risk factors. cost of special needsservices, enable families to provide supporttotheirspecial services to familiesand children at an earlystage in development canreducethe delays whennot that can leadto later behavioral challenges addressed. Providing Early interventions have thepotential to mitigate the impact ofdevelopmental Intervention Services Division for Early Childhood Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · criteria: Generally, eligibility is conditioned on achildmeeting atleast one offollowing three different disciplines performsacomprehensive evaluationof achild’s abilities. To determine eligibility for ECIservices, ateam of atleast two professionalsfrom Eligibility · · · services: Future Steps: Leaving ECI Next Steps: ECI Services Getting Started Medically diagnosedcondition: Children with medical diagnoses thathave a develop and learn. 84 percentoffamiliesreportedimprovements intheirabilitytohelp children in the acquisition ofknowledge and skills. 52 percent left the program functioning equal totheir typically-developing peers and skills (thinking, reasoning,problem solving, early literacy, andmathskills). 75 percent of children experienced increases in acquisition and useofknowledge 7. 6. 5. 4. 3. 2. 1.
405 Children must transition out ofECI by theirthird birthday. ECI Service Delivery Begins Review of Child’s Progress Individualized Family ServicePlanMeeting andIFSP Development Evaluation and Assessment First Visit Referral f or 399 Services A Child’s Journey through ECI :
398 401 InTexas, as aresultof ECI Theoperating 400 State 404 .402,403
DARS 171 http://www.dars.state. osts Retrieved from from Retrieved 2013. report Annual C 406 ECI is a cost share program, meaning that meaning share program, ECI is a cost and 408
tion, tion,
407
409 Utiliza 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 Legislative Session) implemented changes to the family cost-share changesimplemented Session) Legislative cost-share the family to nd Children with developmental delays of at least 25 at least of delays developmental with Children delays: Developmental development. areas of more in one or function that affect percent high probability of resulting in developmental delays. For a list of diagnoses that that of diagnoses a list For delays. developmental in of resulting probability high http://www.dars.state.tx.us/ecis/resources/diagnoses.asp. ECI see for qualify or visual impairments auditory with Children impairments: or visual Auditory Agency. Education Texas by the as defined families with the ability to pay are expected to financially contribute to the cost of contribute to the cost to financially expected are to pay the ability families with free of charge.ECI services all receive Other families Children on Medicaid services. care foster family size, the child’s income, Family basis. on a sliding scale for ECI pay into account when arriving at a are taken insurance public and private and status, due to be turned away not will Families monthly chargemaximum for ECI services. to pay. an inability ervices, Services, and of their income level ECI regardless children can participate in Eligible of charge,free ECI services are certain case evaluation and assessment, including Service Plan (IFSP), and management,Family of an Individualized development services. and interpreter translation ECI evaluates a child for developmental delay using the Battelle Developmental Developmental the Battelle using delay developmental ECI evaluates a child for delays. social and emotional child’s of the an assessment which includes Inventory, family work the child’s professionals and ECI of this evaluation, the results Based on a range include The plan may plan. service individual family an as a team to develop family counseling, and psychological planning, service as evaluation, such of services work services. and social Source: Texas Department of Assistive and Rehabilitative Services. (2014). (2014). Services. Rehabilitative and ofDepartment Assistive Texas Source: Percentage Enrolled by Reason for Eligibility for Eligibility by Reason Enrolled Percentage 73. Figure tx.us/reports/annual2013/annualreport2013.pdf. · · Rider 31 (82 Rider 31 DARS 172 during the 84th legislative session. levels for children already in theECI system will likely continuetobeakey issue advocates, securingfundingtosupport the growing payment structure with multiple federal, state, and localfundingsources. resource levels that do not support adequate service levels, andacomplexcontract by the significant growth inthe numberof childrenandfamiliesreceivingservices, However, long-term sustainability of the current ECI structure inTexas ischallenged The 83rd Legislature restored someof the ECIfundingreductionspassedin 2011. may receive multiple types ofservices. Note: Total planned service types sum tomore than 100percentbecausechildren · · · · · · · · of enrolled children using each of themajortypes services is: The percentage · · · groups,the three key age asfollows: The distribution ofenrollmentin the ECIprogram by isfairlyevenly splitamong age tx.us/reports/annual2012/annualreport2012.pdf. Source: Texas Assistive Department of and Rehabilitative Services. (2014). * based on comprehensive services the costs ofECIcannot exceed five percent ofafamily’s adjusted monthlyincome. will be required tocover thefull cost ofECIservices. However, theircontributionto Families withanadjusted grossincomeabove 400percent ofthefederalpoverty level provisions that increased the cost of ECI services to some families as of May 1, 2014. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas The Division for Rehabilitation Services (DRS) encompasses an array ofsocial Division for Rehabilitation Services Figure 74. IndividualsutilizingECIServices Characteristics of Average monthly cost per consumer services Total children who received comprehensive Total children referred Audiology: 2% Vision services:2% Psychological/social work:6% Nutrition: 9% Physical therapy: 24% Occupational therapy: 30% therapy:Speech language 55% Developmental services: 84% 25 to36months:30% 13 to 24 months:34% 0 to12 months: 36% 415 412 $421* 48,193 68,172 FY 2013 Annual Report 2013. Retrieved from caseload and maintainservice http://www.dars.state. 414 For ECI 413 411 410
DARS 173 417
426 The national employment national The the general for rate in 2012 population was 64 percent. the Comparatively, for employment rate persons with a disability was 17.6 percent.
419 am
423,424 Individuals with with Individuals 422 tion Progr tion a To locate a DRS office an individual can call the a DRS office locate To Accordingto research 427 420 In the same year, 34 percent of percent of 34 year, same In the .418 ehabilit
R 416 Yet for persons living with mental illness, illness, with mental living for persons Yet 421 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 Within DRS, the Vocational Rehabilitation and Independent Living Independent Rehabilitation and the Vocational Within DRS, 428 425 tional a oc employment can help promote recovery. promote can help employment from the National Institute on Disability and Rehabilitation and Rehabilitation on Disability National Institute from the mental illness persons with rates for employment Research, no mental for those with than lower 30 percent are 20 to conditions. health In 2013, almost one-fifth (14,428) of the total individuals served by the VR program individuals served the total of (14,428) one-fifth almost In 2013, V PROGRAM OVERVIEW Rehabilitation (VR) program is to help people withVocational purpose of the The keepfind and prepare for, conditions or disabilities developmental mental or physical, individuals’ needs and abilities andinto account The VR program takes employment. establish a service portfolio to help identify appropriate job opportunities, develops the workforce.and access support to maintain and succeed in goals, employment counseling,Services offered in this program are individualized and can include placement assistance. and job devices, assistive training, medical services, Comparatively, the employment rate for persons with a with rate for persons employment the Comparatively, percent 17.6 was disability services and programs meant to improve the quality of life for individuals living with living with for individuals of life quality the to improve meant programs and services vocational Life skills, disabilities. or intellectual mental, developmental, physical, self-sufficiency. to elements key are services living and independent rehabilitation, overall greater is correlated with which Self-sufficiency to self-esteem, linked is health. psychological workers with a disability were employed part time, compared part time, employed were a disability with workers disability. a documented without to 19 percent of individuals The national employment rate for the general population in 2012 was 64 percent. was for the general rate population in 2012 employment The national Services programs are especially pertinent to the delivery of services for Texans of services for Texans the delivery to are especially pertinent programs Services mental illnesses. and disabilities living with A 2013 report by the Texas Workforce Investment Council stated that based on Council stated Investment Workforce Texas the by report A 2013 in individuals with disabilities number of second largest had the Texas data, 2011 the nation. disabilities or mental health conditions are a valuable resource are a valuable health conditions or mental disabilities when provided of Texas growth to the economic contribute and can for employers and supports. opportunities appropriate with the inquiry line at 1-800-628-5115. A list of local offices is also available at www.dars. available is also of local offices A list at 1-800-628-5115. inquiry line . state.tx.us Unemployment rates (percentage of people who are jobless, (percentage rates jobless, who are of people Unemployment generaljobs) for the looking for work, and for available percent 7.1 were with disabilities and for persons population respectively. percent, and 13.2 The program partners with businesses to develop new employment opportunities. opportunities. new employment to develop with businesses partners The program students with target to districts with public school also work staff Program from secondary education to them transition who need services to help disabilities or work. school post-secondary DARS 174 be short term. However, ifanindividual requires waiver servicestheycancontinue employment services are intended to through the waiver program.DARS-supported community-based waiver services may continue to receive supportedemployment with intellectualand development disabilities who transitionto1915(c)home and can perform satisfactorily without long-term one-on-one support.Individuals assistance to learnskills related to getting and keeping ajobbutwho, aftertraining, The supportedemployment program is intended for peoplewhoneed extensive · · · · · · · · · Vocational rehabilitation services are based onindividualneeds and may include: institutions to community-based settings. in the community and alsosupport their movement from nursing homesandother Vocational rehabilitation services are intended to support peoplewith disabilities SERVICES · · · Eligibility is basedon meeting the following conditions: the department. rehabilitation counselor may alsorequire additional assessments, whicharepaidfor information about how theperson’s disability impacts the abilitytowork.The information may berequested from doctors, schools and other providers whohave to become and remain employed. If needed to make thedetermination, additional isto determinework. The goal how rehabilitation services willenabletheindividual the services available, and determine if anindividual’s disability makes itdifficult to A counselor is assigned to discusstheeligibility process andrequirements, explain ELIGIBILITY PROCESS were individualswhose primary disabilities were mental/emotional/psychosocial. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Supported employment. Follow-up afterjobplacementto ensure job success. mental ability. Job placementassistance to findjobs compatible withtheperson’s physical and expectations. Training in appropriate work behaviors andother skills tomeet employer Rehabilitation technology devices and services to improve jobfunctioning. Medical treatment and therapy to lessenorremove thedisability. home. university,Training to learnjob skills intrade school, college, onthejob, orat and adjustvocational goals totheworking world. Counseling and guidance to help the individualand family identifyand planfor degree of thedisability and theindividual’s job capabilities. Medical, psychological and vocational evaluation to determine thenatureand The person is ableto get orkeep work after receiving services. Vocational rehabilitation services are required topreparefor, get orkeep ajob. employment. The person has adisability that results in substantial problems in gaining 430 431 429 DARS 175 In 433 434 http://www.dars.state. http://www.dars.state. 2013 79,578 $2,569 12,102 There are currently 27 CILs across 435 . Retrieved from from Retrieved 2013. report Annual from Retrieved 2012. report Annual
432 Services
83,930 $2,551 11,686 2012 Living 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 Number ofNumber served individuals consumer per cost Average (people closures successful Total jobs) getting Texas, 15 of which are funded by DARS. These 27 CILs serve 157 counties located in: serve These 27 CILs DARS. by of which are funded 15 Texas, Sugarland, Houston, Christi, Corpus Bryan, Marcos, San Rock, Round Austin, Odessa, League City, San Angelo, Abilene, Lubbock, Belton, Tyler, Crockett, Angleton, FY 2013, 5,342 persons received services from Independent Living Centers. services persons received 5,342 FY 2013, Approximately 15 percent of individuals served by the DARS vocational vocational DARS the by served of individuals 15 percent Approximately However, employment. in obtaining succeeded in 2013 program rehabilitation achieving their than other closed for reasons their cases had individuals more many reasons cases closed due to who had their Individuals goals. employment planned were or who be unemployable, to contact, determined losing away, such as moving are considered to have VR services with their planned continue to unable otherwise completed be considered to have may an individual Thus, VR services; completed placed in appropriate ultimately not was that individual though even VR services employment. and 2013. 2012 for FY Texas in individuals served details Figure 75 Services Rehabilitation Vocational Outcomes for Individuals utilizing 75. Figure EXPANSION Independent Centers for with program partners Services The Independent Living CILs are private, nonprofit, These the state. around located Living (CILs) CILs independent living programs. of an array that provide centers nonresidential are funded and organizations and community-based DADS with DARS, partner federal funds. and with state either privately or Independent Living Services offered by DRS are designed to “promote self- “promote are designed to by DRS offered Services Living Independent by disabilities sufficiency with significant life for people quality of and enhanced and self-direction.” adjustment personal communications, on mobility, focusing Independent tx.us/reports/2013AnnualReport/introduction.htm. (2013). Services. Rehabilitative and Assistive ofDepartment Texas Source: tx.us/reports/annual2012/annualreport2012.pdf Source: Texas Department of Assistive and Rehabilitative Services. (2014). (2014). Services. Rehabilitative and ofDepartment Assistive Texas Source: to receive supported employment through the waiver after DARS-supported after waiver the through employment supported to receive include longerare no services may services Continuing available. employment supports such ensuring natural areas, problem about employer with the consulting as services such supportive and providing are in place, from co-workers as assistance management.self-care and transportation DARS 176 CIL. are notservedby a living inareas that disabilities currently residents with amillionstate half are anestimated Census Data, there Based on2010U.S. served by aCIL. half amillion state residents with disabilities currently living inareas that are not · · · · · · · · McAllen, Laredo, ElPaso. Amarillo, Palestine, Dallas, Denton, Fort Worth, Plano, Beaumont,SanAntonio, Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas disability determination for Texans applying for SSDI and/or SSI.Approximately Both SSI and SSDI arecash assistance programs. DARS staff make theinitial individuals receivingSSDI assistance qualifyon the basisofamental healthdiagnosis. conditions willqualifyfor either orboth SSDIandSSI;approximately a third of and SupplementalSecurity Income (SSI).Somepeoplewithseriousmental health for childrenandadultswithdisabilities: SocialSecurityDisability Insurance (SSDI) operatestwo income stabilityThe federalSocialSecurityAdministration programs Services (DDS) Disability Determination Division of Independent living services may include: SERVICES Sherman, Big Spring, Wichita Falls, Liberty, and Rockwall. center services by establishing locations inthe following target centers:Texarkana, maintenance, in order to achieve independent living objectives. Other servicesasneeded, such astransportation, interpreter servicesand stabilize or improve function. Assistive devicessuchasartificial limbs, braces, wheelchairsandhearing aids to Vehicle modification. hearing-impaired. Telecommunications, sensory andother technological aids forpeoplewhoare Rehabilitation facility training. basic education. Adult Training and tutorial services. Counseling and guidance. 437
Expansion plans seek to increaseaccessindependentliving areas. expand independent living center services to underserved million dollarsineachyear for fiscalyears 2014 and2015 to $2,689,283 for fiscalyear 2016 forCILs. independently. assistance will resultin the person’s abilityto function more community. There must alsobea reasonable expectation that the person’s ability to function independently in the family or significant disability that resultsinsubstantial impedimentto individual must becertified by aDRScounselor to have a In order to beeligible for independent living services, an ELIGIBILITY 436 439 Basedon 2010 U.S. Census Data, thereareanestimated DARS requested $2,689,283 for fiscalyear 2016 and 441 438 440 DARS requested 1 442 DARS 177 447
DDS is completely federally federally is completely DDS 444 443
446 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 Reconsideration: Another disability examiner and medical team reviews and examiner the disability Another Reconsideration: submit additional Claimants may proper. was the decision if determine case to their case. to support evidence evidence at a present witnesses and Claimants may Hearing: Administrative judge. law administrative an with private hearing formal, hearing judges Reviews at the administrative by decisions Hearing: SSA Council unchanged.of the decisions remain up to 70 percent level; Texas Department of Assistive and Rehabilitative Services. (n.d.). Disability Services. and Rehabilitative Assistive of Department Texas funded with funding totaling $113,224,755 in FY 2012. in $113,224,755 totaling funding with funded SSDI is governed by rules set out in Title II of the Social Security Act and covers workersSecurity Act II of the Social out in Title set rules and covers by SSDI is governed adult children and disabled widows/widowers, disabled ageare disabled, who 18 to 65 for this program earn eligibility People histories. work with sufficient of workers for SSDI Approval taxes. social security paying by lives working their throughout period.waiting after a two-year coverage for Medicare results in eligibility payments Title XVI of the out in rules set by (SSI) is governed Income Security Supplemental and adults to qualifying children Social Security Act.stipends monthly SSI provides participants are eligible for Medicaid. for SSI, Once approved the ageunder 65. of SSDI benefits. or SSI receive process to claims disability the details below Figure 76 Benefits SSDI and SSI for Process Claims Disability 76. Figure 445 364,428 disability cases were determined in FY 2013. in FY were determined cases disability 364,428 · · · Retrieved from http://www.dars.state.tx.us/services/ Services. Retrieved Determination ddsClaimsProcess.shtml a legal right to appeal have or SSDI determination their SSI with who disagree People of appeal: four levels There are the decision. DARS 178 person retiring 70is$3,425. atage worker left the workforce due to his orherdisability. The2014 monthly benefitfora age atwhicha monthly benefit; themonthly maximumbenefit dependsonthe on the social security earnings record of theworker. ThereisnominimumSSDI be satisfied inorderto qualifyfor SSDI. Monthly benefitsforSSDIaredependent developmental disorders. includes aset Each ofthese categories of criteriathatmust disorders; substance addictiondisorders;andautistic disorder and other pervasive intellectual disability; anxiety-related disorders; somatoformpersonality schizophrenic, paranoid, and other psychotic disorders;affective disorders; as: organicmentaldisorders; basis of a mental health condition are categorized website at http://www.ssa.gov. information on eligibility criteria can be foundontheSocialSecurity Additional a thirdof national SSDI diagnoses. to a2010 report byAccording theSSA, mental health conditionsconstitute about access SSDI or SSIcashbenefits ifthey meet other eligibilitycriteria. conditions, mentalhealth conditions can bedisabling and may allow anindividual to determinations are made by disability officers within DARS. Like serious physical individual has adisability that prevents his orherabilitytowork.Initialdisability Eligibility for both SSDI and SSIisconditioned on the determination that an Process hearing. subsequently granted benefits atthereconsideration state and13percentthrough a 26 percent. Of those who appealed their denial, 3 percentofapplicantswere the number of applicants who were granted awards uponinitialreviewaveraged to areport by theSSAthat trackedAccording SSDI outcomesfrom2002–2010, · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas per eligible individual and $1,082 per eligible individualwithanspouse. The federal maximum monthly payment standard for SSIasofJanuary 2014 is$721 conditions), adults and children must meet strict financial andfunctionalcriteria. To beeligibleforSSI, in additionto having adisability (this includesmentalhealth considers a more exhaustive set ofeligibility criteria. reach this level. U.S. Federal District Court: A hearing at thefederal court level; very fewcases 448 Anewreport is scheduled to bereleased in November 2014. f or Admission 450 449 TheSSA makes thefinaladmissiondecisionand Disability determinations forSSDIon the and Eligibility 451
DARS 179 http://www.dars.state. ired ired Impa lly ally . Retrieved from from Retrieved 2013. report Annual 2013 333,549 * 336,908 34% 70 96% Visu and or Blind or f 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 tion Total SSI and SSDI cases received cases SSDI and SSI Total determined cases Total of allowed cases disability initial Percent days) (in time process case initial Average decision SSA ultimate to regards with Accuracy tx.us/reports/annual2013/annualreport2013.pdf. tx.us/reports/annual2013/annualreport2013.pdf. The Division for Blind and Visually Impaired Services (DBS) provides services to Services (DBS) provides Visually Impaired Blind and for The Division visual blind or have who are for Texans of life outcomes increased quality achieve and services operating programs of the an overview provides Figure 78 impairments. DBS. under Division *This is the number reported in the DARS annual report. It is unclear why the number ofnumber the why unclear is It of the number exceeds determined cases total report. annual DARS the in reported number the is *This received. cases (2014). Services. Rehabilitative and ofDepartment Assistive Texas Sources: Figure 77 shows statistics about the number of cases received and determined, along determined, and cases received of the number about statistics shows Figure 77 average case cases allowed, initial disability of on the percent outcomes with program decision. final SSA’s the time, and accuracyprocess against Texas of Utilization in Services Determination Disability 77. Figure a Utiliz DARS 180 Figure 78. DBSServices Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Texas Business Enterprises of Program Discovery and Development Children’sBlind Vocational Program Name Program and TreatmentScreening Blindness Education, Programtions Assistance Specialized Telecommunica- Services Vocational Rehabilitation Center Criss Cole Rehabilitation Texans. opportunities for blind food management of assistance in the form Provides employment their community. fully active members of competence to become the confidence and years old in developing Assists children up to 22 Services treatment. needed eye-medical with paying for urgently assists uninsured adults blindness.prevent Also Program goal is to button telephones. telephones, and big way pagers, amplified equipment such as two- to acquire assistive hearing impairments vouchers for Texans with Provides financial vocational training. transition services, and ing assistive technology, employment by provid- impairments obtain blindness or visual Helps people with career guidance. living, and advanced training, braille, daily orientation and mobility adults in the form of and visually impaired living training for blind provides independent Austin,in located Texas Residential facility 1,584 4, 417 Number Served 4,428 issued 26,781 vouchers 10,066 200 456 457
454 455 452 453 N/A Individual Average Cost Per on the device. $8,420 depending range from $90 to Voucher values $4,650 $108 monthly N/A $98 TDCJ 181
184 195 196 197 198 188 190 191 191 193 194 194 184 197 185 187 195 183
At A At A Glance
ontents 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 C
oncerns C Courts Specialty Medically Recommended Intensive Supervision Supervision Intensive Recommended Medically Programs Special Parole on Release Legislation Health Mental and Justice Criminal Session 83rd Diversion Jail Financial Summary Financial System Justice Criminal State the in Programs and Services Health Behavioral Services to Access Services Health Behavioral Services Community-Based Post-Incarceration Inmates Female for Concerns Special Standards Jail on Commission Texas Need to divert low-level offenders with mental illness or addictions into treatment illness mental offenders with low-level divert Need to settings correctional rather than settings on mental health issues, staff correctional and for jailors no training Cursory or and de-escalation suicide risk, and other restraints, repeated segregation, prolongedUse of administrative illness with mental on inmates interventions aversive re-entry upon eligibility Gap in benefits jail or prison to community, from support in transition intensive Need for and Community Treatment, Assertive Forensic jail in-reach programs, including peer support forensic through a DSHS Forensic perhaps issues, on forensic coordination Need for Lack of Crisis Intervention Training in rural jurisdictions to guide law in rural jurisdictions to guide law Training Crisis Intervention Lack of crisis in psychiatric people in interactions with enforcement Texas Department of Criminal Justice and Local Criminal of Local Justice and Department Criminal Texas Environment Changing Justice Agencies System Justice Criminal Texas ofOverview ofDepartment Justice Criminal Texas Systems Justice Criminal Local Programs Prevention Incarceration · · · · · · Policy · Agencies: Agencies: Local JusticeCriminal Local of le Tab Criminal Justice Justice Criminal and Texas Department of Department Texas TDCJ 182 Organiz · · · · F Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas ast F cost per day of housing and feedingan inmate was $50.04. Director 69.95% capacitywithatotal jailpopulation of 66,807. On December1,2013, Texas county and cityjails were collectively operatingat $49 per day. The average cost perday per prisoner for medicalcare in Texas isbetween $42and On August 31,2013, there were 136,340 offenders in Texas prisons. mental health condition and that 15% to24% have aseriousmentalillness. Studies estimate that half ofalladult inmates in U.S. prisonshave atleast one facility is $138. a cts 461 Theaverage cost perday for aninmate in apsychiatric correctional tional 462 Chart 463 460 459 Theaverage 458 TDCJ 183 The risk Contrary 467 468
465
Unfortunately, the science of risk assessment has not advanced of risk assessment has not the science Unfortunately, 471 470 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 Nonetheless, the significant and growing number of people with and growing the significant Nonetheless, 466 County- and city-run jails house a similar population, with one study population, with one study jails house a similar and city-run County- The vast majority of people with a diagnosable serious mental illness never serious mental illness never a diagnosable people with majority of The vast 464 469 engage in violence. serious mental illness in criminal justice settings raises important challenges for the settings in criminal justice serious mental illness and state and the management of the facilities, individuals, of these rehabilitation budgets. county dangerous to mental illness is linked of a serious the presence to which The extent to violent illness is linked mental it seems some cases In is unclear. behavior majority of weak and in the vast this link is that however, Research shows, behavior. increase the risk of violent behavior not illness does of mental presence the cases, crime and violence are the factors for The research suggests risk others. towards in the generalas persons mental illness persons with for population. same sufficiently to enable us to identify which individuals will commit violent acts; individuals will commit which identify us to to enable sufficiently than they can identify out who is not going can rule violent better to be psychiatrists be violent. who will People living with mental health conditions sometimes become involved with the become involved sometimes conditions health living with mental People is directly or indirectly related conduct that as a result of system criminal justice mental that this “criminalization of indicates Recent research condition. to their 7% of individuals in one setting with only phenomenon, be a modest illness” may to a mental illness linked of behavior because system justice the criminal entering disinhibition, or emotional hostility, factors like to other linked behavior of instead reactivity. Agencies Local JusticeCriminal Local are settings criminal justice Texas residing in of individuals number A significant a co-occurring have and many health conditions mental one or more living with prisons inmates in U.S. all adult of that half Studies estimate use disorder. substance a serious mental have 24% that 15% to and condition health one mental least at have illness. Criminal Justice Justice Criminal and Texas Department of Department Texas of violent behavior is increased when a substance use disorder is present. is use disorder a substance is increased when behavior of violent showing that 14.5% of male jail detainees and 31% of females had symptoms of a of of females had symptoms and 31% male jail detainees of 14.5% that showing serious mental illness. to the impression created by highly publicized shootings, persons with serious shootings, publicized highly by impression created to the homicides in which a gun is of violent proportion small only a illness commit mental used. TDCJ 184 Figure 79. 83rd SessionCriminal Justice andMentalHealth Legislation He 83rd of the criminal justice and mental health-related legislation: justice system during the 83rdlegislative session. Figure 79below offersan overview Legislators addressed anumberofmental health concerns withinthecriminal Changing Environment Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas SB 1003 SB 213 Passed alth Session Legisla this state. segregation in facilities in and juvenile administrative adult regarding the use of and report a review of Carona – Health Care Committee. the Correctional Managed Pardonsof and Paroles and the Board the functions of ham School District and to inal Justice, and the Wind- Texas Department Crim- of Criminal of Justice and the functions of Texas Board ing to the continuation and Whitmire, Nichols – Author and Description Relating to Criminal tion Relat - segregation. administrative no work has been done on the review of Oversight Committee has not been called to meet and September 2014, the Criminal Justice Legislative juvenile administrative segregation practices. As of adult and dent third party to conduct a review of gifts, grants and donations” to appoint an indepen- Committee funds from “subject to the availability of Requires the Criminal Justice Legislative Oversight disciplinary seclusion lasting at least 90 minutes. placements in to collect data about the number of Requires the Texas Juvenile Justice Department (TJJD) the bill.mental health aspects of and directives. the The above is simply a summary of Note: SB 213 is complex and includes many details out requirements for these contracts. vide health care to people confined by TDCJ and sets physicians and hospitals to pro - provider network of Authorizes TDCJ to establish a managed health care professionals appointed by the governor. Care Committee to include two licensed mental health Correctional Managed HealthChanges composition of a community supervision program. developed by an individual in TDCJ upon placement of to utilize the risk and needs assessment instrument local Community Justice Assistance Departments the board considers the inmate’s release. Also requires Pardonsment plan to the Board of and Paroles before required to develop and submit an individual treat- individuals seeking parole, the department is now service delivery by TDCJ and related agencies. For Makes numerous changes to reentry and reintegration the efficacy and performance of TDCJ) to 2021. Extends Sunset Review (the legislature’s assessment of Summary Justice and Ment al TDCJ 185 day ofday in participation th day and 55 and day st the pilot program, (2) reporting requirements upon requirements reporting (2) program, pilot the ofdetermination psychiatrist’s restoration competency (3) restored, be to unlikely is individual the that or competency restore to failure upon requirements days. 60 within Summary program pilot diversion jail health mental a Creates or 500 than fewer no serve will that County Harris in individuals. 600 than more of provision the Authorizes restoration competency pilot restoration competency jail-based a in services be would otherwise who individuals for program residential or facility health mental a to committed services. those for facility care - pro private or public with contract to DSHS Authorizes ofviders services restoration competency jail-based a counties. two to up in programs pilot for of Commissioner a establish shall DSHS Executive The - develop the in participate to workgroup stakeholder ofment program. pilot the for rules of operation the conditions for out Sets jail-based a (1) including: program, pilot restoration competency of requirement not evaluations psychiatric full two 21 the than later Relating to a a to Relating 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 Author and Description and Author the to Relating – Huffman of creation health mental a program. pilot diversion jail – Duncan of restoration jail-based program. pilot competency Passed 1185 SB 1475 SB Individuals involved in the criminal justice system may be placed in a variety in a variety be placed may system justice criminal in the involved Individuals offenses and defendants of lower-level convicted offenders Many of settings. The Texas or municipalities. counties by jails operated are in local trial awaiting Standards (TCJS) agencyas the regulatory acts for all county on Jail Commission Justice of Criminal Department Texas The jails. municipal operated and privately who of more serious offenses convicted (TDCJ) manages been individuals who have prisons and private correctional state jails, residing in state are sentenced and are with TDCJ. that contract facilities system. used in the criminal justice typically of terms contains a glossary Figure 80 Overview of Texas Criminal JusticeCriminal Texas ofOverview System TDCJ 186 Source: Bureau of Source: BureauJustice Statistics. of www.harriscountytx.gov/cscd/faq.aspx other inmates(excluding police and court costs). jail inmates with mental illness was $7,017 peryear, comparedto $2,599 annuallyfor of the cost ofjailstays. Thestudy also found that Harris County’s annualcosts for persons with mental illness represented 25% of alloffendersbutaccounted for 37% people released from jail between January 1, 2004andJanuary 29, 2008 and found (MHMRA) and HarrisCounty’s examined all Office ofBudgetand Management A study by theMental Health and Mental Retardation Authority ofHarris County Source: Harris County Community Supervision & Corrections Department. (n.d.). Figure 80. Common Criminal Justice Definitions Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas probable matches alert the local mental health authority to exchange pertinentdata. matches; and approximately 48percent (536,587) hadnomatch.Theexactand DSHS mental health database; approximately 47 percent (527,148) wereprobable (58,356) of thequeries were exact matches with informationmaintainedinthe for atotal of1,122,091 unique queries for adults in 2013. Approximately 5percent report showed that all local orcounty jails used the ContinuityofCareQuery(CQQ) number of jailinmates who hadcontact with the public mental healthsystem. The queries by localandcounty jails inthe DSHS mental health database tocalculatethe the criminal justice system withmental health conditions. That reportexamined identify, collectand report data to theLegislative Budget Boardonindividualsin Department of State Health Services (DSHS), along withcommunity centers, to During the 83rd Texas Legislature, Rider 43ofthe Appropriations Billdirectedthe from a mental illness, and housing instability. is characterizedashaving less familyand community support, deeperimpairment from DSHS were involved inthe criminal justice system. Inaddition,thispopulation 2007 and 2009, 19%ofall adults receiving behavioral health treatmentorservices portion of thetotal population receiving public behavioral healthservices. Between People who become involved withthe criminal justice system alsomake upasizeable Restitution Prisons State jails Local jails Parole adult probation) (previously known as Community Supervision Terms and Definitions: Corrections. Retrieved from ment is usually done in monthly installments. a victim.Monies that a court orders an individual to pay to a family of Pay- with punishment ranges from two years to death. third-degreeDesigned to house offenders felonies or higher convicted of from 180 days to two years. felonies with punishment ranges Designed to house offenders convicted of for misdemeanor convictions. Designed to house offenders awaiting trial or serving short-term sentences community. and Paroles, a sentence under supervision in the to serve the remainder of A a person from discretionary prison, release Pardons of by the Board of nity Supervision Officer on a regular basis. specified period time. of The individual must also meet with their Commu- programscommunity and ordered and sanctions for a to a continuum of An alternative to a prison sentence whereby an individual is released to the 473 472 Frequently Asked Questions.
http://www.bjs.gov/index.cfm?ty=tdtp&tid=1. Retrieved from http:// TDCJ 187
474 http://www.tdcj.state. Retrieved from from Retrieved http://www.tdcj.state.tx.us/unit_directory/unit_map.html Agency Strategic Plan Fiscal Years 2015 – 2019. 2019. – 2015 Years Fiscal Plan Strategic Agency 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 tx.us/documents/finance/Agency_Strategic_Plan_FY2015-19.pdf at: available is facilities TDCJ ofmap and list complete A TDCJ is responsible for providing health services, including behavioral health health including behavioral services, health for providing TDCJ is responsible prisons and state jails, to state and sentenced are convicted people who to services, Care Committee ManagedCorrectional The Health facilities. correctional private in the TDCJ care services for persons coordinates health and oversees (CMHCC) system. and has headquarters in both the state throughout of facilities TDCJ has a number and distribution population depicts the Figure 81 below Huntsville. and Austin facility. type of by capacity 81. Figure Source: Texas Department of Criminal Justice. ofDepartment Justice. Criminal Texas Source: a serious impact on their can have of inmates confinement The placement and prior to conditions existing mental health any to health. In addition mental the conditions exacerbated by or her condition his have may an inmate incarceration, particularly have may that of confinement Isolation is a form of confinement. isolation inmates in 8,784 TDCJ housed effects. psychological detrimental of those 2,000 More than in 2011. called “solitary confinement”) (colloquially The aim of TDCJ is to provide public safety, promote positive changepositive in offender promote public safety, TDCJ is to provide The aim of In addition victims of crime. and assist into society, offenders reintegrate behavior, jail diversion community-based TDCJ provides felons, convicted to confining following into society reintegration for felons’ options and administers programs of community agency their sentence. The and certain oversight funding also provides the is responsible for and adult probation), as known (previously supervision parole or mandatory supervision. from prison on released of offenders supervision Texas Department of Department Justice Criminal Texas This report can be found at: http://www.dshs.state.tx.us/WorkArea/DownloadAsset. found can be report This aspx?id=8589986096 TDCJ 188 for FY2013 was $3,118,728,577. abuse. for convictions ofassailants may be sexual misconduct,fondling,or On August 31,2013, therewere136,340 offendersin Texas prisons. Financil investigations of offender-on-offender sexualabuse allegations. the facilities. InFY2013 the PREAOmbudsman Office reviewed 742administrative federal regulations to monitor and implement efforts toeliminatesexualassaults in the PREA Ombudsman is responsible for ensuring that TDCJis in compliancewith rape by instituting in correctional settings. a zero-tolerance policy WithinTDCJ, (PREA), afederal law passed in 2003,Rape EliminationAct seekstoaddress prison U.S. prisons with the highest inmate-reported sexual assault complaints. ThePrison A 2008 study by the Bureau ofJustice Statistics ranked 5Texas prisonsamongthe10 Traumatic experiences during incarceration can impactaninmate’s mentalhealth. inmates had adiagnosisof either serious mental illnessorintellectualdisability. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas per day of housing andfeeding an inmate was $50.04. and the practice itself can have long-term effects onaninmate’s mentalhealth. of time. People with mental health conditions are overrepresented in this population individuals are heldinan isolated cell for upto23hoursaday foranextended period tothemselves,for inmates who are considered dangerous other inmatesor staff), term and is forpunitive purposes. With administrative segregation(whichisused TDCJ usesseveral types of isolation. Disciplinary segregationistypicallyshort by agency goal. goal. by agency 478
Summary 481 See Figure 82 below forabreakdown ofthebudget 480 TheTDCJoperating budget 477 Disciplinarycases 479 Theaverage cost 476 475
TDCJ 189 http://www.tdcj.state.tx.us/ Retrieved from from Retrieved 2013. Year Fiscal Review 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 documents/Annual_Review_2013.pdf Source: Texas Department of Criminal Justice. (2014). (2014). ofDepartment Justice. Criminal Texas Source: for FY 2017. and $3,417,488,167 2016 for FY $3,381,518,042 TDCJ requested TDCJ Operating Budget for FY 2013 FY for Budget Operating TDCJ 82. Figure TDCJ 190 seeing an increasein the number of inmates requiring psychiatric care. the federal Constitution. In line with the nationwide trend,state prison facilitiesare Providing basic medicalcareforaninmate’s serioushealthconditionismandated by psychiatric correctional facility is $138. the Figure 83. Behavioral Health Related Divisionswithin TDCJ each follows. meeting the health and behavioral health needs of inmates. Abriefdescription of Within TDCJ,agencies that thereareseveralhave officesand responsibilityfor victims. operation of theagency, the supervision of convicted felons, and services forcrime TDCJ iscomprised of several sub-divisions that provide for theadministration and Beha Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Texas isbetween $42 and $49per day. a fee-for-service plan. The average cost perday per prisoner formedicalcare in Texas health care planratherthan operatesmedical care forinmates on amanaged Care Committee (CMHCC) Correctional Managed Health ing and Liaison Office Mental of Health Monitor Health Services Division Name tal Impairments (TCOOMMI) Offenders with Medical and Men- Texas Correctional Office for S vior t a te al He Criminal alth - managed health care plan (SB 213). western half. of Texaseastern half and TTUHSC is responsible for facilities in the UTMB is responsible for health care services in facilities in the (UTMB) and Texas Tech University Health Sciences Center (TTUHSC). vices Division, the University of Texas Medical Branch at Galveston partnership arrangement between the department’s Health Ser plan—for all people confined by TDCJ. The committee manages a a managed health care plan—called an offender health services The oversight and coordination authority charged with developing lated issues. provides expert guidance to other TDCJ offices on mental health-re- Monitors mental health services provided to offenders, and Health Care Committee (CMHCC). works with health care contractors and the Correctional Managed investigates grievances and conducts service audits. This division care.health care services and monitors quality of The division also Responsible for ensuring that incarcerated persons have access to Description affecting offenders with special needs. and coordinate on policy, legislative and programmatic issues and human services, and other affected agencies to communicate TCOOMMI provides a formal structure for criminal justice, health representativesComprised from 21 agencies and organizations, of Justice Services 486 487 Theaverage cost perday for aninmateina 484 TDCJ may contract with any entity to implement the System and Progr 4 82 483
ams in 485 - TDCJ 191 488 http://tdcj.state. 490 is provided to all, but all, to provided is standard evolving guide- practice and the controls lines of extent service authorized and authorized all. to provided Availability 489 Services h alt Services l He al 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 Care [the absence ofabsence [the - threaten life immediately not is which] Care maintained be not could patient the which without but ing, where or deterioration of serious risk significant without later repair of possibility the in reduction significant a is there treatment. without Care that is essential to life and health and without which without and health and life to essential is that Care treatment recommended The expected. is deterioration rapid is or difference significant a make to expected is intervention effective. cost very Description ofDescription of Level Service Health vior Continuity of care services of care Continuity services Outpatient services as indicated Psychosocial prevention Crisis management/suicide facility, care approved health a correctional by provided services Inpatient care, transitional care and acute evaluation, diagnostic as necessary including care extended and managementmonitoring medication such as services Professional Emergency mental health services, available 24 hours a day, seven days per week days seven hours a day, 24 available Emergencyhealth services, mental Level II Medi- II Level Necessary cally Level I Medi- I Level Manda- cally tory Level of Level Service TDCJ also administers specialized mental health and substance abuse programs for and substance mental health specialized TDCJ also administers these programs: describe 86 85 and Figure Figure inmates. certain · · · · · · · Beha to incarcerated individuals and treatment services available health diagnostic Mental include: provider health a qualified mental by recommended when Additionally, each TDCJ facility must develop a process for individuals who are a process develop each TDCJ facility must Additionally, dental care. use and substance health, mental access to medical, gain to incarcerated by intake health care services at to obtain on how information are provided Inmates mental also identify people with may Facilities they are assigned. to which the facility receive who from security staff upon referrals, or process, the intake illness during mental illnesses. in identifying training . (2013, August). Offender health services plan. Retrieved from from Retrieved plan. services health Offender August). (2013, . Committee Care Managed Health Correctional Source: Level of Service Level Health 84. Figure tx.us/divisions/cmhc/docs/cmhcc_contracts_fy2014-15/696-HS-14-15-A066-Exhibit-A.pdf The offender health services plan developed by the Correctional Managed Health CareManagedHealth the Correctional by plan developed health services offender The to made available care services of health describes the levels (CMHCC) Committee of health two classifications The plan contains TDCJ. incarcerated within offenders Figure 84 below. in listed as needs, and mental health medical, dental for services Access to to Access TDCJ 192 Figure 86. SubstanceUseServiceDescriptions within its Rehabilitation Programs Division, asdescribedinFigure 86. TDCJ operatesanumber of programs to serve people with substance useconditions http://tdcj.state.tx.us/divisions/cmhc/cmhc_policy_manual.html Source: Correctional Managed Health Care Committee. (2013, October). Figure 85. SpecializedMentalHealth Programs Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas divisions/rpd/rpd_substance_abuse.html Source: Texas Criminal Justice. Department of (n.d.). Rehabilitation programs division. Retrieved from In-Prison Program Intoxicated Driving While Abuse Program StateSubstance Jail Community Pre-Release Therapeutic Abuse Program and Pre-Release Substance Community (IPTC) In-Prison Therapeutic Punishment Facility and FelonySubstance Abuse Program Treatment Track Program – Inpatient Chronic Mentally Ill ties Program Developmental Disabili- sive Mentally-Ill Offender Program for the Aggres- Program apy, family education and counseling. education and treatment activities, including group and individual ther A six-month program with an aftercare component that uses a variety of the state’sthe needs of diverse incarcerated population. provided rehabilitation, counseling and related services designed to meet Addiction Severity Index assessment and their criminal history and are Eligible inmates are placed in a 30-, 60- or 90-day track based on an confinement on a vote by the Board of Pardons and Parole. criminal ideology. Inmates are placed in the program prior to release from ated with serious substance use conditions, chemical dependency and Intensive six-month programs intended for individuals who are incarcer mental health and/or medical diagnoses. A nine-month in-prison program provided for people with co-occurring Pardonsof and Parole can require parole. the program as a condition of prison or state jail time,individuals to a program in lieu of or the Board support groups and supervision.up to one year of Judges can sentence residential aftercare,of outpatient aftercare, six to nine months of and Six-month in-prison treatment programs, followed by up to three months Description mental health reasons.] an offender any of classification that requires housing in a single-cell for population) and other offenders [with chronic mental health needs or trative Segregation offenders (those who are separated from the general To provide a step down inpatient treatment track specific for the Adminis - evaluation. judged significantly impaired, may be referred to a DDP facility for further intellectual functioning] diagnoses, and whose adaptive functioning is having an intellectual disability or [borderline Offenders suspected of his sentence in order to complete the program. of therapeutic modalities. The offender must have at least 2 years left to serve treatment program utilizes a multi-disciplinary approach through specific Located at the William P. Clements, Jr. facility in Potter County. The Description Correctional Managed Health Care Policy Manual. http://www.tdcj.state.tx.us/ 491 Retrieved - - TDCJ 193
495 497 Services 494 TCOOMMI 496 sed ased 492,493 492,493 ommunity-B C tion tion 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 arcer Identifying incarcerated people with special needs who require aftercare with special needs people incarcerated Identifying services. treatment the department. with planning treatment in joint Participating to the community. transition from incarceration a positive Providing offenders referred for all in the community resources and securing Identifying needs. with special agencies. and other criminal justice state coordination among improve to Working reports. monthly through follow-up post-release Providing contracts with select communities in the state for offender programs, targeting for offender programs, in the state communities with select contracts on community supervision. and offenders supervision on parole offenders The recidivism rate for overall parolee populations was 24% for 2010-2012. 24% was populations parolee overall The recidivism rate for Continuity of care programs are designed to conduct pre-release screenings of pre-release screenings to conduct programs are designed of care Continuity which are services, treatment psychiatric for aftercare referrals and detainees people with mental incarceration, from release Upon LMHAs. by delivered typically management,including case for services, their LMHAs referred to illness are and medication services, psychiatric services, psychological services, rehabilitation application federal entitlement services including eligibility and benefit monitoring, processing. in or jail can be instrumental after prison for inmates supports Transitional use problems and substance health Inmates with mental recidivism. reducing Linking inmates to community to their communities. return they once need help behind a former inmates’ causes root the help address can and services supports system. into the criminal justice reentry to prevent in order behavior criminal abuse health, health, and substance the mental of care for a continuum Establishing of Examples services for inmates. of interruption an prevent can inmates needs of re-incarceration inmates avoid former help that can services community-based job social services, insurance coverage, health care, treatment, use include substance health services. and mental housing assistance, training, finding and The Texas Correctional Office for Offenders with Medical and Mental Impairments Mental Impairments and Medical with Offenders Office for Correctional The Texas a and provides Integration Division and Reentry TDCJ’s the is part of (TCOOMMI) of older reentry to facilitate services and community-based of institutional variety community. the into settings from incarcerated special needs people with adults and terminal or serious mental illness, with include offenders offenders Special needs disabilities. intellectual and/or serious medical conditions Inc Post- Continuity of care provides pre-release screening and referral to aftercare services screening pre-release provides of care Continuity and supports include: Services needs. with special for incarcerated people · · · · · · During the same reporting period, the recidivism rate for parolees that TCOOMMI recidivism period, the reporting same During the illness who received serious mental 13% of adults with although 4.2% was served release. within three years of re-incarcerated were services TCOOMMI were referred for continuity illnesses with serious mental parolees 5,229 In FY 2013, TCOOMMI-funded received parolees 1,023 number, Of this of care services. case managementintensive services after release. treatment and TDCJ 194 parolees. funding enables TCOOMMItoprovide services to approximately 1,800additional house for parolees to ensure there are nogaps in continuityofcareforparolees. Figure 87. SpecialPrograms forOffenders withBehavioral Health Conditions Figure 87 below provides an overview of theseprograms: special programsforoffenderswith mental health andbehavioral healthissues. The division on thereview and release on parole of offendersoperates a seriesof RELEASE ONPAROLE SPECIAL PROGRAMS who pose minimal public safety risk as acost-effective alternative toincarceration. term care, or physical disabilities. The purpose ofthe program is to releaseoffenders mental and developmental disabilities, terminal illnesses, illnessesrequiring long- program that serves incarceratedpeople with special needs, including thosewith Medically recommended intensive supervision is an early paroleandrelease MEDICALLY RECOMMENDED INTENSIVESUPERVISION contracts with localmental health authorities throughout the state. treatment of mentally ill offenders being supervised inthecommunitythrough services and continuity of carefor adult offenders. Thisallows TCOOMMItoexpand In 2013 the 83rd Legislature appropriated $3 million annually formentalhealth Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas parolees. gram (SACP) Counseling Pro - Substance Abuse munity Program Therapeutic Com- Program Sex Offenders Offender Program Special Needs Name 499 500 Twenty-seven caseloadswereadded for additional case management A licensed professional of thehealing arts was alsoaddedtoevery halfway offenders with substance abuse problems. Provides relapse prevention services to abuse felony punishment facility. therapeutic community or a substance offenders who participated in an in-prison a three-phase programConsists for of offenders with substance abuse problems. care services for Offers continuity of testing this treatment is polygraph component of through contract vendors. A significant Services are provided throughout the state illnesses, or physical disabilities]. disabilities, mental impairments, terminal Supervises [offenders with intellectual Description 2013. A total 34,544 of offenders in FY 6,341 offenders received services 4,360 offenders. ities]. terminal illnesses or physical disabil- impairments], 820 [offenders with ities], 6,295 [offenders with mental [offenders with intellectual disabil- intensive supervision offenders, 156 136 medically recommended in FY 2013 Offenders in Supervision Program Monthly Average Number of 498 The additional 501 TDCJ 195 tes http://www.tdcj.state.tx.us/documents/ Even with some unused with some unused Even Monthly Average Number of Number Average Monthly Program Supervision in Offenders 2013 FY in conducted tests drug 156,411 monthly. Inma 505 Additionally, women in prison women in Additionally, 502 The physical, emotional, and emotional, The physical, 503
506 or Female or Retrieved from from Retrieved 2013. Review Annual f Though shackling is still permitted in a large permitted number of states is still shackling Though 504 Description testing. drug Instant-read 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 C Name Testing Drug Program capacity, jails face challenges in providing services. Of all inmate complaints received Of all inmate complaints received services. jails face challenges in providing capacity, 56% of the grievances jails, the agencyTexas by for overseeing responsible in 2013 regarding medical services. filed were throughout the country, in 2009 Texas passed anti-shackling legislation to prohibit anti-shackling legislation to passed Texas in 2009 country, the throughout in labor. women of the shackling TDCJ has a number of offenders, of female special needs many the Recognizing and such program is the Baby One address this population. to designed programs (BAMBI). Bonding Initiative to the immediate is an alternative The program Mother teaching new to combat recidivism by seeking and mother, baby of the separation Typically, behaviors. healthy and encouraging parenting the basics of mothers of their release when they months within six those who are are females eligible including that the eligibility criteria, other meet also must They their baby. deliver hoped that is offense. It a violent for conviction or current no past have offender recidivism rates. aid in reducing bond will mother-child a encouraging Local criminal justice systems consist of local law enforcement agencies, agencies, enforcement of local law consist systems Local criminal justice that are responsible for departments and probation courts jails, prosecutors, in a specified region. Local and local law state enforcing by public safety promoting the trial through point of arrest cases from the for criminal responsible are systems trial and those convicted awaiting defendants Local jails hold and sentencing stages. of an Individuals convicted for short durations. sentenced offenses level of low in local jails. also be held facilities may state to transportation waiting for and offense operating at were collectively and city jails county Texas On December 1, 2013, 66,807. of jail population capacity with a total 69.95% Local Criminal Justice SystemsJustice Criminal Local Annual_Review_2013.pdf Special health and mental health needs greater and possibly distinct inmates have Female report females of incarcerated portion A significant to male inmates. as compared abuse. physical and emotional, of sexual, a history Source: Texas Department of Criminal Justice. (2014). (2014). of Department Justice. Criminal Texas Source: are also more likely than men to have chronic health conditions, including HIV, including HIV, conditions, chronic health have men to than likely are also more C. and Hepatitis diseases, transmitted sexually health effects of experiencing pregnancyeffects health is also or giving birth while incarcerated birth give 250 women each year, that in Texas It is estimated to women. unique while incarcerated. Many jail detainees are non-violent offenders with co-occurring mental health and with co-occurring mental offenders non-violent are detainees jail Many TDCJ 196 health officials. Upon admissiontothe jaileachinmateissupposed tobescreened suicide prevention plan, in coordination with the available medical and mental operator is responsible for developing and implementingamentaldisabilities/ and behavioral observation,including state of consciousness andmentalstatus. admission. It shouldat a minimum contain current medical andmentaltreatment, procedure administered by health personnel or by atrained booking officerupon separate health record on eachinmate. The record is toincludeahealthscreening for inmate medical, mental health and dental services. Thisincludesmaintaininga activities relating to policy development and enforcement. activities relating to policy grievances, provides consultation, and performsother management various It alsoaudits and reports on inmate populations, provides resolutionofinmate standards, andprovides technicalassistance and trainingregardingjailmanagement. proposed construction reviews and renovationTCJS plans to assess conformityto verify compliance with minimum standards for jail construction andoperations. istoperform on-site inspectionsof jails to The principal operation of theTCJS inspections. responsible for enforcing compliance with adopted standards throughon-site standards and operation of jails. for the management also monitors andis TCJS fiscal year. the jail. the attention of health personnel and/or the supervisor on dutyat admissions to medical or mental health need in the medical record andthesearetobebrought tag.”Upon admission tojail each individual receives a“health Thetagnotes aspecial The standards includerequirements for thecustody, care andtreatment of inmates. all county jails and privately operated municipal jails. The Texas Commission on Jail for isaseparateregulatoryagency Standards(TCJS) Texas local countiesandcities. to treatment can lead toanindividual’s in andout of jail,whichiscostly cycling to Untreated mental health needs and alackof post-incarceration planningforaccess practices for meeting the treatment needs of inmates with mentalhealthconditions. local jail systems may lack the adequate resources to implementpoliciesandbest with the mental health treatment and support they need. Moreover, countyand health needs injails, jail officialsoften lackthe trainingto provide theseindividuals their mental health while injail. Despite the high proportionofpeoplewithmental criminal justice system. Other inmates however, may experiencedeterioration of link inmates to community-based social services to prevent re-entrance intothe services vary widelybetween facilities. Some jails provide treatment and successfully to provide health services to inmates while they are incarcerated,mentalhealth that results in their entrance into thejail system. Thoughjailsarelegallymandated substance use issueswhose untreated mental health needscanleadto behavior Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas population. more frequentlyin jail thanamong the general Comprehensive national data show that suicideoccurs roughly threetimes addition to 9privately operated facilities. in Texas, all but 19operate at least travels one jail;therefore TCJS to235countiesin 512 Eachfacility should have and implement a written healthservicesplan 511 C ommission on 507
Jail 510 Eachcountyisvisitedatleast onceeach S t and 508 TCJS establishes TCJS minimum ards 509 514 Eachsherifforjail Out of the254counties 513 TDCJ 197 The Sequential Intercept The Sequential Intercept 518 The goal of these programs is to prevent unnecessary The goal unnecessary these programs is to prevent of 517 http://www.nami.org/Template.cfm?Section=cit2&template=/ContentManagement/ 516 In 2013 TCJS, in collaboration with multiple state agencies state with multiple in collaboration TCJS, In 2013 Developing a Comprehensive Plan for Mental Health & Criminal Justice Collaboration: The The Collaboration: Justice Criminal & Health Mental for Plan Comprehensive a Developing 515 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 Diversion Model developed by Munetz and Griffin in conjunction with the GAINS Center gives the GAINS Center gives with in conjunction Griffin and Munetz by developed Model an individual each level at strategies to target framework structural a communities system. criminal justice the with intersects 88. Figure incarceration, which is costly to the state and often fails to address the underlying fails to and often state to the costly which is incarceration, as a mental health condition. such behavior, criminal causes behind an offender’s that they ensure communities, in their individuals can retain services Community and help individuals become productive they need, and services supports the receive of society. members Administration Services (SAMHSA) Health and Mental Abuse The Substance of opportunities set a comprehensive model with intercept a sequential promotes process. justice the criminal throughout for diversion . ContentDisplay.cfm&ContentID=101341 Jail underlying mental health identify an models seek to jail diversion Typically, Upon a positive system. criminal justice enters the a person at the point condition rely on mental models jail diversion condition, health of a mental identification possible treatment and identify detainee the to examine professionals health local mental model encourages The jail diversion collaboration between options. in order to identify court system and the enforcement, law authorities, health goal to incarceration. The alternatives to community-based the client is to link Source: CMS National GAINS Center. Center. GAINS National CMS Source: from Retrieved Model. Intercept Sequential Incarceration Prevention Programs Programs Prevention Incarceration community-based provides (DSHS) Services State Health of The Department multi-service provide to collaborates and TCOOMMI also interventions, contracts special needs through with to incarceration for offenders alternatives centers. community with 37 immediately utilizing the TCJS approved mental disabilities/suicide prevention prevention disabilities/suicide mental TCJSthe utilizing immediately approved instrument. screening including TCOOMMI, introduced a new training program titled “Assessing “Assessing titled training program introduced a new TCOOMMI, including health from local mental Staff Impairments.” Mental and Medical for Suicide, to 352 training which provided course, the in teaching included was authorities in 12 classes. participants TDCJ 198 jail diversion pilot to the legislature by December 1, 2016. year. DSHS is legislatively mandated to submitan evaluation ontheHarriscounty pilot target istoserve atleast 200 frequent recidivists with serious mentalillnessper The Jail Diversion Pilot Program had ananticipated start dateofAugust 2014. The jail ison psychotropic medications. pilot in Harris County, where20-25% of thejail population in theHarrisCounty SB 1185 (83rd Legislature) provided for thecreation of amentalhealthjaildiversion Texas. Itemploys both pre-booking and post-booking diversion methods. Bexar County’s jaildiversion was implemented in 2003 andisseenasamodelfor case management. dedicated mental health prosecutor, mental health publicdefenders, andindividual coordination, mental health court programs for misdemeanor andfelony cases, a oriented programming including misdemeanor mental health jaildiversion from county to county. For example, Dallas County offers anarray ofdiversion- Programs and servicesavailable todefendants with mental healthconditionsvary jail diversion programs withlaw enforcement, judicial systems and localpersonnel. funds by localmental health authorities (LMHAs) to createavariety of collaborative Section 533.108 of the Texas Health and Safety Code permitstheprioritizationof the health of individuals by providing them with the treatmentthey need. achieved. Jail diversion effortscan save money, improve public safety, andimprove mental health treatment and services inlieu of incarcerationsothat recovery canbe Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas veterans. be culturally competent and sensitive to the specificneedsofmen,women,and has recognizedthatindividualizedtreatment plans, systems, andservicesshould training, supportive employment, and peer advocacy. Moreover, the advisory panel and sustain recovery by expanding services in the areas ofhousing,educationand Bexar Countyby 14 percent in recent years, fromahigh of 4,259 to3,676 in2012. diversion programs, combinedwithfalling crime rate, reduced thejailpopulationin priority to providing services when people are released fromjailorprison.Jail to jail, such ascommunity-based treatment or mental healthbonds. Finally, itgives with mental illness already in the system andrecommends appropriatealternatives intent) before they are arrested or booked. Second, the program identifiespeople whose behavior ismorea symptom oftheir illness than an actdriven by criminal to identify individuals with mental illness forwhom diversion isappropriate(those mobile crisis outreachteamsandlaw enforcement crisis intervention teams work According to a2013 Criminal JusticeAccording Council report, there are Advisory prosecutors, defense attorneys, law enforcement and mentalhealth professionals. to incarcerationand operate under a modelthat requires thecollaborationofjudges, courts utilize problem-solving processes to provide community-based alternatives plan, serving people with serious mental illness and substance useconditions. These Specialty courts often are utilized as onepiece of alocality’s jail diversion larger SPECIALTY COURTS conditions in Tarrant County. court is the onlymajor diversion initiative fordefendantswithmentalhealth 525
520 Incontrast, amisdemeanor/low-level felony mentalhealth 521 524 Thekey aims ofthe program areto promote 526
522 519 First, 523 TDCJ 199
534 Thirteen 532 535 529 Of the participants 531 In Texas, specialty courts courts specialty In Texas, 527 In 2001, the 77th legislature via HB 1287 In 2001, 536
The court’s usual caseload is around 60-65 cases. usual caseload is around 60-65 cases. The court’s 533 530 528 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 Frequent appearances before the felony mental health court judge.court mental health felony the before appearances Frequent supervision officers. community with specially trained visits Regular mental health professionals. by treatment Intensive health and with co-occurring mental participants for use treatment Substance use conditions. substance testing. Random alcohol and drug Comprehensive evaluation to determine the participant’s strengths and needs. strengths participant’s the to determine evaluation Comprehensive have been credited with a reduction in incarcerated offenders; however, the state has state the however, offenders; incarcerated in a reduction with credited been have of outcomes and the performance to measure resources the necessary allocated not courts. specialty 86.3% had a mental illness and co-occurring substance use disorder. substance and co-occurring illness had a mental 86.3% The court team is comprised of two district court judges, a project director, three a project director, judges, court district of two team is comprised The court district dedicated part-time assistant two clinicians, health licensed mental full-time three dedicated defenders, public assistant part-time four dedicated attorneys, a bailiff and the participant. a clerk, officers, supervision community full-time Prospective participants undergo participants Prospective a criminogenicrisk assessment, which helps as well as a comprehensive criminal behavior, engaging in of likelihood to predict the and needs to assist strengths their to help identify evaluation psychosocial re-entry plan. individualized the client’s in developing clinical team More information on mental health courts is available at https://www.bja.gov/ available courts is mental health information on More Publications/mhc_essential_elements.pdf Drug Courts than and intensive comprehensive is more supervision that provide Drug courts supervision. of community forms other · · · · · of 88 participants. a total had served the court 2013 As of July · Harris County implemented a felony mental health court, originally funded by a court, originally funded by health mental Harris County implemented a felony applicants and began screening Assistance, Justice Bureau of federal from the grant who qualify for the specialty People 2012. in March for admission to the program characterized by is The program 18 months. at least lasting a program court follow components: the following The most common types of specialty courts relevant to criminal law and mental and law criminal to courts relevant of specialty common types The most DWI drug courts, family courts, drug courts, health are mental use health/substance courts. veterans and courts, Courts Health Mental for the country as an alternative, across developed been have courts health Mental These specialty adjudication process. the standard to illness, with mental people that system the cyclingin part, to reduce are designed, courts out of the justice in and cause address the root to attempting by mental illness of untreated the result is often professionals collaborate to mental health and Court staff behavior. for criminal for the participant. plan a judicially supervised treatment develop approximately 140 operational specialty courts in Texas. courts specialty operational 140 approximately participants successfully graduated and another ten participants were on track to ten participants were and another graduated successfully participants of 2014. the fall by graduate TDCJ 200 approximately 100 drug courts incounties throughout the state. sanctions operating separately. more effective inreducing drugusage andcrime thaneithertreatment orjudicial model assumessupervised treatment in combination with judicialmonitoringis receiving TCOOMMI services. with a diagnosis ofschizophrenia, bipolar disorder ormajordepressioniscurrently Medical or Mental Impairments(TCOOMMI), only one offourformerinmates with mental illness through the Texas Correctional Office onOffenderswith challenging time. Although the state provides re-entry assistance forsomeinmates criminal record. For individuals leaving prisons and jails, re-entry isaparticularly forindividualswitha Successful integration in the community can be achallenge Forensic Peer Support jail in one tofive years sincethe inception of theMHPD in2007. who were provided assistance remained out ofcustody and/or hadnot returned to in 2011, revealed that 41.2% ofmisdemeanor (no felony included)clients charges A cost benefitanalysis oftheperformance of theTravis CountyMHPD, published counties. In Texas there arecurrently three MHPD identified inBexar, Travis and Ft. Bend · · · · apply for federaland other funds to establish drug courts. (Thompson) mandated all Texas counties with populationsexceeding 550,000 to Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas defendants with mental health conditions. The mission oftheMHPD isto: Defender Offices (MHPD), incontrast tomental healthcourts, to better serve county-wide publicdefendershave established specialized Mental Health Public mental illness iscalled forensic peer support and is ayoung,butgrowing field. Policy Priorities, “peer support provided toandby individuals with mental illness. to arecent report by theCenterforPublic According in other contexts, interest isgrowing in usingpeer support for justice-involved juvenile, mental health orappellate court. in Texas that provide a publicdefender’s office, whether in-house,specialized for legal issues that require specialized knowledge and skills. Thereare23counties Criminal cases involving people with mental health conditionsoften presentunique Mental Health PublicDefender social services for defendants charged withfelonies.social servicesfordefendantscharged misdemeanors. TheTravis and Ft. Bend MHPD alsoprovide referralsforavariety of involvement. 38% decrease in bookings and 13%decrease of jailbed days consumedpost- MHPD needed to defendpersons with mental illness. Enhance legal representation by providing attorneys withspecialized knowledge Reduce recidivism by providing services. intensive casemanagement Increase the number of dismissals among defendants with mentalillness. Minimize the number of days aperson with mental illness spendsinjail. 542 The three counties all have with MHPD representing defendantscharged 545 546 539 Aspeer support becomesanestablished service
540 Some counties withoutdesignated justice-involved individuals with 543 537 There arecurrently 544 538 There was also a Thedrugcourt 541 547
TJJD 201
205 206 208 208 216 210 212 213 213 215 215 216 218 219 218 205 206 210 217 219 219 204
At A At A Glance
ontents 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 C
oncerns C Disproportionality in the Texas Juvenile Justice System System Justice Juvenile Texas the in Disproportionality Community-Based Services Community-Based Programs Intervention and Prevention Sources Funding 205 Legislation Pilot Therapy Behavioral Cognitive Trauma-Focused Center Treatment Residential Corsicana Office of the Independent Ombudsman for the Texas Juvenile Justice Department Justice Juvenile Texas the for Ombudsman Independent of the Office Behavioral Health Services in State Secure Facilities Facilities Secure State in Services Health Behavioral Facilities Secure County-Level in Services Health Behavioral Parole on Youth for Services Health Behavioral Departments Probation Juvenile Local by Offered Services Health Behavioral Community-Based Health Behavioral with Departments Probation Juvenile Local to Available Programs State-Funded Components Service Juvenile Specialty Courts Program Diversionary Needs Special Initiative Diversionary Front-End The Adequate independent oversight of residential placements of residential Adequateoversight independent and community interventions secure facilities state for of outcomes Assessment confinement from secure needs health behavioral of youth with Diversion facilities Prolonged facilities confinement of youth in secure isolation facilities confinement use in secure Restraint facilities adult correctional in Youth age court jurisdiction based Adjustmentof juvenile limits upper and lower to the Texas Juvenile Justice Department (TJJD) and Local and Local (TJJD) Justice Department Juvenile Texas Environment Changing Juvenile Justice Agencies Overview System Justice Juvenile System Justice Juvenile the in Services Health Behavioral Conditions Health Behavioral with Youth for Programs Diversion Programs Diversion Funded Federally and Privately Other Injuries Brain with Youth Identifying Policy · · · · · · · Agencies: Agencies: Local Juvenile Justice Juvenile Local of le Tab Department (TJJD) and (TJJD) Department Texas Juvenile Justice Juvenile Texas TJJD 202 · · · · · · · · F Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · ast F 22.2% ofyouth have amental health condition causing severe impairment. Overcriminalization of youth for status offenses School-to-prison pipeline for youth in special education on science of adolescent development provide mentalhealth or substance use services. Local juvenile probation departments use a mix oflocal, state andfederalfundsto Misdemeanor offenses make upthe majorityof juvenile probation referrals. The juvenile justice system isacivil system designed to emphasizerehabilitation. funding accounted for only30% of total funding. In FY2013, counties funded 70% ofprobation services while state andfederal youth with substance use conditions. mental health conditions and 28identify themselves asproviding programs for 34 county-level post-adjudication facilities, 23offer programsforyouthwith not enough to need placement at astate-level dangerous securefacility. Ofthese facilities are foryouth adjudicated for misdemeanor offenses andfelony offenders Texas has34 post-adjudication secure facilities operated at thecountylevel. These population to have mental health and substance use conditions. Youth in the juvenile justice system are more likely thanchildreninthegeneral based on a 2006multi-state study of Texas, Louisiana and Washington. residential facilities were assessed ashaving at least one mentalhealthcondition, 70% ofjuveniles in community-based programs, detention centersandsecure Texas atan average cost of $366 per day. As ofApril 2014, there were 1,058 youth committed tostate securefacilitiesin a cts 552 551 553 548 Nationally, 550
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m E venti r venile e ce r io a Ju P l & Co n P e S a aniz Org TJJD one mentalhealth condition assessed ashavingat least residential facilitieswere detention centersandsecure community-based programs, juvenilesin 70% of 204 state lockups.” “increasing the proportion of youths in localcustody, ratherthancommitted to created TJJD,system. In theirplace, Senate Bill 653(Whitmire) with charged (TYC), the state’s the two state that previously managed agencies juvenile justice Texas Juvenile Probation Commission (TJPC) and the Texas Youth Commission of youth in the juvenile justice system have trauma. experienced prolonged addition, not onlydo they have higher prevalence of chronic abuse andneglect,they a mental health disorder also struggle with asubstance usedisorder. plan for their successful futures. In 2011, the 82 partnership to provide a continuum of services designed to rehabilitate youth and (TJJD) andlocal juvenile probation departments throughout the state thatworkin Texas’ juvenile justice system is comprised ofthe Texas Juvenile Justice Department Agencies Local JuvenileJustice Department (TJJD) and Texas JuvenileJustice Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas condition, based on a 2006multi-state study of Texas, Louisiana and Washington. secure residential facilities were assessed as having at least one mental health comparison, 70% ofjuveniles incommunity-based programs, detention centersand of youth have amental health condition causing severe impairment. significant treatment isalmost 30%. The number of youth with acondition serious enough to require immediateand population to have mental health and substance use conditions. Youth in the juvenile justice system are more likely thanchildreninthegeneral needs and strengths. criminal justice system by providing a uniquetreatmentplantailored to eachyouth’s ofTJJDyouth. The ultimate goal is to prevent the youth’s entrance into theadult former TYC, including the operation of alimited number of secure facilitiesfor probation departments across Texas while continuing some of the functionsof 554 To thisend, TJJD fundsand provides oversight tolocaljuvenile violence and substance use. are alsooften exposed to domestic violence, community system. different levels of involvement withthejuvenile justice the behavioral health services available to youth at 558 Furthermore, over 60%ofyouth experiencing nd Texas Legislatureabolishedthe 561 Thissection will describe 555 Nationally, 22.2% 556 559 In Themajority 560 In 557
TJJD 205 apy The pilot The pilot 565 Ther Treatment al 563 Training in TF-CBT has Training in TF-CBT 564 vior ognitive Beha ognitive C 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 tion TF-CBT is an evidence-based treatment designed to reduce negative to reduce negative designed treatment evidence-based is an TF-CBT 562 -Focused uma-Focused a focuses on distorted beliefs and attributions related to trauma and provides a to trauma and provides related and attributions beliefs distorted focuses on experiences. traumatic to discuss environment supportive is expected to be completed and a report developed by the end of July 2015. 2015. the end of July by a report developed and to be completed is expected emotional and behavioral responses following traumatic events. following responses and behavioral emotional Tr Trauma-Focused is piloting TJJD de Putte), (83rd–Van to SB 1356 In response Correctional State Juvenile Ron Jackson at (TF-CBT) Therapy Behavioral Cognitive and Giddings Correctional Facility, Juvenile County State McLennan Complex, Center for Social Work of Texas the University with School in partnership State Research. Pilot Changing Environment Changing a Legisl parents and guardians allows in 2013, also passed (83rd-Raymond), 144 Bill House chemical and disability intellectual illness, mental for evaluations to request system. justice in the juvenile dependencyinvolved becomes their child when such a request. ability to make court had the juvenile only the Previously, mental health conditions, youth with of the criminalization In an effort to reduce facing Class C misdemeanor chargespeople refers young Bill 393 (83rd-West) Senate of a determination dismissed because was a previous complaint court if to juvenile C misdemeanors usually are Class capacity. or lack of disability illness, of mental in In contrast, courts. are adult criminal which JP courts, municipal or tried in services, community worker, to a social access have may court a youth juvenile a Thus, detention. of instead for services be recommended and may and mentors, entrance into from unnecessary the youth divert court may to a juvenile referral courts to dismiss a complaint if the also requires SB 393 system. justice the criminal that a young person facing to believe cause there is probable that court determines the proceedings chargesClass C misdemeanor to understand lacks capacity potential the conduct of the wrongfulness appreciate either capacity to substantial or lacks A Class C misdemeanor law. of the the requirements conduct to or to conform their more not term, only a fine of include a jail and does not basic offense most is the longer can no a judge. be issued SB 393 students Under guilty by if found than $500 a The school can file a complaint, but misbehavior. Class C misdemeanor for tickets to charge the student. whether decides prosecutor to requires the board of TJJD passed in 2013, de Putte), (Van Bill 1356 Senate probation for juvenile care training trauma-informed oversee and implement community-based and court-supervised supervision officers juvenile officers, is also required to bill, TJJD senate the same As directed in personnel. program early identification of departments for probation of juvenile the practices evaluate sex trafficking. are victims of people who young been provided to 18 clinical staff and ongoing coaching is being provided. clinical staff to 18 provided been TJJD 206 youth’s criminal history. the primary difference isthecounty ofconviction, not thecriminal offenseorthe getoffenders arethose thatsent toadult criminalcourt, although thedatashow that or itcansentence the youth to TJJD custody. In theorythemost seriousyouth with the juvenile informally and allow thejuvenile toremaininhisorhercommunity whether a youthisintroduced into the TJJD system. A juvenile court can either deal criminal justice system. Typically, makes a juvenile thedetermination court judge on court certify the youth as an adult andassign the youthforentranceinto adult state of Texas, buthelps to avert the even more consequential result of having the intotheTJJDAdmission isone of the most seriousplacementsforayouthinthe Juvenile Justice System Overview services provided on-site by licensed mental health professionals. andother treatment, assessment, medication management chemical dependency included evidence-based psychotherapy andbehavioral skill-buildinginterventions, mental health needs. Services offered atCorsicana ResidentialTreatmentCenter of Dallas in Navarro County designated solely for committed youthwithsignificant the closure of the Corsicana Residential Treatment Center, afacility located south operated secure facilities from sixto five. In June 2013, recommended theagency During the 2013 legislative sessionTJJD was ordered toreducethenumberofstate- C Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas of the Corsicana facility. while awaitingpartnership with Navarro College adecisionfromtheLBBonfate are responsiblefor maintaining the grounds and continuing anemployee training to other TJJD facilitiesthroughout the state. The remaining threestaff members were eliminated. The other employees were given the option torequest transfers administrative duties. Effective July 31,2014, allbutthree staff positionsatCorsicana to maintain grounds, inventory property, process records, andcomplete other end of 2013 housedany andnolonger youth, 25 employees remainedat the facility in Mart, Texas. youth were transferred to the McLennan County State Juvenile Correctional Facility whether their needs could bemet in alessrestrictive setting. InDecember2013, 65 In addition, TJJD reviewed each youth in themonths prior toclosuredetermine In the years leadingup to theclosure, the population at thefacilitycontinuedtodrop. agency’s juveniles, yet itexperienced 32% of allviolent incidents in TJJD. behavior and safety concerns. In2012 the facility housed only10percent of the the treatmentneeds of youth, staffing challenges, high incidence of self-harming long argued that Corsicana should be closed dueto its long-standing failureto meet years 2012 and 2013. referrals and dispositions of youthinvolved inthe juvenile justice system infiscal restrictive andhigherlevel of intervention. Figure 89below shows the number of are reserved foryouths who areconsidered chronic offenders and inneed of more orsic an 568 Though Corsicana was closed as anormaloperationsfacilityatthe R esidential 569 570
Withinthe juvenile justice system, theTJJD facilities Tre a tment Center 566 Advocates had Advocates 567
TJJD 207 In contrast to the adult criminal In contrast which emphasizes justice system, the punishment and public safety, juvenile justice system is a civil places an emphasis on system that rehabilitation. Analogous Criminal Term/Concept Justice Conduct Criminal Arraignment trial to prior detained are individuals where jail Local Trial trial at of“guilt/innocence” Finding Sentence Incarcerated sen- short serves offender where jail state or Local tences Prison Retrieved Retrieved Board. Budget Legislative and Governor the to Report 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.tjjd.texas.gov/statistics/TJJD_Dec_LBB_Rider_Report_2013.pdf Juvenile Term/Concept Justice Delinquent Conduct Delinquent hearing Detention facility Pre-adjudication hearing Adjudication adjudication at true” of“true/not Finding hearing Disposition “placed”) (also Committed facility post-adjudication County-run facility correctional juvenile secure State
from from system, justice criminal to the adult In contrast public safety, which emphasizes punishment and that civil system is a system justice the juvenile As a result, rehabilitation. on emphasis places an in juvenile used concepts and terms the legal used in the differ from those procedures justice X X and Figures setting. adult criminal justice terms in for the of reference a point offers below as systems, criminal justice and juvenile the adult used in the definitions for terms well as common system. justice juvenile and Concepts Terms 90. Figure Source: Texas Juvenile Justice Department. (2013, December). December). (2013, Department. Justice Juvenile Texas Source: 2013 and in 2012 youth ofTJJD Dispositions and Referrals 89. Figure TJJD 208 procedures and regularly visits and inspects secure TJJD facilities. suicidal attempts andideation.TheOIO provides informationregardinggrievance of complaintsincluding medical and mental health concerns, abuseallegations, and Texas Office of For a full list terms of and definitions commonly used throughout TJJD, see: texas.gov/about/glossary.aspx Source: Texas Juvenile Justice Department. (2013). Figure 91. Common Juvenile Justice Definitions Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas represented in the juvenile justice system at both the federal andstate level. InTexas, Youth who are members of racialorethnic groups are disproportionately SYSTEMDISPROPORTIONALITYJUSTICEJUVENILE IN THETEXAS in state facilities and on parole. responsible for investigating,agency evaluating and securing therightsofjuveniles The Office oftheIndependent Ombudsman (OIO),createdin2007, isaseparate state Halfway House Plan Individual Case tion Juvenile Proba- Stay of Minimum Length Offender Chronic Serious Adjudication (CINS) supervision of Conduct in need conduct Delinquent Juvenile Juvenile the the risk of recidivism or relapse when compared to a releasethe risk of directly into society. while still providing monitoring and support; this is generally believed to reduce reintegrationhouse is to allow the persons to begin the process with society, of tution such as a prison, hospital or rehabilitation facility. a halfway The purpose of convicted felons are placed immediately after their release from a primary insti- A residential center or home where drug users, sex offenders, the mentally ill, or specific strengths and risks. Youth’s individualized plan for treatment and education, based on his or her their progression into more serious problem behavior. informally monitoring at risk youth and preventing even use probation as a way of or first-time juvenile offenders from the court system. Some communities may niles adjudicated in court, diverting status offenders and in many cases as a way of A mechanism used by juvenile justice agencies that serves as a sanction for juve- is set by TJJD policy. time an indeterminate sentenced youth must stay in Minimum period of TJJD. This process hearings. committed at least three at least separate one felony in each and distinct due of A youth whose TJJD classifying offense is a felony and who has been found to have a “conviction” in adult court. Is a finding that a youth has engaged in delinquent or CINS conduct. It is similar to away from home. committed by an adult,conduct that is not a violation if such as truancy or running Generally conduct that, committedif by an adult, could result in only a fine or confinement in jail. Generally conduct that, committed by an adult, if could result in imprisonment or ted an act defined as “delinquent or conduct” “conduct in need supervision.” of A person who was at least 10 years old but not yet 17 at the time he or she commit- Independent Justice 571 Definitions for Common TJJD Terms & Acronyms. The independent ombudsman investigates a variety Department http://www.tjjd.texas.gov/about/glossary.aspx Ombudsman Retrieved from 572 f http://www.tjjd. or the TJJD 209 In Texas, African In Texas, and American youth, to a lesser extent are Hispanic youth, in overrepresented the juvenile justice to system relative Anglo youth. In fiscal In fiscal 573 The likelihood of experiencing of experiencing likelihood The
575 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 Additionally, African American and special education American and special education African Additionally, 574 Data driven strategies Data driven development Leadership workforce competent Culturally engagementCommunity collaborations Cross systems principles by anti-racist defined Training poor racism and the impact on institutional of the history of An understanding color. and communities of communities students are more likely to be disciplined outside the classroom the classroom outside to be disciplined likely are more students on ticketing Misdemeanor C in Class and to be overrepresented school campuses. year 2013, 48,275 juveniles were formally referred to juvenile to juvenile referred formally were juveniles 48,275 year 2013, 49% of these the state; throughout departments probation certified youths 206 of the Additionally, were Hispanic. juveniles four juvenile from were of these 17 percent in 2013, as adults a heavily border, Texas-Mexico along the departments probation ongoing experiencing drug trafficking is still region that Hispanic problems. confinement or of being tried as an adult is higher for African American youth than youth than for African American adult is higher as an tried being or of confinement all Though background. racial or ethnic other of any for youth Hispanic probation, receive to likely are equally groups ethnic youth. rates than Anglo at higher are also confined youth African American youth, and to a lesser extent Hispanic youth, are overrepresented are overrepresented youth, Hispanic lesser extent to a and youth, American African youth. to Anglo relative system justice juvenile in the SB 501 created the Interagencycreated the SB 501 Addressing Council on of the agency The aims practices for 2011. in Disproportionality are to examine best and services agencieshuman health in the addressing disproportionality to make and disproportionality in the long- of eliminating means the best on recommendations The agencyterm. report to the legislature examining a developing with tasked was groups in the health and minority racial or ethnic of children of status the current of recommendations for the reduction appropriate make human services and to here: be found can on December 1, 2012, released full report, The disproportionality. http://www.hhsc.state.tx.us/hhsc_projects/cedd/11-29-2012-Report-to-the-83rd- Legislaturel.pdf disproportionality through the to address model” the “Texas highlighted The report model components: following · · · · · · · in to be effective and had shown DFPS settings utilized in model had been The Texas children. and Hispanic African American disparities in outcomes for reducing The Interagencyon Addressing Council Disproportionality will release a new addressing model for of the Texas of the implementation on the status report 2014. in December disparities and disproportionality TJJD 210 facilities in FY2013, 44%committed non-violent felony offenses. F but modified toreflect theunique individualneeds andabilitiesofthegirls. similar to those now offered atthe McLennan CountyResidentialTreatmentCenter, state secure facility that serves girls. Programming and servicesatthisfacilityare The Ron Jackson State Juvenile Correctional Complex inBrownwood istheonly cost of $366 perday. As ofApril 2014, there were 1,058 youth committed tothesefacilities at anaverage Source: TexasDepartment. Juvenile Justice (n.d.). Texas hasfive state secure facilities foryouthadjudicatedfelony offenses. Beha available in thesesettings. the communityon probation or parole.The following sectiondescribesthe services treatment centers, andcounty secure facilities. Theyalso provide servicestoyouthin juvenile justice settings, including state secure facilities, specialty secureresidential services for youthwith mental health andsubstance useconditionsina variety of Impairments (TCOOMMI), and local juvenile probationdepartmentsprovide TJJD, theTexas Correctional OfficeforOffenders with Medicaland Mental SystemJuvenile Justice Behavioral Health Services in the Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas development. CoNextions, whichincludeslifeskills training andworkforceeducation All state secure facilities use amulti-faceted rehabilitation program called 190 girls. units that consist of orientation and assessment. facility typicallyserves anaverageof 100 girls with 5% inshort-termplacements Figure 92. TJJD Secure Facilities Figure 92 below shows the nameand location of these facilities. scheduled to opena program for boys inOctober2014. under15 years ofage recidivism and criminalbehavior among youth. to reduce risk factors and increase protective of decreasing factors with thegoal facilities.aspx Ron Jackson State Juvenile Correctional Complex Facility & McLennan Residential Treatment Center McLennan County State Juvenile Correctional Giddings State School Gainesville State School Evins Regional Juvenile Center Facility a cilities vior 581 Thefacility also serves youthful male offenders. Amaleintake unitis 583 Thistherapeuticframework emphasizes skillsbuildinginorder al He 577 Ofallnew admissions of youth committed tostate-operated alth TJJD Facilities Address List. Services in Brownwood Mart Giddings Gainesville Edinburg Location 584 Retrieved from 580
InFY2013, the facility served S t a http://www.tjjd.texas.gov/aboutus/ te Secure 578 579 582 576 The
TJJD 211 Treatment Services Treatment feel- connect people young Helps violent their with associated ings alternative identify to and behavior with faced when respond to ways - Partic future. the in situations risky their reenact to required are ipants of role the play to and crimes both victim. and perpetrator - pro treatment TJJD’s the on Builds cognitive-behavioral using gram - preven relapse a and strategies receive Youths component. tion group and individual additional focus that interventions counseling in sexuality, deviant youth’s the on arousal deviant on and particular, fanta- sexual deviant and patterns youth’s the to contribute which sies, Additional sexual abusiveness. psy- include components program those for and, education chosexual trauma ofhistories with abuse, therapies. resolution Participants com- are who Youths murder, for mitted and murder, capital involving offenses ofuse the weapon a force. deadly or Sex offenders. Sex - Location State Giddings School SOTP: Intensity High State Giddings McLennan School, Juvenile State County Facility, Correctional and Jackson Ron - Juvenile State Correc Complex. tional Intensity Moderate SOTP: State Gainesville Giddings School, Mart School, State Treatment Residential McLennan Center, Juvenile State County Facility Correctional Ron and term, Long – Juvenile Cor Jackson Complex. rectional 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. services. these Inten- Moderate Treatment sity consist Programs ofdeliv- treatment licensed by ered staff trained or youth address to moderate a with special- for need treatment. ized is treatment The youth to provided general the in rehabilitation program. “High Intensity” and Intensity” “High Intensity” “Moderate Sex Residential Treatment Offender (SOTP) Program Intensity High Note: programs treatment based dorm are intensive residential special for program offenders needs for need high a with Program Name Program and Capital Violent Serious - Treat Offender Program ment Psychiatric and psychological services also are available at all facilities. Youth who Youth facilities. at all available are also services psychological and Psychiatric risk at high are who or services specialized for a high need as having are identified TJJD. within treatment services to specialized are assigned reoffending for violent violent for serious specifically are designed programs treatment These specialized mental with offenders offenders, dependent chemically sex offenders, offenders, Figure 93 below disabilities. with intellectual and offenders impairments, health the state. programs in treatment the specialized highlights in Texas Programs Specialized Treatment 93. Figure TJJD from 49.2%to83.7%. mental health needsincreased identified withhighormoderate treatment programs forjuveniles enrollment inspecialized From 2010to2012the 212 programs/special_treatment.aspx Source: Texas Juvenile Justice Department. (2013). Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas substance use conditions. health conditions and28 identify themselves asproviding programsforyouthwith county-level post-adjudication facilities, 23offer programsforyouthwithmental not enough to need placement at astate-level dangerous securefacility. Ofthese34 facilities are foryouth adjudicated for misdemeanor offenses andfelony offenders Texas has34 post-adjudication secure facilities operated at thecountylevel. These Secure F Beha Programs Mental Health Programs Use TreatmentDrug Alcohol or Other Program Name vior a al He cilities in the state. institutional facilities services at all the professionals provide Mental health McFadden Ranch. secure facilities and offered at all five state dential programs are halfway houses. Resi- facilities and several all the institutional Services available at Location alth 589
mental health treatment. juvenile facilities were determined to have aneed for specialized program increasedfrom19.2% to 53.0%. 49.2% to 83.7%. or moderate mental health needs increased from treatment programs for juveniles identified withhigh From 2010 to 2012 theenrollment in specialized these services. significantly increasing thenumber ofyouth receiving treatment programsby 86%fromFY2009to2012, TJJD hasincreased the provision of specialized Specialized Correctional Treatment. Services in health conditions. Youths with mental dent offenders. Chemically depen- Participants 587 585 InFY2013, 48% ofyouth in state Thenumber of youth completing a C Retrieved from and relapse cycles. their life stories, offense histories, and offense; participants examine drugs to the youth’suse of life story is addressed through linking the prevention. The criminal behavior individual counseling, and relapse social skills training, group and lum and substance use education, evidence-based treatment curricu- Program components include needs. mental health and correctional therapy in a program that addresses his or her with his or her family and community cerns reintegrating the young person patterns behavior.of The final goal con- changing the delinquent and criminal benefit from treatment that focuses on the young person is better prepared to behavior. Once this is accomplished, youths to regain control over their problem or illness and allowing the is treating the basic mental health The immediate goal for this group Treatment Services 588 ounty-Level
http://www.tjjd.texas.gov/ 586
TJJD 213
594
591 Services Twenty-seven percent Twenty-seven on on outh tion h alt 593 Y or f l He al vior Approximately 400 Texas youth spent over 100 over youth spent 400 Texas Approximately 590 Services 596 ba Pro Juvenile al h alt sed Beha ased oc L y l He al 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
Youth charged with felonies accounted for 21 percent of referrals, chargedreferrals, for 21 percent of accounted with felonies Youth 592 595 vior Service coordination Service monitoring Medication Advocacy services programs treatment other to services Transitional eligibility Benefit Individualized assessments Individualized ommunity-B arole In FY 2013, 48 percent of juveniles served by local probation departments were probation departments local by served of juveniles percent 48 In FY 2013, referral. health one behavioral at least as having identified By law, all Texas youth are screened for mental health needs at first contact with contact at first needs for mental health are screened youth all Texas law, By the recognized instrument, a nationally using departments probation local juvenile If a screening indicates that (MAYSI-2). Screening Instrument Youth Massachusetts probation requires local juvenile the department is appropriate, assessment further percent of sixteen Approximately for further evaluation. youth to refer departments recommended for further mental health were in FY 2013 referrals screened Texas assessment. C ered Off · · · · · Beha on parole after youth released care services to of continuity provides TCOOMMI be placed in illness also can with mental youth Paroled facility. secure in a placement arrangementsor group living or residential treatment facilities. foster therapeutic illness that a serious mental who have on parole youth released for targeted Services include: treatment post-release requires · days in secure pre-adjudication facilities at the county level in 2013. About 32 percent 32 About 2013. in level county the at facilities pre-adjudication secure in days offenses. non-felony with formally referred individuals were of these P rtments Depa In addition, there are 51 pre-adjudication facilities operated by counties to detain to detain counties by operated facilities pre-adjudication 51 there are In addition, Sixteen adjudication. awaiting while the community back to to release unsafe youth use substance have seventeen and programs mental health facilities have of these individuals. for detained programs violations of probation for 16 percent, and child in need of supervision (CINS) child in need and percent, for 16 of probation violations for 11 percent. accounted offenses Because local juvenile justice systems rely heavily on county and local funding on county and local funding rely heavily systems justice local juvenile Because support services vary across and treatment of availability the type and sources, facilities and the justice juvenile of all county-level a registry For the state. http://www.tjjd.texas.gov/publications/other/ visit: by each, offered services . searchfacilityregistry.aspx Youths chargedof referrals at the majority made up with misdemeanor offenses Youths 52 percent. of juveniles who were referred to juvenile probation had a mental health need. probation to juvenile referred who were of juveniles TJJD 214 having a mental health need. FY 2013, approximately 29 percent of formally referred juveniles wereidentifiedas 2013 Behavioral Health treatment, care management and support services in FY Figure 94. Youth Discharged and linked to Community Services, including released but not discharged. TJJD custody, supervision, and/or services. Youth onparoleforexample,have been and support services in FY2013.management, referstotheendingofall Discharge services through TCOOMMIorCRCGs, including behavioral healthtreatment,care whowerelinked tocommunity Figure 94 indicates the number of youth discharged supervision were identified ashaving amentalhealth needduringFY2013. Approximately 44 percent of juveniles on deferred prosecutionorprobation youth access mental health services prior toentering the juvenile justice system. of mental health needs among the youth in thejuvenile justice system, but few services spill over into the juvenile justice system, since there isahighprevalence resources and providers. in gainingaccess to appropriatemental health Challenges to mental health treatment is not an entitlement but is based onavailableAccess participate in either residential or community-based treatment programs. charges. Youth whoareadjudicated and placed onprobationmay be requiredto offered deferredadjudicationandprovided treatment asaconditionofdismissing supervision to include mandated behavioral health services. Youth may alsobe variety of reasons. Some may bediverted fromthe probation system andprovided departments, for a orCommunityResource Coordination Groups (CRCGs), Youth with mental health needs receive services from localjuvenile probation Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas the communityin FY 2013. Figure 95 indicates the number of youth with behavioral healthconditionsserved in Source: Texas Juvenile Justice Department. (2014, August). Data Request: Mental Health Services services in the community TJJD parole receiving mental health aftercare the community Received mental health aftercare services in Referred to TCOOMMI or CRCG services Type Discharge of 598 125 (hallway house) youth released to a non-secure residential facility (includes youth released on TJJD parole, as well as 178 288 Number Served 597 In TJJD 215 al oc
L 601 omponents C le to to ailable Number Served Number of30,781 out 2,758 served) juveniles oftotal (9% of1,487 out 657 served) juveniles oftotal (44% of30,781 out 5,100 served) juveniles oftotal (16% 2,737 3,965 ms Av ams rtments with rtments Depa Service However, counties provide the majority of funding for counties provide However, tion h alt 599 l He al 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
vior 600 te-Funded Progr te-Funded a t Type of Service Type Mental health programs and mental health health mental and programs health Mental programs court health mental a for services health Behavioral drug programs, treatment drug (ex. problem programs) prevention and education, programs Counseling programs treatment Drug programs education/prevention Drug Using a mix of local, state and federal funds, local juvenile probation departments juvenile local funds, and federal of local, state Using a mix including use services, and substance health of mental wide array a provide and use prevention substance services, in-home family intensive counseling, angerintervention, managementmanagement. case and intensive ba Pro Juvenile Beha S departments via various probation juvenile in local funds programs TJJD in their aimed at serving youth are initiatives and grant funding. The initiatives to state-operated committed from being them keeping local communities and programs of a variety describes section following The facilities. institutional secure health service behavioral with a departments probation to local juvenile available component. Definitional Note: “Services” are typically one-time events designed to meet a designed to meet events one-time “Services” are typically Note: Definitional an assessment, or as a medical appointment, need, such immediate juvenile’s with planned activities or interventions “Programs” are testing. psychological specific anger counseling, goals and curricula. These include management and Program. Special Needs Diversionary FUNDING SOURCES Legislature to Texas the general by appropriated funds revenue distributes TJJD activities, probation a number of underwrite to boards probation local juvenile substance conditions and health with mental to juveniles services special including Title IV-E federal justice, juvenile in involved youth care foster For use conditions. resource. is a key funding Source: The Texas Juvenile Justice Department. (2014, August). Data Request: Mental Health Services Mental Health Request: Data August). (2014, Department. Justice Juvenile Texas The Source: Youth with Behavioral Health Conditions and Juvenile Justice Justice Juvenile and Conditions Health Behavioral with Youth 95. Figure 2013 FY Community, the in Served Involvement community-based juvenile probation services. In FY 2013, counties funded 70% of counties In FY 2013, services. probation juvenile community-based accounted for only 30% of total funding and federal state while services probation funding. TJJD 216 active. and listedas Services Registry Program & the TJJDwithin been identified programs had community-based FY 2012, 1,562 At theendof programs. the initial investment of $1.5 million for24 prevention and earlyintervention Prevention and intervention programs were funded by the82 PREVENTION AND INTERVENTION PROGRAMS Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas the supervision. Program duration varies widely from lasting oneafternoon to theentirety of 39% ofthe mental health programs. The use of community-based juvenile justice programs hascontinuedto grow COMMUNITY-BASED SERVICES and contract for 45% of theirprograms. provides it. Generally, departments provide 39% ofprogramsintheirjurisdiction program in FY2013. average expenseof $575 peryouth, 3,418 youth participatedinafundedprevention skills and services tobetter challenging behaviors. manage character development, and educational programs for atriskyouthaimed at teaching ofservices frommentoring, skills buildingprograms,The programsofferarange In 2013 there were 21 programsin operation. prevention and early intervention services in 2013 was $2.6 billion dollars. intervention/first referral programs. school dropout,orreferral to the juvenile justice system. to prevent orintervene inat risk behaviors that canlead to delinquency, truancy, Williamson, Zapata, and Karnes/Wilson. Hale, Tarrant, Randall, Tom Green, Travis, Van Zandt, Webb, Wharton,Willacy, located in thefollowing counties: Comal, Ellis, El Paso, Fort Bend,Guadalupe, 603 The programs are designed to serve youth ages 6-17 Theprograms are designed to serve youthages andtheirfamilies. 619 programs, withanaverage of42perdepartment. The ten urban juvenile probation departments have themost Registry and listed asactive. programs had beenidentifiedwithin the TJJD Program&Services meant to serve the needs ofawide array ofjuveniles. courts. Instead, they may offercounseling andeducationalprograms they often do not offer targeted programs suchasmentalhealth small departmentsoffer an of5programs perdepartment, average courts and drug courts. counseling and educationalprograms as wellmental health departments offer variousprograms, includingspecialized average of 11 and18programs are offered, respectively. each fiscal year. steadily with new offerings by juvenile probation departments a department is crucial to whether a programisoffered andwho Intensive supervision programs willlast thanearly- longer 607 The average age ofthe participants was 11yearsold. Theaverage age 611 At theend of FY2012, 1,562 community-based 618 620 617
614 610 Localmental health authoritiesprovide In medium to large departments an Inmedium to large
612 605
Thetotal amountbudgetedfor 602 609 In2012, TJJD approved Theprogramsare nd Legislature(2011) 613 These 616 Thesizeof 615 While 606 608 At an
604
TJJD 217 621 Days in Program in Days 109 70 170 161 These funds are 625 In fiscal year 2013, 7,596 In fiscal year 2013, Funding is provided in is provided Funding Tier 2 funding goesall to 623 626 630 Departments without a Departments without 629
624 These funds also are used to support These funds also are used to support 622 Community-Based Program Evaluation Series: Overview of Community-Based ofCommunity-Based Overview Series: Evaluation Program Community-Based http://www.tjjd.texas.gov/statistics/CommunityBasedJuvenileProbationPrograms.pdf If a department has more than 80 beds they receive receive beds they than 80 has more If a department 631 628 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 with one or more facilities with fewer than 80 beds facilities with fewer than or more Departments with one 627 Counseling Cognitive Therapy Behavioral Court Health Mental programs Health Mental Other Program Type Program to only be used to provide mental health services to juveniles and may not be used not and may to juveniles health services mental to provide be used to only funding. local expenses or to supplant for administrative two tiers. Tier 1 funding goes to departments with secure pre- or post-adjudication goes Tier 1 funding with secure pre- or post-adjudication departments to two tiers. facilities. receive funding for one-full-time mental health professional to provide screening, professional to provide mental health funding for one-full-time receive to youth with mental health treatment and/or evaluation diagnosis, assessment, conditions. or emotional probation departments to provide resources for screening, assessment, diagnosis, for screening, assessment, diagnosis, resources to provide departments probation and treatment. evaluation Diverting youth with mental health conditions from incarceration and further from incarceration conditions mental health youth with Diverting benefits. has significant human and cost system justice juvenile with the involvement but no statewide the state, around scattered initiatives of has a number Texas operating diversion on currently is information Following effort exists. diversion programs. Diversion Programs for Youth with Youth for Programs Diversion Conditions Health Behavioral Source: Texas Juvenile Justice Department. (2013, June). June). (2013, Department. Justice Juvenile Texas Source: from Retrieved Programs. Probation Juvenile Program Diversion Corrections Community (Grant Program Diversion the Commitment created Legislature 81st the In 2009, state generalRider 21 in the C) through program provides bill. The appropriations diverting decrease their commitments by that departments local probation funds to incarceration. state-based from offenders Average Expected Length of Stay in Various Community Programs Programs Community Various of in Length Expected Stay Average 96. Figure Mental Health Services Health Mental was allocated each year to fund mental $12,804,748 and 2015, 2014 fiscal years For departments. probation local juvenile by provided services health funds for two full-time mental health professionals. mental health two full-time funds for juveniles participated in a commitment diversion program or received a service received program or diversion in a commitment participated juveniles these funds. or in part with funded completely facility receive funding to secure mental health services. mental health to secure funding facility receive a range of community-based services. Probation departments typically use these departments Probation services. a rangeof community-based programs. educational and life skills, counseling, funds for TJJD 218 juvenile probation departments. skills, anger management, and mentoring), and parentalsupporteducation. skills, and mentoring), management, anger services (includingindividualandgroup therapy), probation services(includinglife authorities, hasworked to implement this program with specializedcaseloads. in coordinationwiththe TCOOMMI and in cooperationwithlocalmentalhealth home and to reducefurther involvement with the juvenile justice system. TJJD, use, intellectual disability, autism, and pervasive development disorder)fromtheir prevent the removal of youth with mental health conditions(excluding substance The 77th Texas Legislature established the Special Needs Diversionary Program to Special 2013 there were 458 identified juvenile drug courtsnationwide. Similar specialtycourts exist withdrugrelatedcrimes. forjuveniles charged Asof and successfullymeet dismissed. programrequirements to get charges The youths must cooperate with probation supervision andmentalhealthtreatment who are eligible for deferred adjudication and have committed familyinvolvement. manager, andmental health professionals work with youthsamentalillness representatives for the youth, the district attorney, a probation officer, acase A multi-disciplinaryteam whose members include a courtrepresentative, alegal juvenile court project funded throughthe federal BureauofJustice Assistance. Collaborative Opportunities for Positive Experiences (COPE) isaTravis County followed by SanAntonio, ElPaso, Houston, and Dallas. country. InTexas, there are five suchspecialized courts. Thefirst beganin Austin, As of2012, there were approximately 50 juvenile mental health courtsacrossthe and immediatelylinkyouthtotreatmentservicesinthecommunity. Courts utilizeindividualtreatmentplans, andjudicialsupervision, casemanagement, diversion servicesfor youth withbehavioral health conditions. Juvenile Mental Health continuumof facility may be inappropriate. Theyoftenoperateasonepieceofalarger the underlyingcausesofjuvenile justice involvement andforwhomresidenceinasecure Specialty courtsserve individuals whowillbenefitfromprogramsdesignedtoaddress Specialty Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas facilities and re-offense ratesaremeasured asindicatorsofprogram effectiveness. In FY2013, 70% of enrolled youth completed the program. Referralstosecure state secure state facility. 59% for all programparticipants. Only 2% ofyouth in theprogramweresenttoa In FY2012, the program served 1,009 juveniles. The one-year re-offenserate was $1,974,034. mental health treatment prior to entry into the program. 20 ofthosejuvenile drug courts were located in countiesthroughout Texas. 22 localjuvenile probation departments. Services from these programs are provided tojuveniles underthesupervision of juveniles with mental illness and are amoreefficient useof publicresources. psychiatric and detention facilities because they reduce recidivismratesamong that juvenile mental health courts arean effective alternative to placement in 641 Sixty-nine percent of thoseserved by thisprogram(1,002) received Needs Juvenile 639 InFY2013, the program served 1,444 juveniles across 22 Diversionary Progr 640 C Thetotal amountappropriatedforFY2013 was ourts 637 Typical servicesincludementalhealth 632 A2011 evaluationfound 642 am 634 Inthatsame year, 635 633
636 638
TJJD 219 646 In 2014 the Initiative the Initiative In 2014 tive 645 The sites continue to The sites continue 644 Initia Research has identified a Research high level ofbrain traumatic injury among juvenile justice study one key populations; over 18% ofshowed that juveniles had a “significant” head injury with loss of consciousness of 20 minutes. least at
647
643 Diversionary 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 TJJD collaborated with HHSC collaborated on a TJJD U.S. from the based grant research and Human of Health Department Texas the youth in to identify Services with undiagnosed system justice juvenile to that contribute brain injuries with pilot Beginning behavior. delinquent Brownsville, that included communities Antonio, San Lubbock, Houston, El Paso, facilities, corrections youth state and the Brain for Traumatic are screened youth Injury the Brain (TBI) utilizing Injury (BISQ) Questionnaire Screening provided Youth FY 2011-2014. grant from the by was designated a “Promising Program” by the National Institute of Justice. of the National Institute Program” by designated a “Promising was Identifying Youth with Brain Injuries Brain with Youth Identifying of a high level has identified Research among juvenile injury brain traumatic study one key populations; justice had juveniles of 18% over that showed with loss of a “significant” head injury 20 minutes. of at least consciousness The Front-End Diversionary Initiative, funded through the MacArthur Foundation’s MacArthur Foundation’s funded through the Initiative, Diversionary The Front-End illness mental offenders with a links first-time Change for in 2007, initiative Models who helps the youth and family officer probation juvenile a specialized diagnosis to and family and development workforce It also includes access community services. in Austin, were initiated sites demonstration Texas engagementyouth activities. Houston. expanded to Antonio and Lubbock, San Dallas, End Front- The Youth with mental health needs may be diverted from the adjudication process adjudication process from the be diverted may needs health mental with Youth of adjudication. lieu in mandated treatment including supervision, and provided goingrequired the opportunity or be be offered adjudication may through Youth In either case, youth with probation. as a condition of in treatment to participate outpatient community-based receive may use conditions illness or substance mental or residential treatment. services youth that divert projects underwritten have grant funds foundation and Federal local through several incarceration or from formal adjudication illness with mental in Texas. departments probation Other Privately and Federally Funded Funded Federally and Privately Other Programs Diversion maintain the program and served 92 youth during FY 2013. youth during 92 and served the program maintain TJJD 220 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas objectives thataddress the youths’ special needs. identified withaprobabilityofTBI areprovided appropriateservicesandcaseplan 648
TEA 221 227 227 228 228 232 232 232 234 234 230 231 236 236 236 237 237 239 241 242 226 224 225 230 232 235 223
At A At A Glance
ontents C
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 C Mandatory v. Discretionary Removal Removal Discretionary v. Mandatory Special Education Funding through IDEA through Funding Education Special Medicaid through Funding Education Special Education Special for Eligibility Utilization Service and Services Education Special Supports and Interventions Learning Emotional and Social Care Trauma-Informed Centers Service Education Model Health School Coordinated Schools in Communities Behavioral Positive Wide School (OSS) Suspensions Out-of-School and (ISS) Suspensions In-School (DAEPs) Programs Education Alternative Disciplinary Juvenile Justice Alternative Education Alternative Justice Juvenile Streets the to Expulsion / (JJAEPs) Programs Misdemeanors C Class – Ticketing School Schools in ofUse Force Discipline Exclusionary to Alternatives Expansion of school wide Positive Behavioral Interventions and Support (PBIS) Interventions Behavioral Positive of school wide Expansion Learning (SEL) and classroom-based Social and Emotional special education services receiving of students representation Disproportionate and JJAEPs DAEPs, OSS, minorities in ISS, and racial/ethnic with disabilities on students punishment of corporal use Disproportionate including a enforcement, law of school district and training accountability Lack of Training (CCIT) Intervention Crisis Children’s need for from bullying side effects Negative and truancyinfractions minor disciplinary for ticketing Use of use in schools spray and pepper on Taser and reporting Training in schools of restraint Reduction Potential impact of budget reductions on school mental health services mental on school reductions impact of budget Potential Texas Education Agency and Local School Districts School Local Agency and Education Texas ofDelivery Schools in Services Health Mental Environment Changing Services Education Special Schools for Systems Support Health Mental Health Mental Student to Approaches Holistic Schools in Discipline Exclusionary · · · · · · · · Policy · Districts: Districts: and Local School Local and o f le Tab Texas AgencyEducation Texas TEA 222 Organiz · · · · · F Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · Efectiv Da:Jnury29 ast F Texas EductionAgy the country. population in Texas received specialeducation services, thelowest in percentage into JJAEPs andexpelled 893 students to thestreets. In the 2012-2013 school year, Texas school districts placedover 2,800students 17.8 percent of allstudents sent to OSS. education services but they represented 14 percentof all students senttoISSand In 2012-2013, 8.7 percent of allstudents in Texas publicschoolsreceived special bullied experienced negative side effects asa resultofthebullying. In astudy of250middle school students, 90percent of thestudents whowere services with aprimary diagnosis ofemotional disturbance. Approximately 25,663 of Texas students, or0.5 percent,received specialeducation education across allstates. A 2011-2012 report found that onaverage, 12.9percent of students areinspecial qualify. reasons, only 18 percent receive themental health treatmentforwhichthey or atrisk of beingremoved fromtheir homes orclassroomsformentalhealth Among Texas kidswitha diagnosed mental illness, seriousemotional disturbance Standrs & Progams Education Ply Fedral &St Curiclm Instrucioal Educationl Technolgy Materils & 653 a Educator Leship Fingerpt cts Educator Tesing Acountabily Quality Investigao & Certifcaon Mangemt Prepation Progams Educator Educator Progam 650 Deputy Comisnr Policy & – tional , 2014 RuleMaking &
& Progams
Texas PrmntScholFud Asemnt & Acountabily Governmtal Ris Genral Cous Perfomanc Asemnt Resarch & Reporting Studen Analysi 649 Chart Schol Imprvent Acreditaon During the same years, 8.7 percent of thestudent Charte Scols Improvent & Intervios Monitrg & Waivers Progam Suport Schol Comisner fEducat Texas Govrn Education ServCs & Chief Dputy Cordinat & Enforcemt Governac Resourc 655 Investigao Complaints &
Human Stae Fundig Finace Ofr Directo fCmunas Compliance Chief Scol Chief Advsor, Finacl Interal Audio Operations Policy and 656 Fiscal Compne Grants & Adminstrao Fedral isc Fedral isc Compliance & Monitrg Reporting Grants Finace &Admstro Deputy Comisnr Fedral 651,652
Agency Srvi Chief Fnacl Purchasing, Contracs & Of Education Acountig
Stae Bord Budget & Planig Oficer 654 Informati Techlgy/ Staewid Eucon CIO Dat Sysem / IRM/CDO TEA 223 In 661,662 Approximately 25,663 Approximately or 0.5 percent, students, special education received services with a primary diagnosis of emotional disturbance.
664 The 2011-2012 National The 2011-2012 663 mental illness, serious emotional emotional serious illness, mental of being removed or at risk disturbance for or classrooms homes from their only 18 percent reasons, health mental they health treatment mental the receive qualify for.” Survey of Children’s Health revealed that revealed Health of Children’s Survey children in Texas 500,000 an estimated percent but 40 needs, health mental have the receive not did children of these services. needed Schools have a long history of providing of providing a long history Schools have 75 to students; health services mental mental receiving of children percent The President’s New Freedom Commission Freedom New The President’s 665 Approximately 25,663 25,663 Approximately 658 Schools can provide convenient access to services for access convenient can provide Schools 666 According to TEA, 5,151,925 Accordingto TEA, 5,151,925
657 667
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 659,660 “Among Texas kids with a Texas “Among diagnosed mental illness, serious emotional disturbance risk ofor at being removed their homes or from for mental health classrooms only 18 percent reasons, the mental health receive they qualify for.” treatment An estimated one in ten school-agedone in youth children and An estimated condition that can negatively health mental or untreated an undiagnosed have and school attendance. behavior performance, classroom academic impact on Mental Health recognized the critical role that schools can play in the continuum schools can play critical role that recognized the Health on Mental health services. of mental 2009, Texans Care for Children reported that “among Texas kids with a diagnosed kids with a diagnosed Texas that “among Children reported Care for Texans 2009, In Texas, school mental health services may be provided by a number of professionals by be provided may health services mental school In Texas, school nurses, school counselors, including of training, a variety who have for Licensed has a special credential also Texas social workers. and psychologists, school counselors their name, Despite (LSSPs). in School Psychology Specialists are only tangentially duties that related to mental health. According many to have and Local School Districts School Local and Education Agency oversight (TEA) provides The Texas and functions for all primary and administrative districts school for the 1,245 public schools secondary of Texas. state in the Texas AgencyEducation Texas students were enrolled in Texas public schools during public in Texas enrolled were students year. academic the 2013-2014 students, or 0.5 percent, received special education received percent, or 0.5 students, diagnosis of emotional with a primary services disturbance. children and families in an environment less stigmatizing than a traditional mental than a traditional less stigmatizing an environment and families in children of mental health services varies by types access to various Though setting. health and level, location, academic as region, urban/rural such school characteristics of mental health screening, level offer some schools most population, student or services. referral health services receive them in school. them in services receive health TEA 224 percent of theirstudents received adequate counseling services. services to students. Nearly halfof the counselors in the study said lessthan25 to mental health services found that ruralschools struggle to provide mentalhealth school year. the 2010-2011 schoolyear and aratio of 462students per counselorinthe2011-2012 of 250 students per counselor, Texas hadaratioof 440 students percounselorfor recommends a ratio Although the American School Counselor Association (ASCA) conditions. associated with mental health conditions, andafailure to recognizementalhealth unable to provide access to mental health services due to lack ofresources, stigma approaches. Whilethese services are available acrossthestate, many districts are School-based mental health services encompass a widevariety of program Schools Mental Health Services in Delivery of to fully develop each student’s academic, career, personal, and socialabilities.” Texas law, “the primary responsibility of aschoolcounseloristocounselstudents Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Figure 97. MentalHealth ServiceDeliveryMethods below in Figure 97. to school. The different methods ofservicedelivery includetheservicesdescribed mental health service delivery lead to inconsistent mental healthcarefromschool role in providing mental health services to students. among childrenarehigher in ruralareas and thatschool counselors play acritical referenced prior research that said depression, substance use and suiciderates School District Mental Health Units or Clinics Health Services Formal Connections with Community Mental School Financed School-Based Mental Health Service Delivery 670 669 ADecember 2011 Texas A&M University-Kingsville study onaccess
consultation. cial and mental health services, training and staff health units or health clinics to provide psychoso- School districts may operate their own mental community agency. agencies to provide services at the school or the Agreements made with community mental health social workers. personnel, such as counselors, psychologists and ing that are provided on-site by licensed school programs and basic treatments such as counsel- Typically include mental health prevention Description 672 Barriersschoolsfacein 671 Thestudy also 668
TEA 225
678 673, 674 673, Examples 675 The Texas The Texas 676 Training teachers in Mental Training teachers in Mental 679 Models or frameworks utilized by an entire school entire an by utilized frameworks or Models the meeting to approach holistic a take that of examples Some ofneeds these students. all Interventions Behavioral Positive are approaches Learning Emotional Social (PBIS), Supports and ofEach these Care. Trauma-Informed and (SEL), detail more in discussed be will frameworks of remainder the throughout section. this Description prevention-oriented available make may Schools instruction teacher through provided materials social through learning enhance to designed and students. all for growth emotional and and activities multiple together bring can Districts of range full a provide to agencies community needs. health mental with students to services Legislative Session have the potential to improve to improve the potential Session have Legislative rd Interventions to address bullying show moderate success. The moderate success. show address bullying to Interventions 677 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 School-wide Behavioral and Emotional Support Support Emotional and Behavioral School-wide Frameworks School-Based Mental Health Service Delivery Delivery Service Health Mental School-Based Classroom-Based Curricula Curricula Classroom-Based Integrated and Multi-Faceted Comprehensive, Approaches most effective were intensive programs that avoided peer-based approaches and peer-based avoided that programs intensive were effective most supervision. playground and better firm discipline, parent meetings, included mental health support in Texas public schools. SB 460 (Deuell) requires all certified 460 (Deuell) requires all SB schools. public in Texas health support mental who are at and educating students in detecting to be trained teachers public school bill also specifically requires This needs. mental health other suicide or have risk for school health efforts. concerns in coordinated health of mental the inclusion programs created two grant (Coleman) HB 3793 changes, important other Among individuals and interested to available Aid training First Health making Mental the signs of individuals about teaches This training Texas. throughout educators mental abuse and of substance impact the addiction and mental health conditions, a situation assess plan to action a 5-step a crisis, to help in how conditions, health support. for additional and local resources and help, Education Code requires each school district to have an anti-bullying policy an that to have each school district requires Code Education bullying. prevent to and methods measures appropriate enforce educators ensures and parents, educators, administrators, a webpageTEA has developed to provide http://www.tea.state.tx.us/CSH_Bullying. about bullying: with resources students risk factors the same of share many and victims that bullies html. Research indicates their problem-solving skills and to improve interventions from benefit and could social interactions. Several bills passed during the 83 bills passed during Several Texas legislators and others have recognized the negative impact of bullying in impact the negative recognized have legislators and others Texas who the students percent of 90 students, middle school of 250 a study In schools. of the bullying. as a result side effects negative experienced were bullied Changing Environment Changing Health First Aid (MHFA) can strengthen the mental health support for all students. health support for all students. the mental strengthen can Aid (MHFA) First Health of these side effects include anxiety, low grades, and social rejection. grades, low include anxiety, side effects of these TEA 226 the country. services, thelowestpercentage in in Texas received special education thestudentpopulation percent of states. Duringthesameyears, 8.7 are inspecialeducation across all average, students 12.9percent of A 2011-2012report foundthat on www.dshs.state.tx.us/mhsa/sb831/. programs list istobeupdated annually and canbe found on the DSHSwebsitehttp:// identifying and addressing problems before they escalate. Thisbest practice-based the potential toreduce the cost of reactionary interventions for existing issuesby location. The emphasis on prevention and mental health promotion in the billhas of the bill istoprovide a way forschool districts toaccessinformationfrom acentral prevention and substance abuse prevention and intervention programs. Theintent recommendations, mental health promotion, positive youthdevelopment, suicide education setting. This list shouldprovide information on best practice-based best-practice programs for public schools that can beimplementedinthegeneral State Health Services (DSHS) to work together tocreatealist ofrecommended behavioral health conditions. provide MHFA trainingin 2015 forstaff whoserve students with emotional and training, and theDepartment of Agingand Rehabilitative Services (DARS) will has authorizedContinuing Education Units for educators who complete theMHFA students’ needs aswell as toprevent actsof violence by intervening sooner. TEA crisis hasthe potential to better prepare schools in theUStoidentifyandmeet 12,295 educators will undergo MFHA training inFY 2014.12,295 educatorswillundergo Special Education Services Special Education Services PBIS implementation is expected in 2015 for the 84 is anexample of thistype of approach. Legislative attention tosupportstate-wide the needs of allstudents. Positive Behavioral Interventions andSupports (PBIS) Schools are increasingly moving to proactive, coordinatedapproachestomeet at school. youthoccur data shows thatlessthan 1 percent of homicides among school-aged While some of theinterest inMHFA isdriven by fear over school shootings, recent Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas trainers. in MHFA, and asofJuly 2014, 353staff orcontractors werecertifiedasMHFA SB 831 (83 Support sections. Exclusionary Discipline and theSchool-wide Positive Behavior Interventions and information about PBIS canbe found laterin this chapter in theAlternatives to 682 680 rd TheDepartmentof State Health Services (DSHS)estimates 479staff and , Taylor) requires TEA, educationcenters, andtheDepartment of Training teachers to support and recognize mentalhealthneedsand 681 AsofJune 2014, 1,829educatorshadbeentrained A 2011-2012 report found that onaverage, 12.9 supports. may include mental health treatment and individualized educational plan (IEP), which education and related services based on an (IDEA) requiresschoolsto provide special Individuals with Disabilities EducationAct is impacted due toastudent’s disability, the conditions. Whenacademicperformance with emotional disturbance ormental health performance of allstudents, including those Schools are accountable for the academic 685 th Legislative Session. 683 684 More TEA 227
694 aid A Despite this Medic IDE 691 During the same same the During 686 Overall, spending Overall, 692 From the 1999-2000 school year the 1999-2000 From 687 Additionally, the percentage of students identified the percentagestudents of Additionally, 688 . Retrieved Retrieved districts. school local on impact cost – Act Education Disabilities with Individuals The reason for the percentagefor the The reason special in decrease h throug Funding tion h roug th Funding tion 689 a a As shown in Figure 98, local funding for schools must make up thismake for schools must funding local Figure 98, in As shown 693 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 Educ Educ To support schools with increased costs, the federal government committed government federal the support schools with increased costs, To 690 http://febp.newamerica.net/background-analysis/individuals-disabilities-education-act-cost-impact-local-school-districtshttp:// Declining State Support for Special Education Support Declining State 98. Figure years, 8.7 percent of the student population in Texas received special education education special received in Texas population student the of percent 8.7 years, percentage country. in the lowest the services, for special education programs has increased since the inception of IDEA and itsIDEA and of programs has increased since the inception special education for increasedspecial education has not funding for but national and state predecessor, proportionately. to contributing up to 40 percent of this anticipated additional cost. to contributing up to 40 In addition to funding from the federal and state government through IDEA, schools through IDEA, schools government and state federal from the to funding In addition Related Services and Health School services. eligible for certain Medicaid can bill Education Agency and the Texas of the coordination by is made available (SHARS) (HHSC).Services Commission and Human Health SHARS is a Medicaid Texas Source: New America Foundation. (2013). (2013). Foundation. America New Source: Special from febp.newamerica.net/background-analysis/individuals-disabilities-education-act-cost-impact-local-school-districts IDEA first passed in 1975 (as the Education for All Handicapped Children All Handicapped in 1975 (as the Education for passed first IDEA Act, PL created, the expected When IDEA was times. reauthorized multiple and was 94-142) to be twice as much as projected with special needs was of educating students cost require special education who do not students the national average of educating services. Special percent of students are in special education across all states. across all education in special are students of percent education enrollment in Texas is unclear and further research on this topic is needed research on this and further is unclear in Texas enrollment education and and national enrollment levels state between discrepancies understand to better to all children who need them. services provide all it can to is doing Texas to ensure with emotional disturbance in the special education population has decreased has decreased population special education in the disturbance with emotional and in Texas. nationally increase in necessary spending to meet the funding for services required by IDEA. required by the funding for services spending to meet increase in necessary commitment, the federal government has given less than half of their committed less than half of their has given government federal commitment, the year of funding in 1981. first financial support since IDEA’s to the 2011-2012 school year, the population of Texas students receiving special receiving students Texas of population the year, school 2011-2012 to the of students average national the while percent., 3.6 by services decreased education percent. only 0.3 by decreased TEA 2014 schoolyear. emotional disturbanceforthe2013- were identifiedashavingserious Over 25,000 Texas students 228 serious emotional disturbance forthe 2013-2014 schoolyear. mental health conditions. Over 25,000 Texas students were identifiedashaving receive specialeducation services are diagnosedwith emotional disturbance orother services under IDEA,and have anIEP. provided to students who are Medicaid eligible, qualifytoreceive specialeducation or contract qualified professionalsto provide these services. of atemporaryreaction to home, school orcommunity situations. also seek evidence that the student’s behavior and need for servicesisnot theresult In determining whether specialeducationserviceswillbeprovided, schoolpersonnel · · · · · free and appropriate public education under IDEA. 3-21withdisabilitiesEligible children andadolescentsages areentitledtoreceive Eligibility already exist. Medicaid fundingismet by usingstate and localspecialeducationallocationsthat provided to students in special education. The state match requirement for SHARS (ssa’s) toobtain Medicaid reimbursement for certain health-related services financing programthat allows local schooldistricts/shared servicesarrangements Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas health include assessment, medical services todiagnoseorevaluate astudent’s depending on the student’s needs. Someexamples of servicesrelated to behavioral ofsupports Special educationand related services can include a wide range Special educational performance: degree over anextended period of time inways that adversely affect the student’s student exhibiting one ormore of thefollowing characteristics toamarked Eligibility to receive servicesforserious emotional disturbance isbasedonthe special transportation and personal care services. occupational therapy, physical therapy, psychological services, speechtherapy, include assessment,audiology, counseling, school health services, medical services, or socialproblems. todevelop physicalA tendency symptoms, pains or fears associatedwithpersonal mood ofunhappiness and depression. A general Inappropriate types of behaviors or feelings under normalcircumstances. An inability to relate appropriately to peers and teachers. impairments. An inability to learn that cannot beexplained by intellectual, sensoryorhealth Educ 695 School districts/ssa’s must enroll as Medicaid providers andemploy f or a tion Special 701 Services school. with half of thispopulation dropping out of high disturbance have thehighest rateof school failure, students identified ashaving seriousemotional are not reflected in thesenumbers. Nationwide, health needs, suchasanxiety ordepression, that disabilities and autism)thatalsohave mental on other primary disabilities (e.g.intellectual students who receive special education based Educ 700
and a 697 tion 698 SHARS services must be Service Anumberofstudents who 696 699 SHARS services Thereareother Utiliza tion tion TEA 229
Legislature passed HB 617 rd
States decide what to call this category, how to define it, and to define it, how call this category, to decide what States 703 The following are possible diagnostic areas that can fall under areas that can fall diagnostic are possible The following 702 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.transitionintexas.org/site/default.aspx?PageID=1 PPCD services are provided in a variety of settings such as pre-kindergarten, of settings in a variety PPCD services are provided
resource classrooms, self-contained classrooms, or community settings such as Head such as Head or community settings self-contained classrooms, classrooms, resource pre-school. Start and with special needs transitioning bridge to worked has also students a gap for Texas services with special education who receive students assist To high school. out of such as activities, post-school to appropriate school from transition a successful independent and employment or integrated education, or vocational postsecondary their and planning with students transition individual begin schools must living, courses and related needed to identify are required Schools age 14. families by through adult living objectives and to develop education for postsecondary services services transition quality of and comprehensiveness The availability, the IEP. 83 The state. widely across the vary in Texas available (Rodriguez) which requires school districts to assign at least one employee to provide provide to one employee least to assign at school districts which requires (Rodriguez) receiving special education services. to students services and employment transition through their transition information available to make also requires districts The bill website the broad category of developmental delay: physical development, cognitive cognitive development, physical categorythe broad delay: of developmental or development, social or emotional development, communication development, development. adaptive Texas names this development delay category delay “Non-Categorical this development names Early Childhood” Texas agesthe as able to qualify of three and five children between and designates (NCEC) category Children who fall under the NCEC category. delay under this developmental for Children with called Preschool Program a program services through are provided children category, the NCEC through to eligibility (PPCD). In addition Disabilities specific diagnoses: following under the PPCD services also qualify for may in Texas or Learning Disability, Specific Disturbances, Emotional Disability, Intellectual Autism. It is often difficult to diagnose a young child, and there are children without a specific children without there are and child, a young diagnose to It is often difficult bridgeTo the gap for early intervention. benefit from still diagnosis who would receive would often not diagnosis and a specific have do not children who young for children between IDEA allows in Kindergarten, school before entering services the agesservices under a broader education for special and nine to qualify of three category delay” “developmental called instruments proper the with if diagnosed and procedures. disability, counseling, case management,case counseling, skills training, and counseling parent disability, reasons. educational for treatment and residential classes specialized training, to available multiple services there are services, health to behavioral In addition other and conditions, physical delays, to developmental that are related students supports provided and services special education types of The of disabilities. types (ARD) meeting and dismissal review, admission, an annual through are determined personnel. An individualized and school or caregivers, parents student, with the supports and behavioral specify the to is developed plan (IEP) education for the student. school district the by provided be to interventions what agesin this category. to include TEA 230 information, visit the Region XIIIwebsite at http://www4.esc13.net/behavior/. campuses with technical assistance in theareaof behavior supports. For more Team and special education specialists that has general whofocusonproviding Additionally, theRegion XIII Education Service CenterinAustin hasaBehavior the Region IV website at http://www.esc4.net/default.aspx?name=ses.behavior the needs of students with behavior challenges. For moreinformation, refer to ofenhancing the education experience for allstudentswith the goal andaddressing in Houston specializes in Positive Behavioral Interventions andSupport(PBIS) to schools across thestate. For example, the Region IV EducationService Center IDEA. Servicecenters may alsospecialize in aparticularareaand offer thatexpertise is shown in Figure99. This infrastructure also supports schools incomplyingwith including special educationandbehavioral support. A mapofservicecenterregions technical assistance to all school districts throughout the state inavariety of areas, Created in 1965, 20 regional educational service centers inTexas provide supportand Educ Those mentalhealth service structures and related programs are described below. districts, but there are certainmental health services available acrossthe state. services. Mental health supports and servicesvary between individualschoolsand in anIEP, thereare students population who receive mental health in the general population. Although schools are not required to provide theseservices unlessstated Plan (IEP). Mental health services are not education required for thegeneral special educationservices if thoseservices are part of their Individual Education Mental health services are required by law tobe provided for students who receive Schools Mental Health Support Systems for Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas a tion Service Centers . TEA 231 http://ritter.tea. Retrieved from from Retrieved Model h alt
The Coordinated School Health Model is directed Model School Health The Coordinated 705 Snapshot 2012 service tables: Education service center region. region. center service Education tables: service 2012 Snapshot ool He School The Department of State Health Services (DSHS) State Health of The Department 704 ted 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 oordin by a mandatory, multidisciplinary team, known as the School Health AdvisoryHealth as the School team, known multidisciplinary a mandatory, by on serve to the school district by are appointed members (SHAC). SHAC Council School Coordinated the district’s for recommendations make and level the district for program quality and community to the accountable SHAC is Model. Health effectiveness. of eight health- consists Health School for Coordinated Model The 8-Component together that are linked the school environment all aspects of areas covering related entire the benefit of the to system effective a unified, as and coordinate to function is one of the core Services” Health Mental and “Counseling school community. health services in schools. of mental importance the demonstrating components, defines coordinated school health as “an integrated, systematic set of planned, set systematic integrated, health as “an defines coordinated school advance services designed to activities and strategies, sequential, school-affiliated social emotional, physical, optimal their promote and academic performance student and educational development.” state.tx.us/perfreport/snapshot/2012/region.srch.html. Coordinated of TEA’s element a core are health services mental and Counseling Model. Health School Source: Texas Education Agency. (2012). (2012). Agency. Education Texas Source: C Map of Education Service Center Regions of Map Regions Center Service Education 99. Figure TEA 232 students from theprevious biennium. number of students from CISby able toreceive casemanagement morethan50,000 Legislative Sessionfor the 2012 and2013 fiscalyears, dramaticallyreducingthe fiscal years. the $6 million cut in theprevious session was restored for CISthe2014 and2015 Interventions School mental and emotional problems in children. number of states including Texas are promoting positive approachestopreventing positive environments and bolster students’ social andemotional competencies. A Several key classroom-basedstrategies for allstudents seek to build respectful, with risk factors, andindividualized services for students withextensive needs. include campuswideprevention activities, targeted earlyintervention forstudents coordinated approaches to meet the needs of all students. These initiatives generally all students’ developmental needs. Schools are increasingly moving toproactive, and trained professionals, thereare also modelsthat provide holistic support for While some students with mental health needs require tailoredinterventions Health Holistic Approaches to Student Mental in 129 schooldistrictscase management throughout Texas. CIS served 603,697 students withschoolwide basic support and63,730 students with counseling, and other mental health-related services. Inthe2012-2013 schoolyear, through state andlocal support. CIS provides individualizedcase management, Communities in Schools (CIS), isanational dropout prevention programfunded C Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · · individual responsibility. Theprogram consists of the following three tiers: to replace a punishment-oriented system with a campusculturebased on respect and and reinforce appropriate behaviors for allstudents. SWPBISprogramsare designed SWPBIS is an evidence-basedframework that uses a three-tieredapproachto teach an illustration ofthis model. wide Positive Behavioral Interventions and Supports (SWPBIS). SeeFigure100for A well-known example of aproactive framework of school-based servicesisSchool- amount of students as inthe2010 and 2011 fiscal years. 2015 than the previous biennium; however, funding isstill too short toserve thesame during the 2012-2013 schoolyear. of the students services fromCISstayed receiving case management inschool ommunities in Tier 2,the secondary prevention level, focuses on the10 percent to 15percent of and school personnel are expected to follow. Teachers use a curriculum to teach social skillsandexpectationsthatallstudents Tier 1, the primary prevention tier, isfor80 percent to 90 percentofstudents. 711 Thisrestored fundingallows CISto serve morestudents in2014 and Wide Positive Beha and Schools 708 Supports CISreceived over $6millionlessfromthe82 709,710 During the 83 713 vior 712 al
rd Legislature,$5millionof 706,707 Allbut 2 percent nd
TEA 233
717 718 In 2009, more than In 2009, 716 Implementation blueprint and self-assessment: Positive behavioral interventions and supports. and interventions behavioral Positive self-assessment: and blueprint Implementation 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 Technical assistance to implement SWPBIS is available through through SWPBIS is available implement to assistance Technical 714 . https://www.pbis.org/Common/Cms/files/pbisresources/SWPBS_ImplementationBlueprint_vSep_23_2010.pdf TBSI was designed to build capacity in Texas schools for the provision schools for the provision Texas capacity in designed to build TBSI was 715 students who have risk factors such as exposure to violence or loss of a loved one a loved or loss of violence to exposure as factors such risk have who students health mental developing of risk a higher-than-normal have them to cause that protective skills and increasing developing focus on Interventions conditions. their families. and for students factors of 5 percent to percent on the 1 focuses level, tertiary prevention the Tier 3, includes support and of system an in-depth who need population the student or severe with the most students for intervention individualized comprehensive, chronic issues. of positive behavioral interventions and supports to all students. TBSI training to all students. and supports interventions behavioral of positive wide rangea and implementing in developing campus teams of modules assist interventions. prevention-based and strategies behavior Texans Care for Children, a child advocacyfor Children, Care organization, recommends SWPBIS as an Texans Source: Technical Assistance Center on Positive Behavioral Interventions and Supports, U. S. Department of Education, & Office of Office & ofEducation, Department S. U. Supports, and Interventions Behavioral Positive on Center Assistance Technical Source: (2010). Programs. Education Special from Retrieved Education Agency utilize SWPBIS school districts that recommends The Texas related required to use it or other are not but schools behavior, student to address approaches. Continuum of School-wide Instructional & Positive Behavior Sup- of Continuum Positive School-wide Instructional & 100. Figure port · Schools that implemented the model have achieved favorable outcomes including favorable achieved model have the implemented Schools that restraints. use of physical disciplinary referrals and less reduced 800 schools were actively participating in the PBSI trainings facilitated by TBSI. PBSI trainings facilitated by in the participating were actively 800 schools regional educational service centers and the Texas Behavior Support Initiative Support Initiative Behavior Texas and the centers service educational regional (TBSI). TEA 234 hire additionalstaff to implement SELinaschool. choose from a variety of proven, effective SEL programs, but itisnot necessary to with an SEL program are staff training and student surveys. and conduct problems. high school and have the ability to improve dropout rates, truancy, substance abuse, working with individuals does not re-traumatize them. of trauma survivors,triggers and uses this understanding toensureitsapproach in An organizationthat is trauma-informed also understands thevulnerabilitiesor made during the 84 toward statewide support for SWPBIS. These recommendationsareexpectedtobe planning stage and are expected to make recommendationsfornext steps tomove the support of SWPBIS implementation on a state-wide level. Theexpertsareinthe for Children organized experts across the state to explore how Texas canfacilitate implemented SEL with over half of thetotal students enrolledinAISD. docman&task=doc_download&gid=867&Itemid=. Rules, Break Budgets,athttp://www.texasappleseed.net/index.php?option=com_ information on potential costs can be found in theTexas Appleseed report,Breaking implement a PBISprogram.There are variables that canaffectthisnumber, and of itsstudents by the 2015-2016 school year. is tohave all schools using SEL as aframework to holistically meet theneeds of all and ethical. appropriately settle conflicts, work moreefficiently, and make decisionsthatare safe productively withothers, develop positive relationships, copewiththeiremotions, Social and Emotional are tohelpstudents Learning’s(SEL) main goals workwelland Social behavior. evidenced-based approach to support all students, especiallythosewith challenging Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Many childreninTexas public schools have experiencedtraumainsomeform. Tr organization takes steps to understand how trauma affects thelifeofan individual. help change theschool’shelp change approach to working with students. given hope relating to theirown recovery; that there isaconnectionbetween trauma trauma-informed organizations recognize that survivors need to berespectedand of teachers and other school personnel who interact with children.Ingeneral, an overarching concept thatcanbe implemented through the educationandtraining properly socially interact with their peers. this canlead to anxious behavior that interferes with thechild’s abilityto learn and Children whohave experiencedtrauma may seethe world asathreateningplace,and per year. The cost to implement a schoolwide PBIS program could beas low as$23,000 organizing framework for other interventions, several ofwhicharedescribedbelow. Positive Behavior Intervention andSupports is amodelthatoftenserves asakey found at first districts inthecountry tomake thiscommitment. School District (AISD)hascommitted to incorporate SEL initsschools, oneofthe a uma-Inf 721 http://www.casel.org/social-and-emotional-learning/. 719 Thiscost includescompensation forstaff, training,andresourcesto Withagrant from the Hogg Foundation for Mental Health, Texans Care 722 and Effective SELprograms canbeimplemented frompreschoolthrough th ormed Emotional Legislative Sessionin 2015. 723 SELisnot aspecificprogram;rather itisaframeworkto Care Le 731 729 Trauma-informedcare is whenanentire arning More informationabout SEL canbe 720 725
Theprimarycosts associated 727 733 In2013-2014, 73schools Trauma-informedcare is 726 724 Austin Independent Schools can 728 AISD’s goal 730
732
TEA 235 738 Three-fourths of Three-fourths students who qualified for special had education been suspended or once. least at expelled
735
741 742, 742, 737 737
736 Session but the efforts to rd 740 For more information about trauma-informed care, refer to care, refer trauma-informed about information more For 734 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
739 915 students expelled to the streets expelled 915 students 549,305 students sent to In-School sent students (ISS) Suspension 549,305 81,104 students sent to Disciplinary Alternative Education Programs (DAEPs) Alternative to Disciplinary sent students 81,104 Education Programs Alternative Justice to Juvenile sent 2,819 students (JJAEPs) 248,266 students sent to Out-of-School sent students 248,266 (OSS) Suspension The researchers also found that students who had been who had students that also found The researchers · Breaking School Rules: A Statewide Study of How School Discipline of How Study A Statewide School Rules: Breaking , Involvement Justice and Juvenile to Student Success Relates State Council of The by conducted study Texas 2011 a key Research Public Policy Center and the Justice Governments three-fourths of found that University, A&M at Texas Institute suspended had been special education who qualified for students with emotional diagnosed Students once. at least or expelled or expelled. to be suspended more likely were even disturbance suspended or expelled were significantly more likely to drop out to drop out likely more significantly were or expelled suspended The system. justice juvenile in the involved or become of school special education who receive of students over-representation from classrooms for disciplinary removed students of population among the services 83 during the attention legislative reasons received · the Texas Environment and Best Practices sections. sections. Practices and Best Environment the Texas · · or discretionary. mandatory can be disciplinary structures to these Referrals performs a occur when a student code, state by determined referrals, Mandated from the classroom. the removal automatically requires act that specific widely from vary policy, school district by determined referrals, Discretionary teachers or administrators made by are referrals Discretionary district. to district These policies can be vague, code of conduct. local student in their policies based on should behaviors what and how determining when for wide interpretation allowing law; by mandated be disciplined. A largedisciplinary referrals are not of majority of school districts. discretion the they are authorized at instead, Exclusionary Discipline in Schools in Discipline Exclusionary from students that remove practices in schools includes discipline Exclusionary from common, daily students classroom excludes from the the classroom. Removal schools law, state Under development. in student often helpful that are experiences education, to in special those even students, or expel remove to option the have alternative justice or juvenile programs (DAEPs) education alternative disciplinary Texas of thousands school year, In the 2012-2013 programs (JJAEPs). education following: to the and sent from the classroom removed were students and trauma symptoms (e.g., substance abuse or depression); and that collaborative collaborative that and or depression); abuse substance (e.g., symptoms trauma and human and other family, and friends their survivor, the with to be done needs work service organizations. 743 legislate change were unsuccessful. The proposed legislation would have required changelegislate legislation would have The proposed unsuccessful. were special education who receive of students the number data on TEA to examine · TEA 236 the services outlined in theIEP. serves astudent with an individualized education program (IEP)must provide of conduct. suspend a student from school forengaging in conduct identifiedinthe school’s code the Texas Education Code, the principal or other appropriate administrator may also percent of allstudents sent to OSS. education services but represented 14 percent of allstudents sent to ISSand17.8 In 2012-2013, 8.7 percent of allstudents in Texas publicschoolsreceived special cost impact on schools. their own or may join together to support a cooperative program. Every Texas school district is requiredto provide aDAEP. Districts may operate Disciplinary Alterna may be required toremain off campus foraspecified periodoftime. classassignmentsor or more days toaseparate ISS classroom to complete his/her A disruptive student can be removed from the regular classroom and assignedone School In-School actionatschool. services and weredisciplinedbasedon discrepancy Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas (D 5. 4. 3. 2. 1. frequently DAEPs are housed atseparate campuses. rural districts, aDAEP may be a separate classroom on theschoolcampus, butmore infractions: Education Code. Astudent’s removal to aDAEP is For DAEPs, certain infractions requiremandatory removal accordingto the Texas MANDATORY V. DISCRETIONARY REMOVAL poorly served by under-resourced programs.” programming and instruction varies among districts, with somestudents inDAEPs there has been little monitoring and oversight of DAEPs,“because thequalityof perfect attendance. school receives 5percent less funding for that student thantheydo for astudent with special educationservices. services but 17.5 percent of students referred to DAEPs werestudents receiving shows that 8.7 percent of allTexas public school students received special education services are alsooverrepresented in referralsto DAEPs. TEA’s data for 2012-13 Making a terroristic threatorafalse alarm/report. retaliation against aschool employee. Committing anoffense thatinvolves volatile chemicals, public lewdnessor alcohol. drugor Selling, giving, possessingorbeing under the influence ofadangerous Assaulting another student orschool employee. Committing afelony orengaging in conduct punishable asa felony. AEPs) 745 754
Suspensions (OSS) Suspensions (ISS) 748 747 Ifastudent misses nine days inthe 180-day schoolyear, the 753
751 TheBreaking School Rules study foundthat 746 ISSandOSS can leadto significant, negative tive Educ 752 Studentsreceivingspecialeducation mandated and 750 a Additionally, aDAEP that tion Progr Out-of- for thefollowing 749 Insmaller, 744 According to According ams TEA 237 Many school districts Many school districts the have exercised under the latitude Education Texas their to enforce Code own student codes as of conduct and, almost 61 a result, DAEP Texas ofpercent student placements discretionary. are treets
S 763 tion a
Legislative intent in creating Legislative Educ 756 758 Many school districts have exercised exercised have school districts Many
757 755 The primary goals of JJAEPs are to The primary goals of JJAEPs tive 759 e th to xpulsion E School districts without a JJAEP may send expelled students to students send expelled may a JJAEP without districts School Ps) / JJAEPs) 761 a Altern Justice 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 However, the Texas Juvenile Justice Department publishes data that publishes data Department Justice Juvenile the Texas However, 762 ms ( ams Students younger than 10 cannot be sent or expelled to a JJAEP; instead, instead, to a JJAEP; or expelled be sent younger Students than 10 cannot 760 Failure to provide a learning environment equivalent to equivalent environment a learning provide to Failure campuses. mainstream and staff. instructors for DAEP training Inadequate and DAEP between alignment instructional Lack of campuses. mainstream home campus student’s a between communication Insufficient and DAEP. return upon a student’s programming of transitional Absence DAEP. from a Failure to staff the DAEP with certified teachers. certified with DAEP the staff to Failure they are to be sent to a DAEP for conduct that would result in expulsion for children would result in expulsion for children for conduct that to a DAEP are to be sent they and older. 10 years JJAEPs was “to provide continuing educational opportunities for students expelled students for opportunities educational continuing provide “to was JJAEPs serious offenses.” for the most from school provides some understanding of how long students spend in a JJAEP. In 2012-2013, In 2012-2013, JJAEP. spend in a long students of how some understanding provides 80 days. was JJAEP in a students for all of stay length the average the latitude under the Texas Education Code to enforce their own enforce their own Code to Education Texas under the the latitude of 61 percent almost as a result and, of conduct codes student discretionary. are placements student DAEP Texas Questions have been raised about the quality of education quality of about the been raised have Questions Board Budget the Legislative In 2011, in DAEPs. services provided DAEPs: about concerns the following expressed DAEPs or opt to send them “to the street” by having students serve the length of their serve students having by street” “to the send them to or opt DAEPs a school setting. outside and unsupervised expulsion amounts of time of or maximum minimum set that standards no statewide There are regarding time spent districts school across is wide variation there thus, expulsion; in a JJAEP. Progr Juvenile Justice Alternative Education Programs (JJAEPs) were created during the were Programs (JJAEPs) Education Alternative Justice Juvenile ongoing services for students educational in 1995 to provide Legislature Texas 74th than 125,000 a population of more with county Every expelled. been who have boards with oversight juvenile by are operated JJAEPs a JJAEP. have must residents expelled is when a student thus, Department; Justice Juvenile the Texas by provided system. justice the juvenile they enter to a JJAEP, Juvenile · · · · · · As with suspensions, Texas schools also have wide discretion to send students to a to send students to discretion wide have also schools Texas suspensions, As with on the Depending of conduct. code student in their listed offenses other for DAEP range can these offenses disrupting to and gang activity “fighting from school district, hallway in the a tennis ball such as throwing a prank playing profanity, using class, decal, school parking a misusing student, another missing and narrowly to school, or doodling drug or over-the-counter a prescription bringing inadvertently a weapon.” contains the drawing in class when “reduce delinquency, increase offender accountability and rehabilitate offenders and accountability increase offender “reduce delinquency, probation juvenile community-based coordinated a comprehensive, through system.” TEA expelled. than 2.5timesaslikely tobe education studentsare more expelled andHispanicspecial three timesmore likely tobe special education studentsare population, AfricanAmerican compared tothewholestudent Appleseed revealed that A 2010report by Texas 238 ued todecreasein2012-2013 toatotal of 3,831 expulsions. expulsions in 2006-07, expulsionsdropped to 8,202 in 2008-09. Expulsionscontin- The most recent national data shows thatwhile Texas educates about 9percentofall JJAEP re-offendedwithintwoyears. for “serious orpersistent misbehavior” or engages inserious criminal behavior.or engages Mandatory expulsions occur when a student uses, exhibits, orpossessesaweapon removal to DAEPs, students canbe expelled for mandatory or discretionary reasons. into JJAEPs andexpelled 893 students to thestreets. In the 2012-2013 school year, Texas school districts placedover 2,800students Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas nile justice system.” behavioral problems, but leadsto increased risk for future involvement in thejuve- students in JJAEPs not for‘serious or persistent onlyfailstocorrect misbehavior’ ofdiscretionarylargest percentage expulsions. Texas Appleseedfoundthat“placing Discretionary representthe expulsions for “seriousorpersistent misbehavior” discretionary expulsion of students. discretionary reasons suggest awidevariation in schooldistricts’ policiesgoverning trend of expulsions between the 2002-2003 and 2012-2013 school years. placements are for discretionary reasons. The majority of expelled students are sent to aJJAEP, and55percentofJJAEP on ateacheroremployee, to “serious orpersistent misbehavior inaDAEP.” from serious criminal offensesthat occurwithin 300feet fromtheschool,to assault districts in Texas, about half didnot expel any students in 2007-08. not correlate with the number of student expulsions. Of themorethan1,000 school JJAEPs atahigher rate than others. Moreover, thesize of theschooldistrict does 769 About 71 percent of students who wereinitiallyexpelledtoa are more than 2.5times as likely to be expelled. to be expelled and Hispanic special education students special educationstudents are three times more likely the whole student population, African American report by Texas Appleseed revealed that compared to accounted for 15.6 percent of all expulsions. percent of thestudent population in Texas but students receiving special education made up only 8.7 between 2007 and2009. From ahighof 11,135 total 26 percent decrease in expulsions from Texas schools five-year periodbetween 2002and2007, there was a street, increased approximately 38 percent during the While total expulsions, whether to a JJAEP ortothe from the nation’s public schools. for approximately 12percentofthe students expelled childrenintheU.S.,school-aged thestate isresponsible 766 768 Discretionary expulsionsvarywidely Themajorityofexpulsionsoccurringfor 764 Someschooldistricts use 774 Figure101 shows the 771 In2012-2013, 765 Similar to 772 767 A2010 770 773
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778 779 http://ritter.tea. anors ;Texas Education Agency. (2006-2013). Discipline (2006-2013). Agency. Education ;Texas Although the goal of JJAEPs is Although the goal of JJAEPs 775 Misdeme C ss Class Furthermore, students sent to a DAEP or a JJAEP or a JJAEP a DAEP sent to students Furthermore, 777 For example, students who have been sent to ISS, OSS, or a DAEP a DAEP or OSS, ISS, sent to been who have example, students For 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 776 http://www.tea.state.tx.us/acctres/Comp_Annual_2005.pdf icketing – Ticketing ; Texas Education Texas ; http://www.texasappleseed.net/index.php?option=com_docman&task=doc_download&gid=380&Itemid to rehabilitate and integrate students back into a mainstream school environment, school environment, into a mainstream back students integrate to rehabilitate and to increase levels been linked have programs education the mentioned alternative of delinquency. are more likely to be sent to a JJAEP than those who are not referred to one of these referred to who are not those than JJAEP sent to a to be likely are more actions. discipline exclusionary About 80 percent of adults in the criminal justice system dropped out from school. dropped out system criminal justice adults in the 80 percent of About While these correlations do not imply a direct causation of exclusionary discipline of exclusionary a direct causation imply do not correlations While these of the effectiveness question call into statistics these in incarceration, resulting a back into rehabilitating students in successfully JJAEPs and DAEP, OSS, ISS, School-to-Prison Pipeline: School report Texas’ The setting. educational mainstream at http:// and is available expulsions, Texan on detail greater , provides Expulsion - www.texasappleseed.net/index.php?option=com_docman&task=doc_down load&gid=380&Itemid=m School low level students for to can issues tickets resources officers school law, Texas Under for Class C misdemeanors arrest in lieu of are citations tickets These misbehavior. court. The in municipal or J.P. to appear and a parent the student and require right to a have does not student and the proceedings criminal are public proceedings jail time. punishable by are not Class C misdemeanors because an attorney hearing focused on school Committee Criminal Justice a Senate 2010, In April the hearing During use of ticketing. practices including the high disciplinary state.tx.us/adhocrpt/Disciplinary_Data_Products/DAG_Summaries/Download_State_DAG_Summaries.html Many experts agree that there is a school-to-prison pipeline for many students who students pipeline for many is a school-to-prison that there experts agree Many practices. discipline exclusionary to are referred Sources: Texas Appleseed. (2010, April). Texas’ school-to-prison pipeline: School expulsion –the path from lockout to dropout. Retrieved Retrieved dropout. to lockout from path –the expulsion School pipeline: school-to-prison Texas’ April). (2010, Appleseed. Texas Sources: from Education Texas the from Legislature Texas 79th the to report A schools: public Texas on report annual Comprehensive (2005). Agency. from Retrieved Agency. from Retrieved groupings. action discipline by actions discipline and ofstudents counts 2006-2013 products: data Texas Public School Expulsions from 2002-2013 from Expulsions School Public Texas 101. Figure are more likely to drop out from school and enter the adult criminal justice system. criminal justice the adult and enter out from school to drop likely are more TEA 240 double their representation of the total student population. districts, students receivingspecial education were ticketed at a ratemorethan ticketing included abreakdown ofthe special educationpopulation. Inboth ofthese receiving Class Cmisdemeanors. receiving special education services are overrepresented inthenumberofstudents student’s 17 tickets cannot afford. Failure topay fines couldresult ina warrant forarrest uponthe they can also cost upto $500, afinancial burden many familiesof students receiving fighting. Not onlydo thesetickets insert students intothecriminaljustice system, issued for behaviors such as disrupting class, andin-school inappropriatelanguage, or neglect; family disorganization; teen pregnancy; poor academic performance; or neglect; family disorganization; teen pregnancy; or other factors that pressure students to stay at homewithfamily; childabuse inadequate identification of students withspecial needs;financial,social,medical, the criteria for FTAS, such as unsafe school environment; poorschoolclimate; school, family, community, and student factors that might cause astudent tomeet Class Cmisdemeanor tickets wereissued to students. ten of more days inasix month period or three more days inafourweekperiod. truancy. to theTexas According Education Code, youth commit FTAS ifthey miss A particularlytroubling type of ticket isfor Failure toAttend School(FTAS), or school discipline. Others expressed concern that the justice system was becomingasubstitute for committee members expressed concern that the useof ticketing was not effective. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas non-court options such as tutoring or counseling. C misdemeanor, andthat prosecutors consider disposingofanoffensethough other students to first-time inactivityatthe level ofaClass offenderprograms ifengaged also require that schools explore alternatives to issuing tickets, forexamplereferring ordismissed.Thebills the court, the complaint can then be filed asacriminalcharge paperwork to besubmitted with the complaint. Once the complaintisevaluatedby complaint states criminal offense andrequires additional the facts ofthe alleged to tickets) forClassC misdemeanors to be issuedby schoolofficers. Acriminal misdemeanors, excluding traffic violations, byonly allowing complaints(asopposed West) work together to prohibit school officers fromissuingtickets forClass C misbehavior. SB393(West, and Hinojosa, andWhitmore) and SB1114 (Whitmore increasing number of students receiving Class C misdemeanorsforminor During the 83rd Legislative Session, two billswere passed thataddressedthe and fines donot appear tobean effective method inaddressing FTAS. that addressedtheroot causes underlying FTAS. review that found the most werethose effective approaches toreducetruancy The Office of Juvenile Justice Prevention publishedaliterature andDelinquency of fines usuallyfallson familiesthat arealready underfinancial strain. possibility of negatively impacting future schooling and/or employment. The burden Some students end up withacriminal conviction on theirrecord,whichhasthe through theformalcourtsystem.may be further alienated from school while going Misdemeanors in 2011, were forFTAS. juvenile court. Texas Appleseed found that 34 percent, or about 76,000 of ClassC court forum, where students are not given many ofthe protections available ina FTAS asa Class CMisdemeanor to be processed inan adult criminal can be charged th birthday. 780 In2012, the Texas Supreme Court estimated that300,000 784
782 Only two schooldistricts’ reportsof school 787 Criminalization,theuseofformal courts, 789 785 Thereisawidevariety of 781 Data suggests thatstudents 783 Thesetickets were 788 Students 786
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790 Truancy Reduction: Additionally, police officers are police Additionally, Corporal punishment can cause Corporal 794 792 http://www.ccyj.org/uploads/PPO/ 791 TEA requires each school to have a team each school to have TEA requires 795 Schools
793 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 Force in Force Legislature passed three bills that begin to address the need to improve address the need to improve begin to bills that three passed Legislature rd Community collaboration Community involvement Family retrieval & intervention Prevention, approach: Comprehensive and sanctions Incentives education, political public community, agency, school, context: Supportive advocacy systemic laws and policies, climate, evaluation Program of school staff trained in restraint that is appropriate for youth. Specific school staff school for youth. Specific appropriate that is restraint trained in staff of school mandate not does but current law this team, part of to be a are required positions officers. of school participation and youth are designed to divert (CIT) for children Teams Crisis Intervention services and supports health to appropriate needs health with mental individuals serious injury, psychological harm, and academic disengagement; an and academic harm, it is not psychological serious injury, practice. evidence-based The variety of root causes that may lead to school truancy requires a multi-faceted truancy to school lead that may causes multi-faceted a requires of root variety The to address in an approach used The specific techniques to address FTAS. approach truancy themes each approach some common are but there to case, case differ from should incorporate. six components the following recommends Justice & Youth for Children The Center truancyfor effective programs: reduction approaches used to reduce cases of FTAS. HB 1470 (Villarreal) HB 1470 the established FTAS. cases of to reduce used approaches truancyto recommend uniform certain counties in a committee for requirement case managers for juvenile funding court through provided (West) SB 1419 policies. fund. SB 1234 (Whitmire) a truancydiversion and prevention and established costs of truancy prevention related to the of FTAS. offense and the law previous amended to truancy policies related schools prevention, to improve attempt bills While these for FTAS. issue Class C Misdemeanors authorized to are still not required to have restraint training. restraint to have required not se of Use is permitted. punishment corporal whether determine districts school In Texas, leads the nation with the Texas According data, Office of Civil Rights to federal with and student punishment corporal receiving students number of highest disproportionately. being punished disabilities · · · · · · Justice, & Youth for Children The Center by report The full at found , can be and Practice Policy, Research, . TRUANCY_Updated_July2012.pdf The 83 low school attachment; lack of self-esteem; and unmet mental health needs. health mental unmet and lack of self-esteem; attachment; school low Use of force by school police officers is also a concern. School police officers often a concern. is also police officers school Use of force by care, agein trauma-informed required training appropriate discipline have do not appropriate techniques for or disabilities, or emotional with cognitive for youth settings. child-centered specific to de-escalation TEA 242 and de-escalationtechniquesspecific to students experiencingacrisis. role-play scenarios that allow officersto gainpractical experienceinactive listening detention;issues relatingtoschool environment and and minors and emergency youth; psychotropic medications; family perspective andcommunityresources;legal mental, learning and developmental disorders and substance abuseinchildrenand in school campus environment; active listening and de-escalation techniques; received any CITtraining. The CCIT includes educationonofficertacticsand safety Education Units (CEUs) for schoolresource officers who have not previously Commission on Law EnforcementOfficer Standards andprovides Continuing Training (CCIT) foruse in schools. The 40-hour trainingisapproved by theTexas the exclusionary discipline practices currently being usedby Texas publicschools. and improvement of student behavior andhave proven tobe more cost effective than Care provide evidence to support the socialand emotional development ofstudents Interventions and Supports, Social and Emotional Learning, and Trauma-Informed $31 million in 2010-2011. Texas Public Schools. Discipline in Texas, academic costs, theyalso have ahighfinancial cost. In theirreport Not only do exclusionary discipline practices have developmental, behavioral, and Alterna report was dueSeptember 1, 2014. and making recommendations ofbest practice based onstudy results. The task force Force. with studying The task force was charged multi-hazardschool safety practices during the 83rd Legislative Session, SB 1556(Davis) created a School Safety Task was anunsuccessful legislative attempt toban Tasers and peppersprays inschools A particular concern is theuseof Tasers and pepper spray inschools. Althoughthere public. to the Texas Police Chiefs Association (TCPA). The policies arenot shared withthe follow the best practice to have about use offorce,according some formof policy information it provided. Texas Appleseed found that most schoolpolicedepartments ISD, EdinburgISD, ElPaso ISD, thisdatavariedwidelyinthe and Houston ISD—and officers, but wasonly ableto obtain information fromfour schooldistricts—Austin Texas Appleseedrequested information from schools about theuseofforceby school to asuccessfulprogram. partnerships to support youth in accessingservices and supportsisthefoundation instead of referring them tothe juvenile justice system. Buildingcommunity Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas students can dealwith student misbehavior and the effects ithasontheclassroom can be implemented by usingrestorative circles in the classroom.Inthesecircles, student behavior on others and how to recover in a healthy way. Restorative justice school setting. When used inaschool setting, it focuses ontheimpactof harmful school community. A restorative justice framework can be applied totheentire of the school’s rule; it seesthebehavior asharming people, relationships, and the Restorative justice bad behavior is a framework that views asmorethan aninfraction 2011. 2008-2009 and morethan $327 million on security and monitoringservices in 2010- 800 798 Thetotal amountthat counties and schooldistricts spenton JJAEPs was tives to Texas Appleseed identifies thecost ofexclusionary disciplinein 799 Statewide, school districts spent $232millionon DAEPs in 796 801 BexarCounty created the Children’s CrisisIntervention Best practices such asSchool-wide Positive Behavioral E xclusionary Discipline Cost ofSchool 797 802 TEA 243 Prior to implementing restorative implementing restorative Prior to 803 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 804 For more information on cost-effective discipline alternatives, visit http:// visit alternatives, discipline cost-effective on information more For www.texasappleseed.net/index.php?option=com_docman&task=doc_ . download&gid=848&Itemid or entire school. A restorative circle allows the students to use community values to values use community to students the allows circle restorative A school. or entire the circles While other. each with communicate and problem the address collectively school the entire used by to be intended is framework the in classrooms, place take while strengthening school community overall the goal and has the of improving justice Restorative institution. as an the school and students between connections than just a whole rather as culture school improve address and schools to allows can vary justice restorative implement to Cost changeseek to individually. behavior in for $16,000 implemented this concept in San Antonio school A schools. between This and materials. consultations, training, staff to related were The costs one year. switching to suspensions after in off-campus decrease an 84 percent school found policy. a zero tolerance from justice restorative justice to handle conflicts, this school had one of the highest rates of discipline in its rates highest the had one of this school conflicts, to handle justice district. TEA 244 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas TDHCA 245 254 254 254 254 255 255 255 255 255 256 257 257 258 249 250 252 253 258 247 805
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oncerns cts C a Development of permanent supportive housing options housing of permanent supportive Development Lack of affordable housing options available to people with disabilities, with disabilities, to people available options affordable housing Lack of illness mental with individuals living including veterans supports for Housing list 8 housing wait Section Program Grants Solutions Emergency Program Services & Housing Homeless Program Grant Block Services Community Program Assistance Homebuyer Texas HOME: Program Credit Tax Home Program Loan Direct HOME Multifamily Assistance Rental Tenant-Based HOME: Program Access Project Housing: 8 Section Disabilities with People for Housing Supportive 811 Section Grant Systems Choice Real Program Removal Barrier Young Amy Programs Prevention Homeless and Poverty Programs for Persons with Disabilities with Persons for Programs · · · · In 2013, TDHCA served 559,032 individuals, or 11.85 percent of the people living individuals, 559,032 served TDHCA In 2013, in poverty. with homelessness and/or a mental health also have who are homeless of people number A significant the cities across 2,600 in over 363 organizations collected by A survey condition. housed in a shelter had a of homeless adults percent 26.2 that showed United Affairs of Department and Community Housing Texas Environment Changing Affordable Housing Affordable 251 Funding Housing Supportive Permanent Conditions Health Behavioral with People for Programs Service and Housing Impediments to Fair Housing Choice Housing Fair to Impediments st F ast · · F Policy Affairs: Affairs: o f le Tab Housing and Community and Housing Texas Department of Department Texas TDHCA 246 Organiz · · Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Chief ofExterna Hous mental health condition. Texas was $677. with $518,313 through Project Access inFY2013.with $518,313 through Project Access community by providing access to affordable housing. TDHCA served 88persons assist low-income personswithdisabilities to transitionfrominstitutions intothe ispart of TDHCA’sProject Access Section 8 Housing Choice Voucher Programto receive $721 amonth from theirSSI income. including many people who areunable to work due toseriousmental illness, Most Texans who areeligible for supplemental security income(SSI)in2014, i n g Re Director s o urc l Affai e Ctr. r s Director o Dire D Financ e c p t u or Housi F ty E ina o e f Multi f andFai M n x c n e ult e g c tional u i f fami M a t i v m 808 a e r i n
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A u dit D General Counsel epu C oun ty G s ener e l al Chi e f o f C o mpl i anc 3/11/2014 e TDHCA 247 A survey collected A by 363 organizations in over 2,600 cities the United across showed that States of26.2 percent homeless adults who housed in a were shelter had a mental condition. health 811 Homeless individuals with mental individuals with Homeless Affordable housing programs focusing Affordable 812 813 in 2003. TDHCA and advocates worked worked and advocates TDHCA Rule in 2003. Housing Integrated 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 furthered its commitment to serving people with disabilities by by people with disabilities to serving its commitment furthered TDHCA 810 Large housing developments with 50 units or more may set-aside no more than 18 no more set-aside Largemore may 50 units or with housing developments with disabilities. for people units of their percent than more aside no set 50 units may fewer than with Small housing developments disabilities. with units for people of their 36 percent on homelessness prevention ultimately reach a significant reach ultimately on homelessness prevention condition. In mental health a who have of people population implementing the implementing together to create the following policies that promote the full integration of people the full integration of promote policies that the following to create together community: in the with disabilities · · a higher percentage prevent of people policies do not The above types of these each of to reside in choosing with disabilities limit their not may development an entire but developments, occupancydisabilities. people with solely to a also have who are homeless of people number A significant 363 organizations by collected A survey health condition. mental that 26.2 States showed the United 2,600 cities across in over a a shelter had were housed in adults who of homeless percent health condition. mental Affairs Housing and Community and Housing performs Affairs (TDHCA) Community and of Housing Department The Texas major affordable several of operation and the development related to functions housing and community funds for disperses federal TDHCA housing programs. Tax Housing Income Low agency as a finance and serves services state’s for the compliance with ensures TDHCA funds. housing and other Credit Program (LIHTC) as a financial housing programs and acts various governing laws and state federal services and affordable housing essential providing resource by and administrative AgencyPublic Housing is also a TDHCA Texans. low-income to opportunities for the operation of subsidized that is responsible entity a governmental (PHA), and Urban Housing Department of The U.S. programs. assistance rental housing and housing programs. PHAs for affordable directly funds (HUD) Development and has programs TDHCA residents, low-income supporting to In addition and those experiencing with disabilities people serve specifically policies that housing face extreme with disabilities of people A significant number homelessness. needs. Texas Department of Department Texas illness are at higher risk of chronic homelessness and remaining and homelessness of chronic at higher risk illness are for longerhomeless people than homeless periods of time a mental illness. without TDHCA 248 their safety aroundaperson with schizophrenia who has not received treatment. schizophrenia. comfortable interacting with an individual with a diagnosisof bipolar disorderor illness are violent. Surveys indicate that only 45 percent of participantsfeel population’sdaily activitiescanbe the general fearthat most peoplewithmental finding housing.Another formental healthconsumersparticipatingin challenge mental health condition who also have acriminalrecordcanhave adifficulttime participating in communitylife and accessingaffordablehousing. People witha The negative stigma associatedwith mental illness also prevents many Texans from homelessness and/or inpoverty. 2013, TDHCA served 559,032 individuals, or11.85 percent ofthepeoplelivingwith Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas serious mentalillness are morelikely to bethe victims ofviolentactivity. substances population. is nogreater than that of thegeneral The incidenceofviolence among people with serious mentalillnesswho do not use Figure 102. Types Housing Assistance of housing terms andconcepts. Figure 102 provides abrief explanation of some the most important affordable reference-guide.htm. health services staff. Theguideis available athttp://www.tdhca.state.tx.us/hhscc/ Reference Guide andTraining Manual to helpcross-educate housingand Agency in Figure 102 below. Additionally, In April of2011, TDHCA publishedtheState programs, andviceversa. Key abbreviations and forms of assistance are described that are essential to the understanding of affordable housingarenot usedinHHS’s agencies. Despitethis, some abbreviations and many oftheformsassistance programs and many of the programs operated by Texas’ healthandhuman services There is significant overlap inthepopulation served by TDHCA’s affordablehousing in their community. with mental illness are unworthy or incapable of livingmeaningful, productive lives inaccurate public perception perpetuates the unwarranted assumption thatpeople tance Development Assis- Program type 815 More than70percent of participants said theywouldbeafraidfor developers. in more detail below, development assistance provided are to examples of Credit Program and the Multifamily HOME Direct Loan Program, described housing funds often come with use restrictions. The Low Income Housing Tax property,construction of existing properties. and rehabilitation of Affordable property,Development assistance funds can be used for the acquisitions of Description 814 817 Infact,peoplewith 818 Still, 816
TDHCA 249 HOME: Tenant-Based Tenant-Based HOME: 820 applies to rental assistance programs programs assistance rental to applies Units developed with HUD Section 811 Supportive Housing for Housing Supportive 811 Section HUD with developed Units dcccxi legislation session, will add support for people with mental add support session, will legislation rd 819 Description near or at rent afford incomes low with tenants help funds assistance Rental allow funds assistance rental Typically, units. housing specified for rate market subsidy A rent. toward income of their percent 30 about pay to tenants eligible specific the for rent market the and amount that between difference the pays unit. Rental assistance comes in two basic forms: basic two in comes assistance Rental in programs assistance rental to applies assistance rental Tenant-based Tenants tenant. the with contract a has subsidy the providing entity the which seek to tenant the allows This housing. own their finding for responsible are locations. more in providers more from housing People with Disabilities funding, described in more detail below, is an example is an example detail below, described in more with Disabilities funding, People ofassistance. rental project-based serve to designed specifically often are funds service provide that Programs - restric use with come funds housing affordable Some disabilities. with people services human and of health coordination and financing the to relating tions (ESG), Program Grant Solutions Emergency low-incomes. with tenants for of example an is assistance. services below, detail more in described Rental Assistance (TBRA), described in more detail below, is an example of example an is below, detail more in described (TBRA), Assistance Rental assistance. rental tenant-based assistance rental Project-based housing the with contract a has subsidy the providing entity the which in the from applies subsidy the which to unit the lease then Tenants provider. provider. 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 type Program Rental Assistance Rental Services Assistance Services Changing Environment Changing care for people with of continuum role in the important an Boarding homes serve and safe some homes provide and disabilities, and other conditions health mental a business that is A boarding home their residents. for living quarters affordable three residents to at least as meals and transportation, basic care, such provides the the residents are unrelated to where elderly, are and/or disability a who have housing continues to be a major challengesafe and Securing affordable owner. been made to Efforts have conditions. health serious mental people with for many safe in terms of affordable and conditions health with mental support people better created were for boarding homes standards Model few years. the past housing in as regulations passed those standards a few local governments and HHSC, the by passed have that governments The local their jurisdiction. homes in for boarding local advocacy generally done so as a result of strong have home standards boarding HB 1191 (Burkett, Texas. America of Health Mental by organized frequently efforts, 83 passed in the Zedler), health conditions by adding a list of available housing information that is specifically housing available of adding a list conditions by health information about boarding homes More conditions. health with mental for people section. Environment Texas in the can be found impact 1191 and its potential and HB TDHCA 250 housing. SSI incometoward their2014monthly of have topay94percent SSI recipients would rent in Texas $677, of 2012 average monthly income. Usingthe month from theirSSI illness, receive $721a due toseriousmental who are unabletowork including manypeople Income (SSI)in2014, Supplemental Security are eligiblefor Most Texanswho burden. households. and live below 100percent of the AMFI compose more than8.5 million Together, Texas renter and homeowner households that face a housingcost burden TDHCA estimates that the state meets lessthan 1 percent of itstotal affordable facilitate recovery from mental illness. Safe, stable andaffordable housing isanessential componentofsupport systems that Affordable Housing are elderly.” in living and decision-makingforindividuals with disabilities andpersonswho or off-site health-related and other servicesand supportsthatfoster independence accessible housing that provides residents with the opportunity toreceive on-site and health services. Service-enriched housing is“integrated,affordableand efforts toofferservice-enriched housingthrough increasedcoordinationof housing withincreasingstate charged Health ServicesCoordinationCouncil (HHSCC), Senate Bill 1878(Nelson) of the 81st Texas Legislature created theHousing and Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas hhscc/docs/14-15-BiennialPlan.pdf housing and service recommendations can befound at http://www.tdhca.state.tx.us/ the Housing and Health Services Coordination Council 2014-2015 BiennialPlanwith representatives.members are either governor appointees or state agency Adraft of of itstotal incomebefore taxes and deductions toward housing. that live below 100 percent of AMFI, 23percent face a housing cost burden. (AMFI), almost 39percent face a housing cost burden. Of allhomeowner households renter households that live below 100percent of AreaMedian Family Income 823 Ahousing cost burden exists whena household pays more than 30 percent 821 826 Theexecutive director of TDHCA chairsthecouncil.Theremaining
a certain period were homeless. of people with four or morepsychiatric hospitalizations within housing market. ATravis County study found that 69 percent options, peoplewithseriousmentalillnessarepricedoutofthe housing need. communities throughout the country. The AMFI calculation American Community Survey to determine AMFI in data onmedian family income andresults from the Census that specific program. HUDusesthe most recent census AMFI todetermine ifa person iseligible to participate in housing programsoperatedby HUD and TDHCA use an facing the greatest housing cost burden, many affordable In order to directresources to those most inneed and SSI income toward housing. recipients would have to pay 94percent of their 2014 monthly Using the 2012 average monthly rent in Texas of $677, SSI mental illness, receive $721amonth from their SSI income. including many people who areunable to work due toserious are eligible for Supplemental Security Income (SSI) in 2014, living with behavioral health conditions. Most Texans who 827 Thishasdire consequences for many Texans 822 However, many Texans faceahousingcost 829 Without affordable housing 830
824 InTexas, ofall 825
828
TDHCA 251
In 836 832, 833 The federal funds are provided The federal funds are provided 834 The Housing Trust Fund (HTF), created in Fund Trust The Housing 838 This funding provides a method of finance to support and a method provides This funding 837 Texas legislative session, is the primary program receiving state the primary program receiving state is session, legislative Texas 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 Low-income households are those whose income does not exceed 80 exceed does not income whose those are households Low-income HUD and DHHS provide the largest financial support to TDHCA. financial support to the largest provide DHHS HUD and 831 835 48,250 for a 4 person household in 2014 in household person a 4 for 48,250 $30,150 for a 4 person household in 2014 household a 4 person for $30,150 $18,100 for a 4 person household in 2014 household person for a 4 $18,100
Low-income = 80 percent and below and = 80 percent Low-income · Very low-income = 50 percent and below and 50 percent = low-income Very · Extremely low-income = 30 percent and below = 30 percent low-income Extremely · administer the housing programs and other indirect administrative costs. costs. administrative indirect other programs and the housing administer $8,177,145 In FY 2013, generalthe state. funds from receives also revenue TDHCA percent of 4.4 about made up which state, from the to TDHCA appropriated was TDCHA. by funds received the total is permitted state. HTF by the program funded housing affordable the only funds and and very low and families of individuals assist to ways: used in the following to be building to nonprofit and capacity technical assistance to provide incomes, low as security for engagedorganizations serve affordable housing, and to in developing housing for individuals and families to finance bonds issued of revenue repayment 1993 during the 73 1993 during TDHCA is funded through several governmental departments, most at the federal at the most departments, governmental several through is funded TDHCA related specifications and restrictions with certain are often given funds These level. certain operation and ability to provide TDHCA’s an impact on has use, which to their appropriated to of funding that was is a brief description The following programs. the FY 2013. for TDHCA which made up 85.4 in federal funds, $151,298,671 received TDHCA In 2013, to TDCHA. appropriated funds of total percent Funding uses information that is unique and specific to a metropolitan area, sub-areas of a sub-areas area, metropolitan to a specific and is unique that information uses counties. nonmetropolitan and area, metropolitan was 2014 in in Texas of four for a household of Texas across all AMFI The average $60,300. addition to supporting their own programs and projects, TDHCA utilizes federal TDHCA programs and projects, their own to supporting addition of funds to disbursement to: the limited not but including ways, of a variety funds in direct assistance, disaster-related agenciesand programs, projects for their other and mortgage bonds. energy needs, to address assistance financial the department collects from comes from fees funding portion of TDHCA’s A second In manufactured housing industry. of the regulation its programs and the housing funds of the total percent 10.2 or $18,367,246, provided source of funding this 2013, to TDHCA. appropriated percent of AMFI. HUD breaks “low-income” down even further as follows: even down breaks “low-income” of AMFI. HUD percent · through different departments including US Department of Health and Human Health Department of including US departments different through (HUD), US and Urban Development of Housing Department US (DHHS), Services Services and Medicaid for Medicare the Centers (DOE), and Energy of Department (CMS). · · TDHCA 252 systems, electricity, paved roads, andsafe and sanitary housing.” may lack some ofthe most basicliving necessities, suchaspotable water andsewer State defines a“colonia” as“aresidential areaalongthe Texas-Mexico borderthat of Agriculturesupports programs serving colonias. TheOffice oftheSecretary of Disability contract with theTexas Services(DADS). Theinteragency Department of AgricultureviaColonia Service Centers, and 2) theDepartmentofAgingand housing programs. Thisfundingisprovided by 1)Texas twoagencies: Department contracts provide anotherInteragency source of fundingforTDHCA’s affordable housing, but itfalls short ofaddressing the overall need inTexas. housing developers, providers, andthe individuals whoultimatelyutilizeaffordable Retrieved from: Source: Texas Housing and Community Department of Affairs. (2012). of low and very low income. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas to SAMHSA, the coreelements of permanent supportive housingare: According component in promoting recovery for people with behavioral healthconditions. in communitylife. PSH isacost-effective, evidence-basedpracticethat isa key who experiencechronic homelessness, tolive independentlyandparticipate ofsupport services that enable vulnerable tenants,to arange especially people Permanent supportive housing(PSH) is permanent, affordable housing linked Permanent Supportive Housing appropriated funding. contracts accounts for less than 1percent,$63,343,from interagency ofthe TDHCA’s with DADS increases housingopportunities for personswithdisabilities. Funding Figure 103. TDHCA’s Funding in2013 in agraph. · A highdegree of choice offered to tenants. http://www.tdhca.state.tx.us/housing-center/docs/12-stratplanFY13-17.pdf 841 Figure103 shows the majority of TDHCA’s fundingin2013 839 Thisfunding stream provides invaluable resourcesfor Agency strategic plan for the fiscal years 2013-17 period. 840 Thecontract 842
TDHCA 253
844 For example, a particular permanent supportive permanent supportive a particular example, For 843 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 Functional separation of housing management and services staff. management of housing separation staff. services and Functional Affordability. community. surrounding with the Integration law. of tenancyrights and state under federal Full Immediacyhousing. to of access supports. services and Available Of the affordable housing programs TDHCA operates, some are specifically designed some are specifically operates, TDHCA programs affordable housing Of the These programs so. that do components have or disabilities, people with to serve and 2) programs for persons programs and homeless prevention poverty include 1) significant housing and most some of the categories provide Both with disabilities. by mental illness currently operated people with for resources service community (HUD) and urban development local housing these programs, addition to In TDHCA. Housing and Service Programs Programs Service and Housing Health Behavioral with People for Conditions · · · · · · to offer all of these is assumed to be able project housing No permanent supportive whether to predict to do so tends they are able to which the extent but core elements, successful. will be the project housing site may require the prospective tenant to demonstrate readiness to live to live readiness to demonstrate tenant the prospective require may housing site tenant This denies the prospective an apartment. leasing before independently will be mean the project necessarily not does access to housing, but immediate more For recovery. facilitating and independence in promoting unsuccessful resources at http:// SAMHSA see the housing supportive on permanent information store.samhsa.gov/product/Permanent-Supportive-Housing-Evidence-Based- Practices-EBP-KIT/SMA10-4510. Services (DSHS) is Health of State the Department TDHCA, In collaboration with housing for people supportive of permanent the availability to increase working in its item request an exceptional granted DSHS was illness. mental with serious match funds for a 1915(i) for state request appropriations legislative -2015 FY 2014 of to support the development program Medicaid Texas to the amendment plan state are used waiver the 1915(i) for Funds opportunities. housing supportive permanent Services-Adult Mental and Community-Based Home of the development for the (HCBS-AMH)Health will address the program. HCBS-AMH, DSHS, by operated care extended consumers who receive health of mental number of a small problem HCBS-no longerafter they facilities in inpatient services. inpatient need acute services to these and community-based of home variety a wide provide AMH will hospital. an inpatient psychiatric outside of can be met their needs so individuals is specific involvement HCBS-AMH and TDHCA’s phases, planning in the is still with will coordinate housing assistance TDHCA that is likely it However, unclear. to people in the HCBS-AMHhousing vouchers to provide public housing authorities the HCBS-AMH more information about and additional services For program. section. Texas Environment to the refer program, though the offered TDHCA 254 initial appropriation of $20millionduringthe81 placement and supportsdesignedtohelppeopleretain housing.HHSPreceived an and familiesexperiencinghomelessness. housing Services include casemanagement, Dallas, ElPaso, Fort Worth, Houston andSanAntonio–toprovide services to individuals this programintheeightlargestcitiesTexas –Arlington,Austin, CorpusChristi, including individuals with mental illness. serve subpopulations that most commonly have higher barrierstoobtain housing, funds.their ESG In 2013, TDHCA applicantswhodeveloped aplanto favored ESG fundingmay choosetoprioritize specific subpopulationstoserve with with ESG preventing families and individualsfrom becoming homeless. Additionally, agencies shelters,of emergency rapidly re-housing homeless individuals andfamilies, and funds are intended to provide assistanceESG by improving thequalityand number the GeneralAppropriationsBillby the81 The Homeless Housing andServicesProgram(HHSP)was established by Rider18in HOMELESS HOUSING&SERVICES PROGRAM $11,587,009, enabling 40,889 program. people to receive servicesthroughtheESG homelessness to regain stability in permanent housing. In 2013, TDHCA dispersed organizations, cities, and counties to assist homeless persons and persons atriskof administered by TDHCA. TDHCA fundstoprivatenonprofit distributes ESG program is funded by HUDand Solutions Grants (ESG) The Emergency EMERGENCY SOLUTIONS GRANTSPROGRAM experiencing homelessness. TDHCA has several programsthatspecifically provide servicestopeoplewhoare Poverty http://www.hud.gov/funds/. tx.us/overview.htm. Alist ofallfederal affordable housingprogramscanbefoundat Find out more about the programs operated by TDHCA athttp://www.tdhca.state. operated by TDHCA and other public housing authoritiesexist throughout the state. affordable housingresourcesin Texas. A numberof other federal and state programs The programsdescribed below donot represent a comprehensive listing of all the when funds areavailable. programs across thestate offer opportunities forhousingpeoplewithdisabilities Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas received assistance under this program. In 2013, TDHCA provided $28,524,262 for the CSBGprogramsothat388,888 people with the aim topromote stability among and self-sufficiency low incomeindividuals. eligible to receive these fundsto provide essential services andpoverty programs funding from HUD.governments Nonprofitorganizations and localunitsof are TDHCA administers theCommunity Services Block Grant (CSBG)Programthrough COMMUNITY SERVICES BLOCK GRANT PROGRAM $5,000,000 was provided toserve 13,721 peopleunderHHSP. session allotted revenue fundingof$10millionover general thebiennium. direct appropriationduringthe82 and Homeless Prevention Progr nd legislative session. st 852 Texas Legislature. 846
st legislative sessionbutdidnot receive a 848,849 However, the83 847 851 TDHCA administers 850 rd In2013, ams legislative legislative 845
TDHCA 255 In 855
856 ilities ab ilities Dis 857 Organizations can use their HBA funding to provide down their HBAcan use Organizations down provide funding to h wit Persons or f 853 These programs facilitate long-term investments for families. investments long-term These programs facilitate 854 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 ams HOME: TENANT-BASED RENTAL ASSISTANCE ASSISTANCE RENTAL HOME: TENANT-BASED HUD funded by is federally (TBRA) Program Assistance Rental The Tenant-Based of tenants with the cost assist These funds Program. HOME the Texas through seeking affordable housing in tenants subsidies to rental provides and moving in households with $2,724,308 to 388 services TBRA provided their community. A variety of programs offered through TDHCA have policies that specifically reserve reserve specifically that policies have TDHCA offered through of programs A variety TDHCA’s example, For disabilities. persons with for program or space in the funding people with funds for program’s of the 5 percent reserves Program HOME Texas with as Persons are known funds These reserved Texas. throughout disabilities specifically policies that programs have The following funds. set-aside Disabilities disabilities. for persons with services a specific percentageallocate and/or funding of PROGRAM ASSISTANCE TEXAS HOMEBUYER HOME: (HBA) HUD Assistance by is federally funded Program Homebuyer The Texas and units of local PHAs, Nonprofits, Program. HOME Texas TDHCA’s through the HBAin to participate are eligible dispersed government program. TDHCA in 2013. $3,775,918 Progr MULTIFAMILY HOME DIRECT LOAN PROGRAM LOAN HOME DIRECT MULTIFAMILY Program is federally funded and is also part Direct Loan The Multifamily HOME and nonprofits, Authorities, Housing Program. Public HOME Texas of TDHCA’s this program in the form of low- funding through to receive are eligible for-profits demolition and construction, for new This program offers funding loans. interest rental of affordable multifamily or acquisition and rehabilitation reconstruction, 19 households in the serve to dispersed $17,404,754 TDHCA In FY 2013, housing. Program. Loan HOME Direct Multifamily addition to providing financial tools, these programs offer educational opportunities programs these tools, financial to providing addition to managehomeownership. how to learn PROGRAM CREDIT TAX HOME Tax Income Home as Low also known program, Credit (HTC) Tax The Home Treasury US the by TDHCA funded to is federally Credit (LIHTC) program, who multifamily housing developers credits to tax provides TDHCA Department. housing. for affordable of the development of units specific number aside a set the market residences below to qualified to be leased units allow credits The tax 60 percent of the Area who are for people units are reserved These affordable rate. are specific to requirements that other and meet Income (AMFI) Family Median that rate at a reduced rental units is set rent for these of The cost the development. to $71,687,011 provided TDHCA rent guidelines. published annually by is restricted 2013. HTC program in the households through multifamily 9,238 serve payment and closing cost assistance for single family homebuyers. Home ownership ownership Home homebuyers. single family for assistance cost and closing payment build equity and promote income households helping a low of has the possibility self-sufficiency. TDHCA 256 request to transition from institutions to community-based living. TDHCA began a temporary solution to provide assistance forindividuals withdisabilities who However, vouchers and TDHCA there isahigh demand forProject Access hassought vouchersthis program. Assistance isnot through Project Access time limited. Services (DADS) andDepartment of StateHealth Services (DSHS) toimplement TDHCA worksincollaborationwiththe Department of AgingandDisability 2) statewide AMFI was $60,300. in either 1 or2below: impedes one’s ability to live independently, and meet the requirementsofcriteria disability thatisexpected to be of long-continued and indefinitedurationthat the Social Security Code orbedetermined to have aphysical, mentaloremotional voucher, an individualmust have apermanent disability asdefinedinSection223of Income (AMFI) guidelines to beable to participate in theprogram. household’s annualgross income be50 percent or below HUD’s AreaMedian Family persons with disabilities, toobtain safe and sanitary housing.HUD requires that a assistance to assist low income families and individuals, includingolder adults and The Section 8 Housing Choice Voucher Program, fundedby HUD, provides financial SECTION 8HOUSING:PROJECT ACCESS PROGRAM Program. program for Section 8 Housing:possibility to beabridge ProjectAccess in the voucher program must be 30 percent or below theAMFI. status, assets, medicalexpenses, andchildcare expenses. determine eligibility, including size andcomposition of thehousehold,citizenship meeting these income requirements, several other factorsaretaken intoaccount to 1) FY 2012. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas up tofive years, pending funding. program. Individuals may receiveparticipation in aself-sufficiency assistance for with $518,313 through Project Access inFY2013.with $518,313 through Project Access community by providing access to affordable housing. TDHCA served 88persons assist low-income personswithdisabilities to transitionfrominstitutions intothe ispart of TDHCA’sProject Access Section 8 Housing Choice Voucher Programto approved rentamount directly to the property owner on behalfof the individual. work directly with landlordstoensure their needs are met, and TDHCA pays the hospitals at the time of voucher issuance. Be eligible for the DSHS pilot program for residents of Texas state psychiatric b) a) prior to expiration of assistance) and Department’s HOME Investments Partnership Program andwithinsixmonths Be anat risk applicant (current recipient of TBRA assistance fromthe as defined by HUD, psychiatric hospital orboardandcare facility atthe time ofvoucher issuance Be acurrent resident of anursing facility, intermediate care facility, state Department of Housing and Urban Development, or psychiatric hospital, or board andcare facility asdefined by the U.S. a previous resident of anursingfacility, intermediate care facility, state 858 TheHOME rental subsidies last upto 24 on months and arecontingent 865 861 Furthermore, 75 percentofhouseholds participating 859 TBRA,ashort-termassistance program,hasthe 864 To beeligiblefora Project Access 863 Onceeligible,individuals 862 Inadditionto 860 InFY2014, the TDHCA 257 The goal The 866
869 from the Centers for Medicaid from the Centers for Medicaid TDHCA and the Texas Health and Human Health the Texas and TDHCA As of the summer of 2014, TDCHA and HUD 2014, summer of As of the 872 873 The academy provided local communities with provided The academy DADS and TDHCA partnered together to achieve together to achieve partnered and TDHCA DADS 874 868 TDHCA received $12 million, the maximum amount, $12 million, the maximum received TDHCA 870 Prior to the changes to the program in 2010, the HUD the HUD the changes Prior to program in 2010, to the 867 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 has indicated that people with serious mental illness are a serious mental illness are a people with indicated that has TDHCA 871 Application for the 811 Project Rental Assistance Application for the 811 Project funds awarded states was one of 13 Texas that notified was TDHCA 2013, In February program. 811 Section for the Services Commission (HHSC)Services inter-agencyan entered agreement, per a have addresses the characteristics agreement This grant application. of the requirement this population will this program, how targeted for that will be population of the the commitments of services from the and program, to the and referred be reached agencies. and human service health three outcomes as part of the grant, including 1) successful application for the HUD including of the grant, as part outcomes three Program, 2) create and Demonstration (PRA) Assistance Rental 811 Project Section and and 3) Housing Academy, (HSP) Partnership and Services a Housing implement Clearinghouse. Online Disabilities with for Persons Services to provide project-based affordable housing for extremely low income persons with low extremely housing for affordable project-based to provide disabilities. target population for this program, along with youth exiting foster care and people youth exiting foster along with for this program, population target institutions. exiting with disabilities are in the final process of signing a cooperative agreement so that the demonstration agreement so that the demonstration cooperative of signing a are in the final process the project rental assistance start preparing to to In addition begin. program can of applying the process began TDHCA in 2013, received program from the award (PRA) Project Rental Assistance 811 the HUD Section funding for to receive the an application for submitted TDHCA a second time. Program Demonstration of 2014. million in May $12 requesting 811 program Section Academy and Services Partnership Housing worked and DADS Grant, TDHCA Choice Systems of the Real outcome As a second (HSP) and Services Partnership a Housing and implement to create together Dallas with 16 local in 2013 14-15, May held was The HSP Academy Academy. participating. teams community Section 811 provided interest-free development funds and operating subsidies to and operating funds development interest-free 811 provided Section With the people with disabilities. housing for of affordable developers nonprofit housing to state rental assistance direct provides HUD now to the program, revisions Low subsidies such as the agenciesother through developed in housing to be used programs. and HOME Credit Tax Income Housing GRANT CHOICE SYSTEMS REAL through the Real Choice Systems $330,000 received and TDHCA DADS In 2011 for Housing Building Sustainable Partnerships Grant: and Medicare Services (CMS). and Medicare working with DADS and DSHS on a process that allows for a person on the waitlist waitlist on the for a person allows that a process on and DSHS DADS with working Access for Project program. TBRA HOME with the relocate to be able to is for a person to be admitted to the Project Access Project the to TBRA the time the admitted to be is for a person by Program transition people to for fix, it allows a permanent this is not While expires. assistance be able to otherwise. would than they sooner settings into community WITH DISABILITIES FOR PEOPLE HOUSING SUPPORTIVE 811 SECTION for people with disabilities programs housing supportive of HUD’s 811 is one Section Cranston-Gonzales the by and is authorized Housing Affordable National of Act reformed in 2010. 1990, TDHCA 258 needed for accessibility for person with disabilities. a one-time grant of up to$20,000 for entities to provide home modifications increase accessibility and remove conditionsintheirhomesby dangerous providing The Amy Young BarrierRemoval (AYBR) Program assists personswithdisabilities to AMY YOUNG BARRIERREMOVAL PROGRAM clearinghouse/main.do The clearinghousewebsite can be found athttps://211texas.hhsc.state.tx.us/211/ as welllocal providers, to findcommunity-based affordablehousingandservices. online clearinghouse provides aninteractive resource for peoplewithdisabilities, were provided to211 people inFY2013. by the state ofTexas through the Housing Trust Fund. About 3.5 million dollars and free housing choice for protected classes. information about programs toassist personswith disability, andbarrierstomobility impediments are lack of accessible housing andvisitabilitystandards, inadequate people with disabilities, includingpeople with mental health conditions. These three Texas Fair Plan for Housing Choice, andthree of theimpedimentswerespecificto the state. Several impediments to fairhousing were identifiedinthe report,Stateof Inc. (BBC) to complete ananalysis of impediments to fair housingchoice throughout with this obligation, in 2012 TDHCA contracted with BBC Research&Consulting, nondiscrimination policies, not just prohibit discrimination. In an effortto comply that law, recipients of HUDfunds are underan obligation to affirmatively further clearinghouse was finalizedandmade available onthe 2-1-1 Texas.org website. Services for Persons with Disabilities Online Clearinghouse. In September 2013, the efforts from theReal ChoiceSystems Grant was thecreationof Housing and The third and finaloutcome asaresult oftheTDHCA’s and DAD’s collaborative site The Housing forPersons andServices withDisabilities ClearinghouseWeb- or those with disabilities.” provide independent access for everyone, including people withlimitedmobility national origin, familial status and disability, including mental illness. of units in theprivate housing market onthe basis ofrace,color, religion,sex, to astheFair which prohibits discrimination inthesale Housing orrental Act, commonlyreferred In 1968, Congress enacted Title VIII of theCivilRights Act, Impediments to Fair Housing Choice people with disabilities in theircommunities. the tools and education necessary to createsafe, affordable, accessible housingfor Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas percent or lessofthe AMFI. Program beneficiaries may betenantsorhomeowners. Program, one must be a personwith a disability and have ahouseholdincome80 eligibility, andoversee construction. To beeligible to receive agrant from theAYBR organizations and localgovernments who process intake applications, verify made recommendations on thestate and localgovernment levels. of improvingdeveloped the goal housing options for peoplewithdisabilities and 881 Inresponse to these impediments, BBCandTDHCA 878 TDHCA disbursesfunds to nonprofit 880 875 The report states: “Visitable homes Thereportstates: “Visitable
877 TheAYBR Programisfunded 879 Aspart of 876 The TDHCA 259 882 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 883 Review their zoning and land use ordinances for language for ordinances and land use their zoning Review group that treats small use. industrial and commercial homes as goalsplanning into their and articulate these to design concepts Build universal local developers.” “Conduct an assessment of the need for affordable, accessible housing serving accessible housing serving for affordable, of the need an assessment “Conduct with disabilities. persons Include information about group home requirements in educational and outreach and outreach in educational requirements home about group information Include efforts. and Councils of planners, officials, local government stakeholders, Educate and visitable housing. design universal of about the benefits (COGs) Governments Work with stakeholders who are knowledgeable about the housing needs of needs the housing about who are knowledgeable stakeholders with Work this provide needs in communities, the specific to identify with disabilities persons these to meet local approaches and promote to local governments, information needs. · · visit http://www.tdhca.state. these recommendations, information on more For tx.us/housing-center/fair-housing/docs/DRAFT-FairHousingChoice-AI-Phase2. pdf · · · for local outlines action steps the report recommendations, to these In addition governments: · The following are recommended action steps that can be taken at the state level: state at the can be taken that steps action are recommended following The TDHCA 260 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas TVC 261 266 267 267 264 264 265 266 266 263
885 888
887, At A A Glance At 884
legislature appropriated $5 million into the DSHS budget to into the DSHS budget $5 million appropriated legislature rd ontents 886
C
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 cts C a increase veterans’ access to community-based mental health professionals, health professionals, mental to community-based access increase veterans’ health services such as mental improve supports to and peer volunteers for programs and jail diversion prevention, suicide counseling, peer-to-peer families. and military members, current service veterans, A 2012 report by the VA estimated that there were 22 veteran suicides per day suicides per day 22 veteran there were that estimated the VA by report A 2012 in 2010. In 2013, the 83 the In 2013, Women are the fastest growing group within the veteran population and are veteran within the group growing the fastest are Women 2035. by veterans of all living 15 percent up to make projected of one hundred men and thirty-eight women of a hundred out Fifty-five such as behavior which includes sexually harassed, been report having displays activity, body or sexual about a person’s comments offensive advances while in the sexual and unwanted of pornographic material, military. Texas is home to nearly 1.7 million veterans of the armed forces, more than armed forces, of the million veterans 1.7 to nearly is home Texas California. except state other any Expansion of veteran peer specialists services peer specialists of veteran Expansion to women veterans extended and services to, outreach of, the needs Tracking state in the service and state of federal Coordination Veterans Women Networks Support Veterans Courts Specialty · · · · · · · · Texas Veterans Commission Veterans Texas Program Counseling and Representation Claims Eligibility for VA Benefits VA for Eligibility Services Employment TVC (FVA) Assistance Veterans’ for Fund Programs Other st F ast F Policy le o f le Tab Commission: Commission: Texas Veterans Veterans Texas TVC 262 Organiz Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Administration/Training Human Resources (2.25 FTEs) (3 FTEs) $GPLQLVWUDWLYH2I¿FHU Administration (12.25 FTEs) Chief Information Resources Communications & Veterans Outreach ( 2FTEs) (3 FTEs) tional TEXAS COMMISSION VETERANS General Counsel Women Veterans (3 FTEs) (1 FTE) Chief Financial Finance (8.5 FTEs) 2I¿FHU ORGANIZATIONAL CHART Chart FEBRUARY 2014 Executive Director Members (5) Commission Assistance Rick Perry Governor Veterans’ Fund for (9 FTEs) Director (9 FTEs)
Hazlewood (3 FTEs) State Program (6 FTEs) El Paso Austin Dallas Education Coordinators Veterans Education (3 FTEs) (22 FTEs) 6 Regions Director Deputy Executive San Antonio South TX Houston Director (1 FTE) Program Federal (16 FTEs) Veterans Women (1 FTE) 'DOODV)W:RUWK2I¿FHV Regional Regional Manager-45FTEs Regional Manager-27FTEs Regional Manager-31FTEs Regional Manager-20FTEs 5 RegionalManagers Employment *XOI&RDVW2I¿FHV &HQWUDO2I¿FHV 6RXWK2I¿FHV :HVW 2I¿FHV Veterans Services (167 FTEs) Employment Director Manager -36FTEs Veterans Liaison (1 FTE) Governmental Relations (2 FTEs) Entrepreneur Veteran (3 FTEs) Force Teams &RXQVHOLQJ2I¿FHV Representation (16 FTEs) & Counseling Regional Director -58FTEs Regional Director -52FTEs +RXVWRQ2I¿FHV 2 RegionalClaims :DFR2I¿FHV Strike State Representation (155.25 FTEs) Claims Director Claims Teams Developed (24 FTEs) Fully Veterans Women (1 FTE) TVC 263
898 Texas is home to Texas 1.7 million nearly ofveterans the more armed forces, than any other state California. except Thus, veterans are at veterans Thus, 894 In 890 An underlying behavioral health An underlying behavioral Additionally, 55 out Additionally, 893 895,896,897 895,896,897 Among those who use Veterans use Veterans those who Among 892 Veterans face a myriad of challenges as they transition face a myriad Veterans 889 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 combat trauma, sexual assault occurring assault trauma, sexual combat to In addition 900 891
899 The Texas Veterans Commission (TVC) serves veterans and their dependents in all veterans serves Commission (TVC) Veterans The Texas It is the designated and rights. benefits disability to veterans’ pertaining matters before the U.S. and its veterans the state represent to agencyof Texas of the state The agencyAffairs in filing veterans represents (VA). of Veterans Department dependents assists and it appeals processes, VA claims and during disability VA veterans’ program areas: following on the focuses The TVC benefits. with survivor claims representation and services, education veterans’ services, employment claims representation and counseling the Both assistance. and funding counseling, health ability to access behavioral veterans’ programs impact assistance and funding services. higher risk for developing mental health conditions and substance use problems and substance health conditions mental developing for higher risk military service. from their stemming use substance illness or (mental health conditions with behavioral Veterans of use higher lifetime legal problems, more serious have PTSD, including disorder), up a large make percentage of suicides, more represent substances, other alcohol and overall have and symptoms, psychiatric more experience population, the homeless general the than worse health population. while in military duty (referred to as Military Sexual Trauma) can Trauma) Sexual as Military (referred to duty military while in of PTSD. in symptoms also result Unfortunately, only about half of all veterans with a diagnosed behavioral health a diagnosed behavioral with half of all veterans about only Unfortunately, adequate received fewer have and even appropriate services, accessed have condition care. Commission other more than any armed forces, the of veterans 1.7 million to nearly is home Texas California. except state Texas Veterans Veterans Texas Affairs (VA) healthcare, 23 out of 100 women report having been having report women 23 out of 100 healthcare, Affairs (VA) sexual touching that involves physical (unwanted assaulted sexually military. while in the of coercion) some form condition is the strongest predictor for homelessness after leaving active duty. active after leaving for homelessness predictor is the strongest condition comparison, 7–8 percent of American adults in the generalthe adults in of American percent 7–8 comparison, PTSDwill experience population during their at some point lifetime. from active duty to civilian life. Among these challengesAmong these civilian life. duty to from active risk for is an increased of the Iraq percent of veterans 11–20 Approximately health conditions. behavioral are and Enduring Freedom) Freedom (Operations Iraqi wars and Afghanistan (PTSD). Stress Disorder with Post-Traumatic diagnosed of 100 women and 38 of 100 men report having been sexually report having of 100 men and 38 women of 100 comments offensive such as behavior harassed, which includes of pornographic displays or sexual activity, body a person’s about the military. while in advances sexual and unwanted material, TVC benefits. compensation andpension more than$2billionin and familymembers, yielding veterans of cases onbehalf handled 179,981benefit In FY 2011, TVC counselors 264 more information, visit www.health.mil. health care toactive duty andretired U.S. military personnel andtheir families. For The U.S. Department of Defense Military Health System isresponsible for providing and pension benefits. veterans’ compensation andpension benefits. health services that can beaccessed with the assistance ofTVC counselors. The following sections describe VA benefits eligibility and available VA behavioral family members apply for disability benefits and enrollin VA healthcareprograms. TVC’s claims representation andcounseling program helps veterans andtheir Program Claims Representation and Counseling In 2013, the 83 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas from active militaryserviceunder other than dishonorableconditions. Eligibility for most VA benefits, including health services, occursupondischarge Eligibility for VA Benefits members, andmilitary families. suicide prevention, and jaildiversion programs for veterans, currentservice peer supportstoimprove mental health services such aspeer-to-peer counseling, veterans’ access tocommunity-based mental health professionals, volunteers and state training coordinator, andan assistant state network coordinator. regional coordinators, four fieldclinicians, ahalf-time clinicalsupervisor, afull-time rehabilitation. awarded specialeligibility due to adisability incurred during treatmentorvocational with adisabilitydischarged incurred or aggravated inthelineofduty, andveterans of war, Purple Heart Medal recipients, Medal ofHonor recipients, veterans groups includeveterans with service-connected disability ratings, formerprisoners are assigned to one of eight priority groups upon enrollment. Thehigherpriority 909 rd legislature appropriated $5 million into theDSHSbudget to increase For acomplete listing of prioritygroups seehttp://www.va.gov/ 906 Texas leads all other states large in monetary recovery of members, yielding more than$2billion in compensation 179,981 benefit cases onbehalfof veterans and family applications for VA compensation benefits. veteran and VA medical facilities andassist veterans with facilities. Claimscounselors actasaliaison between the at many veterans integratedservice network (VISN) assistanceas general with the process of securing benefits provide directrepresentationinclaimsandappealsaswell TVC employs over 75counselors accredited by the VA to in FY2011. service in the armed forces increased by 18percent TVC claims related to entitlements secured through 901,902 AsofMay 2014, newhiredstaff included11 905 InFY2011, TVC counselorshandled 907
904 903 908
Veterans TVC 265 For a comprehensive description description a comprehensive For 916 Since beginning operation in 1979, 1979, Since beginning operation in There were 8.92 million veterans million veterans There were 8.92 914 915 A Non-Service is a pension Connected 910 Additional Non- eligibility requirements for a The TVC offers employment services to assist services to assist offers employment The TVC 911 918 Additionally, 300 Vet Centers nationwide provide provide Centers nationwide 300 Vet Additionally, 913 912 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 Gainful employment is therefore key to ensuring that veterans live live veterans to ensuring that key is therefore employment Gainful 917 http://www.va.gov/opa/publications/benefits_book.asp. of federal benefits and services available to veterans, family members and survivors, survivors, family members and veterans, to available and services benefits of federal visit enrolled in the VA Health Care system in FY 2013. system Care Health enrolled in the VA the Vet Centers have helped 2 million veterans. helped 2 million Centers have the Vet qualified veterans in finding and obtaining meaningful and long-term employment. and long-term employment. meaningful obtaining in finding and veterans qualified job training, and resume job coaching, provide representatives employment Veteran conduct and programs, education to access provide They can also assistance. TVC Employment Services Employment TVC economic mental health and negative can have veterans among Unemployment stable securing in veterans for obstacles additional creates which consequences, housing. VA Behavioral Health Services Behavioral Health VA by a regional level on are administered services care health veterans’ Nationally, (VISN), networks service integrated of 23 veterans each containing a a system outpatient community-based clinics, outpatient on-site of medical centers, hierarchy and referral services to outreach counseling, which provide centers, vet clinics and three VISNs with is divided into Texas post-combat. to life readjust help veterans more information, see For state. the centers throughout and vet clinics multiple . http://www2.va.gov/directory/guide/state.asp?State=TX&dnum=ALL but it does health services to veterans, behavioral operate or provide doesn’t The TVC representation and counseling claims the services through to these link veterans both that provide settings of VA array There is a wide program described above. care clinics, including primary services, health behavioral and outpatient inpatient residential care facilities and generalclinics, mental health outpatient and specialty include specialized PTSD programs and Services services, centers. living community programs, prevention suicide services, and recovery rehabilitation psychosocial also The VA use services. and substance programs psychotherapy evidence-based duty of active and survivors for family members services health behavioral provides veterans. and personnel military healthbenefits/resources/priority_groups.asp. 2) Non- and 1) Service-Connected available: two types of compensation There are that is paid benefit is a monetary compensation Service-Connected Service Connected. during military or aggravated or illness incurred suffered an injury who to veterans experience. regardless of combat service, psychological counseling for war-related trauma and other services such as outreach, other trauma and for war-related counseling psychological case management,referrals. and social services monetary benefit paid monthly to veterans with low or no income who are aged or no income low with 65 and veterans to benefit paid monthly monetary disabled. older or are permanently independently and self-sufficiently. and independently Service Connected pension include having served 90 days or 24 months (depending (depending months or 24 90 days served pension include having Service Connected (combat war-time of period a during day 1 with duty active of service) of dates on than a specified limit (depends family income lower required) and a experience is not on spouse/dependents). TVC 266 insurance, andtohavepoorer health. have lowerincomes, lackprivate Woman veterans are more likely to referrals to other services. brain injury, transportation to medical appointments, andinformation their families, including housing assistance, and traumatic counseling for PTSD for providing direct support servicestoveterans and service organizations (VSO) grants reimbursecharitableorganizations, localgovernment agencies, and veterans the state of Texas were awarded grants totaling over $3 millionfor2014. assistance for veterans and theirfamilies. local government organizationsthat provide temporaryandpermanent housing Other Programs Housing4TexasHeroes, and Veterans Mental Health. to veterans and their families. includeGeneralAssistance, The three categories of grants toeligible organizations that providethree categories direct services through a combination of state funds andprivate donations. TheFVA awards The Fund for Veterans’ Assistance (FVA) is operatedby the TVC andisfunded Fundfor Veterans’ (FVA) Assistance outreach to businesses and employers to promote thehiringofveterans. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Women are thefastest growing group within the veteran populationandare Women obtaining the services and resources they need. programs andinitiatives at the stateAdditional and federal level assist veterans in counseling, and others. Brain Injury (TBI) services, grouptherapy, equine therapy, co-occurring disorder services, of services such as peercounseling, PTSD through a range Traumatic projects that provide direct mental health services to veterans andtheirfamilies members. disabilities and employment services to spousesand caregivers of active duty service employment-related services include vocational rehabilitation forveterans with texas.gov/About-Us.aspx. or organizationsandgrant awards beginning January 1, 2014, visit Employee Charitable Contribution Campaign. tickets, online orcheck donations, vehicular registration donations, andthe State The FVA isfunded through four primary sources: Thesale of$2 scratch-offlottery 920
Veter 924 ans
922 Housing4TexasHeroes grants supportnonprofit or PTSD than men. PTSD population, women are morelikely todevelop better serve woman veterans. In the general embarked onefforts tounderstand how to number of female veterans, the VA has veterans by 2035. projected to make up 15percent of allliving 923 Veterans Mental Health Grantsfund 925 Twenty-three organizationsacross 921 928 FVA GeneralAssistance 927 Itisunclear whether the Recognizingthegrowing http://www.tvc. 926 919 For alist Other TVC 267 http:// However, However, 929 A 2012 report by the 2012 report A that estimated VA 22 veteran were there suicides per day in 2010. 933 Networks Because of their heightened risk for having experienced having for risk of their heightened Because Additionally, female veterans earn almost $10,000 less per less $10,000 almost earn veterans female Additionally, 930 931,932 ourts ourts C ort Support 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 ans woman veterans are more likely to have lower incomes, lack private insurance, and and insurance, lack private incomes, lower have to likely are more veterans woman health. poorer to have lty Specialty in the criminal lead to involvement may conditions mental health untreated, Left facing charges a veteran process, criminal justice the typical Under system. justice to a judgeis assigned challenges the unique with be unfamiliar may who faced by abuse issues. and substance depression, TBI, such as PTSD, veterans, returning better a have may hand, on the other court veterans in a specialty A judge sitting for criminal increase risks that could conditions mental health of the understanding The judge rangethe familiar with also be more may of community-based behavior. be more courts may veterans Thus, benefits. veterans and for veterans services can link and instead system justice the criminal from veterans of diverting capable and supports. services, to benefits, and their families veterans texvet.org. Peer is the Military Veteran network the TexVet on available the resources One of and family members who veterans of an affiliation This organization is Network. and provide veterans resources for community for advocate identify and actively and mental trained in peer support Leaders are Group Peer peer counseling services. The in their communities. meetings peer group and establish awareness health and is supported by the state across chapters has 36 Network Peer Veteran Military (DSHS). Services State Health from the Department of grants TexVet, an initiative by the Texas A&M Health Science Center, Science Center, A&M Health the Texas by an initiative TexVet, who are volunteers and organizations, community providers, of health is a network referrals with and their families military members, veterans, to providing committed more information, visit: For services. and information to successfully access Veter 22 veteran there were that estimated VA the by report A 2012 Line is a resource Crisis Veterans The in 2010. day suicides per of times and friends in their families, to veterans, available the Callers can reach including suicide prevention. crisis, will be chat where they or online text, via telephone, hotline in inception Since its responder. VA a trained with connected calls 890,000 over has received Crisis Line Veterans the 2007, rescues. life-saving 30,000 than more and has made incidence of PTSDof incidence men. military than women military among higher is year than male veterans and are up to four times more likely to be homeless than homeless than to be more likely times to four are up and male veterans year than women. nonveteran military sexual trauma, PTSD, homelessness and financial stress, it is imperative imperative is it stress, financial and homelessness PTSD, sexual trauma, military to woman are directed resources and transitional services, care, support that health serve to better in an effort Initiative Women’s the Texas created The TVC veterans. increase services for women their benefits, them obtain help veterans, women services and supports with local coordinate and the state, throughout veterans Visit http://www.tvc.texas.gov/Women-Landing-Page. organizations. community information. for more aspx TVC 268 and Williamson. Galveston, Guadalupe, Harris, Hays, Hidalgo, Nueces, Tarrant, Smith,Travis, Webb, the state in thefollowing counties: Bexar, Cameron, Collin, Dallas, Denton,ElPaso, in 2009. As ofJuly 2014, there arefourteen veterans courts operating throughout The first veterans court in Texas, located inHarrisCounty, beganaccepting cases Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 934
Best Practices 269 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 approaches are not mutually exclusive, but instead highlight but instead exclusive, mutually not These approaches are If only evidence-based practices are funded, we limit choice and neglect practices evidence-based If only 936
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important directions for new research. for new directions important “bestguide the term In this and “evidence-based” both encompasses practices” “promising” or treatment prevention practices are Evidence-based practices. undergone rigoroushave that interventions evaluation. The Substance scientific the National Services Administration has developed Health Mental and Abuse (NREPP). It is a searchable Practices and Programs of Evidence-based Registry use mental health and substance supporting of interventions online registry at http://www.nrepp.samhsa. can be found The registry and treatment. prevention gov/Index.aspx. person-centered practices. In addition, some researchers have cautioned about some researchers have In addition, practices. person-centered the evidence base too often has that given practices, on evidence-based over-reliance and other genders, ethnicities, races, from various mix of people a broad included not identities.
The increasing demands placed on the behavioral health system have encouraged have health system behavioral placed on the The increasing demands more benefit from to seek stakeholders and other providers service policy makers, has decade, considerable attention the past Over available. resources the limited health dissemination of mental and implementation identification, to the given been and more effective that are programs establish to “bestattempt practices” in an practices, on outcomes and proven value placed increased With the cost-efficient. behavioral outcome evaluation for require agenciesnow funders and oversight many health outcomes. positive evidence of demonstrate and services that programs health consider the potential must of care we system to a recovery-based As we move True person- between for conflict and person-centered services. practices” “best individuals and they accomplish recovery people are recognize that services centered we practices, evidenced-based or best services to limiting By of ways. in a myriad that people bring to their own and strengths medicine” the “personal risk missing recovery. Best Practices Practices Best Best Practices 270 their own life stressors. encouraging consumers to define their own recovery andbuildcapacityto copewith The recovery modelrepresentsaparadigm shift away from themedicalmodelby Figure 104. Recovery Focused Modelvs. Traditional ClinicalModel models of care andtreatment. Figure 104 provides some comparison between recovery-focused andtraditional rather the abilityof an individual to have ameaningful life intheircommunity. can anddo get better. Theterm recovery inthis context doesnot imply“cure,” but The recovery modeliscentered on the belief that those with seriousmentalillness an acute care modelof treatment to arecovery-oriented system ofcareapproach. the promotion ofpeer support activities. The substance use fieldisalso shiftingfrom of levels, andplanning, the provision including policy oftreatment and supports, and areadoptingState andlocalmentalhealthagencies arecovery orientationatavariety recovery from mental illness andsubstance use as: Substance Abuse and Mental Health (SAMHSA)defines Services Administration supports exist forchild and adultmental health and substance use conditions. The Recovery from mental illness andsubstance use is possible.Effective treatmentsand Support Best Practice: Recovery and Peer available at http://www.utexas.edu/research/cswr/tbhc. including a searchableinventory of best practices offered by state agencies, is state are described below. Further information on behavioral health best practices, the same level of research support. Some examples of best practices utilizedinthe Promising practices are those thatshow positive outcomesbut do not yet have Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas The following aresome Texas initiatives promoting recovery-oriented systems. Source: Bell, S., Janov, R., Orlando, R. Implementation and uses to advance recovery. Recovery Focused Model “What “What are your needs?” “What are your strengths” “What happened to you?” Trauma Informed Person Centered Person Centered wellness, live and strive aself-directed to reach theirfullpotential. life, A process ofchangethrough which individuals improve theirhealthand 940 “What are your issues” “What is wrong with you” “What Diagnosis Informed Service Centered Diagnosis Centered Traditional Medical Model 937 939
938 Best Practices 271 More More nd and 944 lists alists Speci
943 lists alists Speci 947 They do not replace professionals replace professionals They do not 941 ecovery ecovery R tion a fic Certi ied Peer Peer fied Certi As of August 2014, 447 peer specialists were certified in peer specialists 447 2014, As of August fied Certi 945 When a peer specialist provides support services, the licensed the licensed support services, provides peer specialist When a Use 942 h alt 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 rtner artner ance l He al More information about peer support certification can be found at http:// peer support about information More 946 mily P amily professional is available to focus on the clinical service delivery for which he or she delivery the clinical service to focus on is available professional to way economical and effective are an peer specialists In addition, trained. was shortageworkforce mental health address the in Texas. . www.viahope.org/programs/training-certification . found at http://www.tcbap.org/ can be specialists recovery about can information in certifies peer specialists trains and Resource Health Mental Texas Via Hope- the Department of State Health and Foundation the Hogg funding from with Texas in recovery is an individual (CPS) Specialist Peer Certified A Via Hope Services. At with recovery. others to assist story recovery to use their trained who has been hospitals and psychiatric six state (LMHAs), health authorities local mental 39 least utilize certified Network Healthcare Texas of Administration Heart the Veteran’s specialists. peer support More information about CFPs can be found at http://www.viahope.org/programs/ can be CFPs information about More . family-partner-training-certification Texas. Similar to the peer specialist role, Certified Family Partners (CFPs) are individuals Partners (CFPs) Family Certified role, specialist the peer Similar to or behavioral emotional a child with mental, parenting experience who have public mental with the involvement had personal have disorders and who health parents and support to other information provides partner A family system. health certification the family partner developed Via Hope in similar circumstances. and has stakeholders and national regional in collaboration with state, curriculum partners. family 114 more than certified trained and F Many agencies have difficulty in recruiting and retaining mental health professionals. health professionals. retaining mental recruiting and difficulty in agencies have Many use and substance peer specialists certified health mental including specialists, Peer who workers mental health of pool additional are an specialists, recovery certified with personal experience specialists’ Peer staff. licensed hard-to-find can augment that other a perspective provides use substance and illness mental from and recovery offer. cannot health professionals often mental Ment Subst but their participation on the care team can provide a different perspective and perspective a different provide care team can on the participation but their outcomes. improve Peer specialists can assist agency administrators, clinicians, consumers and their consumers clinicians, agency can assist administrators, specialists Peer information, foster provide specialists Peer to treatment. related aspects families on to services through group links hope, and facilitate instill empowerment, consumer they Additionally, intervention. and crisis interaction, one-on-one facilitation, approaches strengths-based recovery, mental illness, about the community educate involvement. consumer and delivery, to service Texas Certification by the provided certification is specialist use recovery Substance support individuals specialists Recovery AddictionBoard of Professionals. There recovery. working toward who are use conditions substance experiencing Texas. in specialists certified recovery use 300 substance than are more Best Practices 272 Self-Directed Planning 2013. Legislature, DSHS implemented the Mental Health ProgramforVeterans inFY were served asaresult of 53,566 peer-to-peer encounters. data provided by volunteers andestimates by volunteer coordinators, 30,000 SMVF a personalcrisisby developing acrisisplan. them.Theyalsodevelop strategiesplans tomanage toaddressearlywarning signs for their own wellness tools, andearlysymptoms, identifytriggers andthen create action revenue funds allocated by the83 Subst anational evidence-based practice. (WRAP®), An example of person-centeredrecovery planning isaWellness Recovery Plan Action Wellness disseminate information to increase capacity of COSPs acrossTexas. establish sustainability plans, further their organizationaldevelopment, andhelp support. Via Hope works with seven COSPs by providing technicalassistance to governed by individuals in recovery. A fundamental component ofCOSPs is peer education and advocacy. COSPs areindependent organizations operatedand subcontracts with LMHAs to deliver services such as peersupport,outreach, DSHS funds seven consumer-operated service providers (COSPs) through C revenue funds appropriated during the82 Using $3 million from general Milit Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas of recovery-oriented practice among behavioral healthpractitioners through The overarching of Recovery goal to Practice (RTP) is toadvancetheimplementation R August, 2014, 24 Texas communities are initiating localROSCs. level to prevent, intervene and treatsubstance use problems anddisorders. Asof organizations, agencies, and individuals that coordinatesservicesat the community substance is a network use planning and service delivery systems of AROSC change. DSHS isalso supporting the recovery-oriented systems for ofcare(ROSC) R volunteers were trained in different formsof peer-to-peer counseling. service members, veterans, andfamily members (SMVF). DuringFY2013, 470SMVF focus for FY 2013 was peer-to-peer support services provided by trained volunteer expansion of theprogram. community whereconsumersandfamiliesworktogether topromote recovery. Health Recovery usesWRAPas one ofitstoolsasitstrives tocreate andpromote a consumer-operated-service-provider-institute. More informationabout COSPs can be foundat ecovery to Pr ecovery-Oriented onsumer-Oper 948 DSHSis using $5million per yearin the 2014-2015 biennium fromgeneral ary ance Veter R Use ecovery Action Plan (WR an Peer 949 a a TheMental Health Program forVeterans’ primary ctice ted rd Legislature to continueimplementationand Systems of Service Providers Curriculum Support 954 The East Texas CoalitionforMental 953 Through WRAP®, consumers develop ThroughWRAP®,consumersdevelop http://www.viahope.org/programs/
Care 951
955 AP f
or ® 952 ) 950
Basedon nd
Best Practices 273 It has over 1,000 members and a comprehensive members and a comprehensive 1,000 It has over 957 Clubhouse participants are referred to as members. The to as members. Clubhouse participants are referred 956 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 of activities and events. During the week, programs help members develop programs help members develop the week, During and events. of activities program Weekends independent living. and employment for self-confidence skills and mission is to be “a Joseph’s St. activities. recreational on social and are focused who are living of life for its members, the quality to maximize working community provides in the clubhouse community Regular involvement mental illness. with a through and empowerment resources, access to local growth, for social opportunities Central to community. in the wider and the clubhouse at decision-making work and associated with this goalstigma harmful the eliminating eventually is reducing and The Clubhouse International Clubhouse Model is a day treatment program forprogram treatment is a day International Clubhouse Model Clubhouse The as an SAMHSA by a mental health condition that is recognized adults diagnosed with evidence-based program. Best Practice: Clubhouse InternationalClubhouse Practice: Best Model Clubhouse participation in comprehensive, discipline-specific training. In 2009, SAMHSA SAMHSA In 2009, training. discipline-specific in comprehensive, participation mental five across curriculum Practice to Recovery of the development the funded the Association, American Psychiatric the organizations: professional health Nurses Association, American Psychiatric the Association, Psychological American Association of Peer InterNational and the Education Work on Social the Council into brought was for Addiction the Association Professionals, NAADAC, Supporters. people with including each field, within Workgroups later. one year the initiative and training curriculum developed condition, a mental health experience with lived in-person training. and/or web-based modules through to be delivered materials within each profession, an separately developed been have the curricula Although and to the materials to recovery approach team and interdisciplinary integrated Health for Mental Foundation the Hogg 2014, encouraged.has been September In to Recovery dissemination of the the to coordinate proposals for a request launched curricula in Texas. Practice be found at: http://www.samhsa. Practice can to Recovery information about More gov/recoverytopractice/ goal of the Clubhouse Model is to contribute to an overall therapeutic environment environment therapeutic to an overall goal is to contribute Model of the Clubhouse within the clubhouse (e.g., clerical responsibilities engaging members with by education, meaningful service), outside employment, and food reception, duties, quality of life. Each member is improved an overall housing, and relationships, a community engagedconsidered a critical part of Membership in important work. of lifetime a and choice in staff, activities, of work choice open participation, allows day” “work-ordered The to all Clubhouse services. reentry and access structures the daily activities of the Clubhouse and is integral to the program. Clubhouses International,are accredited and coordinated internationally through Clubhouse (ICCD). Staff as the International Center for Clubhouse Development formerly known counseling, social work, and education. include psychology, members’ backgrounds is voluntary. or membership fees and attendance dues pay members do not Clubhouse accredited by and was in 1995 established was Houston in House St. Joseph in 2006. International Clubhouse Best Practices 274 recently the SanAntonio Clubhouse became the second. to length and reading level. properties of these measures and making them more consumer-friendly withrespect services. both individualexperiences ofrecovery aswell as therecovery orientationof or communities. results or impactthat services, interventions and supports have onindividuals through the collection and analysis of outcome measures designedtotellusthe quality and effectiveness ofbehavioral healthservices. Thisistypicallyattempted legislators and many other are continually seeking better ways todetermine the Federal and state agencies, care organizations, managed mental health providers, Best Practice: Outcome Measures mental illness.” Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas directed life, andstrive to reachtheir full potential. throughwhich individuals improveof change their health andwellness, live a self- recovery—a decrease insymptoms—rather than personal recovery, which isaprocess traditional clinical diagnoses. Historically, outcomes have focusedonclinical Outcomes for people with mental health conditions should focus onfeaturesbeyond the value of community-based behavioral health services forallstakeholders. outcomes and ensure program value. These measures are ultimatelyused toensure and report outcome data oftheir programming in ordertodemonstrate improved Program 1115 Waiver requiresRegional Healthcare Partnerships (RHPs) totrack by the state government, the Healthcare Transformation andQualityImprovement across communitybehavioral health providers. Inadditiontolegislationset forth that allows thepublic to view and compare performance andoutcomemeasures while SB 126 requiresDSHS to develop and maintain a publicreportingsystem quarterly allocations from theLMHAs to beused as performancebased incentives the return on investment. Additionally, Rider 78 requiresDSHStowithhold10%of ultimately necessitate the collection of performance measures in order todetermine massive restructuring projectrequires extensive investment in timeandfundsthat services enterprise to develop an integrated health servicedelivery approach.This included Rider 78, SB58, SB7and126. SB 58and7directthehealthhuman health services. Billsand riders addressing mental healthperformancemeasures the collection,reporting, dissemination and use ofoutcomedatatoevaluatemental legislative session,mental health legislation incorporatedanincreasedemphasison have become more pertinentto Texas’ behavioral health system. Duringthe83rd Over the past few years, mental health outcomes and provider accountability quality improvement. andfor ongoing management resource allocation. More importantly, however, thedatacanbeusedforprogram information that can be usedto make informed decisions on programs, services, and goals. outcome of aperson-centered treatment plan inclusive ofconsumers’life integration. Implicit to therecovery model is theideathat recovery isa measurable symptom reduction and concepts of recovery, such asfunctioningandcommunity 961 There are a number of emerging recovery outcomemeasuresthat examine 962,963 Thereare still issues to be resolved in strengthening thepsychometric 958 959 St.Joseph House was the first clubhouseaccreditedin Texas and Strong outcome measurement data provides significant 960 Outcomesshouldincludeboth
Best Practices 275
966 Across the country, the country, Across care health integrated as an has emerged for strategy effective the whole treating person by addressing mental primary care, and substance health in use problems a systemic and manner. coordinated
965 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 Additionally, integrating primary care services primary integrating Additionally, Legislature, Nelson) takes a step toward integrating health care. SB 58 toward a step takes Nelson) Legislature, 964 rd into behavioral health settings makes integrated health care integrated makes settings health into behavioral it. Models receive not would otherwise who many to available has low population covered the whether based on of care vary They can health needs. and behavioral health or high physical arrangements co-located as be as simple primary care in which in the same work together health professionals and behavioral organizational the at integration as full as complex office, or tailored have communities underserved and other Rural level. sparsely populated to serve approaches care integrated geographicpopulations. areas and culturally diverse ten non-profit to $720,950 awarded Foundation the Hogg 2012, In August implementation of and/or the planning to support across Texas organizations care programs. health and physical behavioral integrated (83 SB 58 Mental health prevention is defined as a “proactive process that empowers process that empowers as a “proactive is defined health prevention Mental challenges the and transitions by life events of meet to and systems individuals and lifestyles.” behaviors healthy that promote conditions and reinforcing creating Best Practice: Prevention and Earlyand Prevention Practice: Best Intervention Best Practice: Integrated Primary, Primary, Integrated Practice: Best Care Use Substance and Health, Mental has emerged care health integrated as an Acrosscountry, the by addressing person the whole for treating strategy effective in a problems use health and substance mental primary care, settings primary care Using manner. and coordinated systemic services, access to health services enhances for behavioral and has good cost-effective care, is to seeking reduces stigma outcomes. requires targeted case management case targeted requires services to be health rehabilitative and mental care coordination for managed goal the with care Medicaid into integrated of better Additional in Medicaid. enrolled individuals about SB 58 can be found in information section. Environment the Texas Payment Incentive Reform System Delivery many level, local and regional the At integrated address Waiver Transformation the 1115 (DSRIP) projects under Healthcare the 20 Regional projects), phase (4-year In the first healthcare. a proposed 396 DSRIP projects with 1115 Waiver through the created Partnerships and these projects plan to integrate physical of health component, and 140 behavioral can be Additionalabout the 1115 Waiver information way. health in some behavioral Section. Environment the Texas found in Best Practices are apparent byage24. age 14and75percent illness are apparent by mental lifetime casesof Fifty all percent of 276 · following: Several DSHS programs focus onprevention and early intervention, includingthe reap the benefits ofahealthy, productive workforce. the opportunity to avoid thehigh costs associated with untreatedmentalillnessand strategies and identifying and treating people when concernsfirst arise, Texas has is estimated at over $5.2 billion. mental and physical health careneeds, substance use, andlost productivity tosociety to heightenedjuvenile andadult criminal justice involvement, specialeducation, In Texas, a 2009 report found that the annual behavioral healthindirect cost due among others. · effective socialskillshave aneasiertime developing relationshipswithpeers and development and improves familylife. Children who enterkindergarten with Early intervention for youngchildren with mental healthissuessupportshealthy from worsening,and mitigate the impact of serious anddisabling conditions. and substance useproblemscanhelp with recovery, prevent mentalhealthproblems For persons of allages, early identification andtreatmentof emergingmentalhealth Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas · and information,resources and expertise. These centersprovide communities, including schools, withprevention materials Substance Abuse Services funds 11 prevention resource centers acrossthestate. and addressingproblems before they escalate. to reduce the cost of reactionary interventions for existing issues by identifying emphasis on prevention and mental health promotion inthebillhaspotential suicide prevention and substance use prevention and intervention programs. The recommendations, mental health promotion, positive youthdevelopment, education setting. This list shouldprovide information on best practice-based practice programs for public schools that can be implemented inthegeneral education service centers to work together to create a list ofrecommendedbest- identified by DSHS. creative work tailored toaddressconcerns announcements and generates Drug-Free.org. The Texas Partnership facilitates the delivery of public service and other drugs. TheTexas Partnership is anallianceofThePartnership at Texasand media exposure to encourage youthto make wise choices about alcohol The Partnership fora Drug-Free Texas millionsofdollars in advertising generates SB 831from the 83 and productively. enforcement, and improve their ability tolive independently likely to complete high school,have fewer contacts with law mental health services and supports are more age-appropriate intervention, schools, jails, andjuvenile detention centers, such asprimary care, mental health providers, early childhood behavioral health conditionscanoccur through many venues percent are apparent by 24. age all lifetime cases ofmental illness are apparent by 14 age and 75 disorders frequently continue into adulthood. Fifty percentof do better in school. rd 972 Legislative Session(Taylor) requires DSHS, TEA,and regional 970 By investing inprevention andearlyintervention 968 967 Without intervention, child andadolescent Young children who receive effective, 971 969 Screening and assessmentfor Best Practices 277 http:// Seclusion and restraint restraint Seclusion and used methods are such as in settings hospitals, psychiatric criminal justice settings, treatment residential facilities and schools. can be practices The and dangerous traumatic to individuals and staff, causing physical and and psychological harm, even death. The practices can be The practices
973 974
975 The foundation also launched and facilitated the Texas facilitated the Texas also launched and The foundation 978 Since 2006, the Hogg Foundation has sponsored a series of has sponsored a Foundation the Hogg 2006, Since Texas Legislature created the Behavioral the Behavioral created Legislature Texas 977 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 One of the products resulting from the STARS grant was a toolkit grant was from the STARS resulting the products One of 976 Six Core Strategies To Prevent Conflict and Violence: Reducing the Use of Violence: Reducing the and Conflict Prevent To Strategies Six Core trainings around the state using an evidence-based curriculum for culture changeevidence-based using an around the state trainings called . and Restraint Seclusion Management Work Group to review and provide and provide Group to review Management Work safety training, in policy, practices best on recommendations managementand risk and reducing seclusion related to issued cross-agencyof the use. The report restraint workgroup, . at http://www.hogg.utexas.edu/ is available in 2006, HHSCgrant from a federal awarded was Texas In 2007, and restraint of or elimination reduction for the SAMHSA Big in Austin, hospitals psychiatric state in four seclusion project, The Falls. and Vernon/Wichita San Antonio Spring, (STARS), and Seclusion to Restraint Alternatives of Texas State infrastructure evidence-based to advance designed was hospitals to psychiatric four state in these improvements and seclusion use of restraint end the and ultimately reduce health conditions, with mental of consumers treatment in the disorders or use substance co-occurring with those including disabilities. developmental Seclusion and Restraint Reduction Leadership Group. This group is composed Leadership Group. Reduction and Restraint Seclusion In SB 325, the 79 In SB 325, . www.dshs.state.tx.us/cultureofcare engaged and actively has been in restraint Health Mental for Foundation The Hogg seminars, statewide trainings, include initiatives Past reduction efforts. seclusion and publications. Creating a Culture of a Culture Creating setting. in any and restraint seclusion to help reduce designed can be found at Environment fora Trauma-Informed Creating A Toolkit Care: traumatic and dangerous to individuals and staff, causing and dangeroustraumatic staff, and to individuals a minimum, At death. harm, and even psychological and physical environment therapeutic with a positive can conflict their use consumer recovery. and hinder Through the STARS grant, Texas has made significant has Texas grant, STARS Through the reflected in notably most hospitals, state care at the culture of in the improvements or seclusion, the numbers of restraint of incidents numbers the in both reductions or seclusion per spent in restraint of time and the length involved, of individuals incident. Best Practice: Seclusion and Restraint and Seclusion Practice: Best Alternatives force, physical use of the involve and restraint Seclusion or medication use of involuntary movement, of restriction to manageisolation in emergencybehavior circumstances. such as used in settings are methods and restraint Seclusion residential settings, criminal justice hospitals, psychiatric and schools. facilities treatment Best Practices 278 informed approach, but they may not identify as “caregiving” organizations. informed approach, but they may not identify as “caregiving” such asthe criminal justice or employment sectors may want to use atrauma- A “trauma-informedapproach”issimilarto trauma-informed care.Somesectors · Texas-based trauma-informed approach initiatives includethefollowing: disorders, as well asbehavior leading tocontact with the criminal justice system. can lead to mental health problems, chronichealth conditions, andsubstance use inducing experiences. Left unrecognized and untreated, thesetraumaticexperiences justice systems have histories ofphysical and sexual abuse andother typesof trauma- such ashomeless and domestic violence shelters, foster care,or juvenile orcriminal Many people seeking behavioral health treatment or whoareinother programs provides the following as aworkingdefinition for trauma: The Substance Abuse and Mental Health (SAMHSA) Services Administration Approach Practice:Best Trauma-Informed representatives of public andprivate agencies. of individuals with mental health conditions, family members, advocates, and Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas applies to a broader range ofsectors and systems.applies to abroader range however, SAMHSAalso recognizes that “trauma-informed approach”isaterm that as behavioral health care or childwelfare may still use “trauma-informed care;” SAMHSA acknowledges thatsectors involved in providing caregivingservicessuch facilitate healing. specifically addressesthe consequences oftrauma onanindividualand isdesignedto 57 veterans were still participating in theprogram. programs with thefollowing results: 86 veterans completed theprogramand Recovery (JDTR) Project 2010 through a pilot site in BexarCounty. With funding from SAMHSA,DSHS started the Jail Diversion and Trauma drug use over thepreceding 30 days, diagnoses, 22 percentreduction inPTSD 29 in employment, 80 percent reduction in homelessness, 54percentreductionin overfollowing percentages thecourse of oneyear: 150percentincrease change have been published. The 86veterans who completed theprojectshow the symptoms from trauma remain to be evaluated, but other outcome measures and Seeking Safety. uses evidenced-based trauma treatments, including Trauma-Informed Care veterans with trauma-relatedmental health needs fromincarceration. JDTR Affairs, the JDTRProjects seeks to createcommunity-based practicestodivert for Veterans. Basedon close collaboration between DSHS, LMHAs, andVeterans program operated byproject is partofalarger DSHS, theMental Health Program and physical, social, emotional, orspiritual well-being. threatening and that has lasting adverse onthe individual’s effects functioning that is experienced by anindividual as physically or emotionallyharmful or Individual trauma results from anevent, series of events, or setof circumstances 983
985 By the end ofFY2013, 147 veterans hadenteredthepilot 982 Atrauma-informedapproach 986 Assessmentsforreduced 979 984 TheJDTR 981
980
Best Practices 279 In FY 987 People with mental People ), directed DFPS nd 994
990 988 A significant number 993 SB 219, (82 SB 219, 991 DFPS has made an online Trauma Informed Care DFPS has made 992 session was SB 1356 (Van de Putte) that directed the de Putte) SB 1356 (Van was session rd ), requires eight hours of trauma-informed care training for Child of trauma-informed care training for Child hours eight ), requires 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 st Additionally, staff members at the service centers reported a positive centers reported a positive service at the members staff Additionally, 989 Partnering with the Department of Aging and Disability Services (DADS), the Services (DADS), Disability of Aging and Department with the Partnering grant that provided funded a two-year Health Mental for Foundation Hogg to service providers care trauma-informed on assistance and technical training disabilities. Beginning and developmental with intellectual individuals supporting for facility staff provided was assistance and technical training 2012, in February An initial centers. living supported two state at providers and community service a reduction in showed project assistance training and technical of the evaluation the trauma-informed care of implementation the following of restraints the use training. HB 1151, (81 HB 1151, shift in the culture of care in the workplace and an improved rapport between staff staff rapport between and an improved workplace of care in the the culture shift in conduct. improved and individuals that resulted in overall 2013, JDTR was expanded into eight additional communities: Austin, Edinburg, El Austin, communities: eight additional into expanded was JDTR 2013, and Tyler. San Marcos, Sequin, Lubbock, Houston, Paso, percent reduction on PTSD severity scores, 82 percent reduction in moderate moderate in reduction percent 82 on PTSD reduction percent scores, severity self-harm, extreme to in moderate reduction 75 percent depression, to extreme 64.5 percent liability, emotional to extreme in moderate reduction 50 percent in substance reduction percent 34.6 psychosis, to extreme in moderate reduction Score. Scale Marker the Recovery on significant improvement use, and Protective Services (CPS) case workers and supervisors, two hours for other two hours for other and supervisors, (CPS) case workers Services Protective care givers. hours for direct and three CPS staff, training available to assist families, caregivers, and social service providers in and social service providers caregivers, families, to assist available training and child traumatic care informed of trauma understanding a greater developing at www.dfps.state.tx.us/training/ be accessed online training can This stress. trauma_informed_care/ the 83 during Also passed to expand trauma-informed care training and to study its effectiveness. It also It its effectiveness. study and to care training trauma-informed to expand care trauma-informed to receive providers Health HHSCdirected STAR to require to trauma-informed care its commitment Legislature renewed The Texas training. trauma-informed care program, maintain its own only to not authorizing DFPS by welfare throughout the child of similar programs in the development assist but to available. if funding is system Texas Juvenile Justice Department to develop and implement trauma-informed implement and develop Department to Justice Juvenile Texas officers as well as and jail supervision probation juvenile for care training staff. program community-based National Child Traumatic with the partnered Foundation the Hogg In 2014, trauma-informed care for to support toolkit a training to develop Stress Network In conjunction disabilities. developmental other and with intellectual children SafePlace to a grant to awarded the foundation of the toolkit, with development state. the trainings across conduct · · Best Practice: Jail Diversion Jail Practice: Best serious behavioral with people divert intended to services are diversion Jail chargeddisorders who are health minor crimes (typically misdemeanors like with in the criminal justice further involvement from conduct) or disorderly trespassing services. to community-based linking them by system · of people with serious mental health conditions are arrested or jailed for minor or jailed for are arrested conditions health mental with serious of people condition. health to their mental related that are often offenses · Best Practices 280 crimes from entering or unnecessarily considered critical strategies forpreventing people with mentalillnesswhocommit probation following a guiltyplea. of bail, deferred prosecution, deferred sentencing or treatment as aconditionof available treatment resources. Jail diversion may entailtreatmentasacondition Services vary widely because local systems differ intermsof theirsize,needand (DSHS) section. information is available in the TexasAdditional Departmentof State Health Service the number of pilot sites. subsequently directed DSHS toallocate $4 million each yeartosupport expanding legal proceedings. with his or herdefense lawyer andhave a rationaland factual understanding ofthe considered restored and competent to stand trial, a defendantmust be able toconsult with crimes but found bycharged a courttobe incompetent tostand trial.To be intellectual disabilities. Competency restoration is neededwhenindividualsare stays andcostly hospital commitments for someindividualswithmentalillnessor Outpatient competency restoration (OCR) is aneffective alternative tolengthy jail Restoration Best Practice: Outpatient Competency or incarcerated. health conditions often experience bad outcomes when inappropriatelyarrested Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas outpatient restoration services. The DSHS Continuity of CareTask Force Report mental health conditions to contribute to the economy. focus on recovery; furthermore, recovery provides an opportunityfor people with with mental illness is significantly higherthanjail diversion andprogramsthat inpatient restoration average cost of $50,520. The average perperson cost inthe pilot programs was $11,894,farlessthanthe per day of $229 versus over $400 perday forrestoration in astate hospital. served a total of1,061 individuals through the end of FY2013 withanaveragecost In 2007, SB 867, (80 be enrolled in community mental health services and have dropped. their charges participating in the pilots either were restored to competencyorimproved enoughto risk tothemselves or others inthe community. About 55percentof the defendants projects, defendants were fully screened to ensure they didnot poseasignificant in Travis, Bexar, DallasandTarrant counties. Before participating in the pilot is described in theTexas Department of Criminal Justice (TDCJ)section. informationonjaildiversion services participation inrequiredtreatment.Additional population. In these situations, the court maintains judicialoversight of the person’s specialty mental health or substance use courts with courtdockets focusedonthis 995 999 Thecost of ineffective criminaljustice measuresforpeople th
), prompted DSHSto establish OCR pilots atfourinitialsites 1003 Thereare currently 12 OCRsites across thestate that 1002 998 Budget Rider 78(82 Anumber of urban communities inTexas have remaining in thecriminaljustice system. 1001 recommended expansionof nd 996 Legislative Session) Jail diversion servicesare 10041005 997
1000
Best Practices 281
1007
1013
1006 Individuals who use 1010 This funding will provide This funding will provide 1008 Additionally, studies consistently show no show consistently studies Additionally, 1012
1011 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 Telepsychiatry also provides an opportunity for individuals to obtain obtain for individuals to an opportunity also provides Telepsychiatry 1009 a second opinion in an area where there is only one psychiatrist, and enables one psychiatrist, is only there area where opinion in an a second as a team. more effectively to work professionals healthcare Best Practice: Telemedicine/Telehealth Best Practice: to deliver is the use of technology telehealth) broadly, (or more Telemedicine use. substance health and mental for including services care services, health services for psychiatric provides that of telemedicine is a form Telepsychiatry The American Psychiatric locations. or underserved in a remote who live individuals to ways effective of the most one currently is “Telepsychiatry states: Association care for individuals living in underserved to psychiatric access to access increase areas.” Best Practice: Child and Family Mental Family and Child Practice: Best of System Health Care for framework organizational and philosophical is the care approach of The system of child and family mental health and delivery planning systemic the collaborative, of care have systems 25 years, for over and research practice in Established services. child and resulting in better approach effective a cost to be nationally proven been supports. and to services access outcomes and increased family The Achieving Successful Systems Enriching Texas Initiative (ASSET) grant was grant was (ASSET) Initiative The AchievingEnriching Texas Systems Successful and Human Health of Texas project and is a joint of Care System Texas create used to Research Social Work Center for and the (HHSC),Commission Services DSHS, HHSC of notified was Texas 2013, In July at Austin. Texas of University at The Care. of System to continue Texas funding additional difference between telemedicine and traditional health care in the provider’s ability health care in the provider’s telemedicine and traditional between difference and create treatment plans. diagnose, clinical information, accurately to obtain telepsychiatry often feel the communication between their physicians has improved has improved physicians their between feel the communication often telepsychiatry from treatment and feel their receive, care they with the satisfied are their outcomes, is reliable. telepsychiatry Programs using this approach provide coordinated care that includes community- coordinated approach provide Programs using this model is based on This and their families. supports for children based services and community of services that are the core value emphasizes that initiative a federal competent. and culturally family focused, centered, based, child system and federal grants to support state received communities have Texas Several through HHSC’s training and support technical which receive of care programs, HHSC2011, Youth. In a received and Coordination for Children Program Office of of care approach. of the system expansion the statewide SAMHSA grant to support support for an additional four years. Further information is available at http://www. information is available Further four years. additional for an support txsystemofcare.org/about-us. Many studies with large sample sizes and sound scientific rigor have found that and sound scientific rigor found that sizes with large have sample studies Many money when compared to and payers providers, patients, can save telemedicine approaches. health care traditional Best Practices 282 telehealth eases the stigma andembarrassment of seekingbehavioral healthcare. areas.mental health professional shortage For some consumers, the useof health care professionals, especially for Texans living in federallydesignated Telehealth increases accesstocare by maximizing the useofavailable behavioral located. consumer is locatedand a hubsitewhere the consultingprofessionalprovider is areas using technology to connect a remote site such asaclinicorschoolwherethe Telemedicine is typically used inTexas to provide services toruralorunderserved increase in expenditures. in number of providers, 128percent increase in numberof clients, and 143 percent use oftelemedicine between state fiscalyears 2009and2011: 113percent increase providers, locationsand pilot projects. found the following inthe changes HHSC from 2001 to2011. These modifications includeprovisions toexpandeligible 1998, serviceshave been modified and expandedthrougheachlegislative session century. potential for thegreatest economic impact on rising healthcosts inTexas duringthis The StatewideHealth Coordinating Council reports that telehealth holds the presentations/Benefits_Of_Telemedicine.pdf. UTMB’s extensive telemedicineprogram is available at http://telehealth.utmb.edu/ community health and mental health centers, andschools. Further informationon multiple settings, includingTexas Department of CriminalJustice (TDCJ)facilities, at Galveston hasawell-established telemedicine program that provides servicesto access to specialists. Inaddition, the University of Texas Medical Branch(UTMB) Community health and mentalhealth centers are using technology to increase subspecialty care in Medicaid. telehealth network expansion initiatives aimed at improving accesstospecialtyand coverage of telehealth services, improved tracking of telehealth services, andother Texans committed suicide. almost twiceasmany deathsasaresultoffirearmhomicide. 2011, therewerenearly20,000 suicidedeathsasaresultoftheusefirearm, Prevention Best Practice: Suicide Awareness and area. chronic care patients or carefrom specialists geographical across a large In some instances, telemedicine has shown improved care, suchas: monitoring Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas In 2011, approximately 39,500 peoplediedby suicideintheUnited States. of students werelikely toattempt suicide. depressed, 16percentof students wereactively consideringsuicide, and 11percent Survey in2011 revealed that 29percentofstudents identified themselves as collected from2,171 Texas high school students through theYouth RiskBehavior with amental illness. suicide, over 90percent of thosewhodie by suicidenationallyhave beendiagnosed the third leading cause of death among young adult females ages 25-35.the thirdleadingcauseofdeathamongyoungadult femalesages 15-34,and issecond leadingcauseofdeathamongmaleadolescents andadultsages 1016 SinceTexas Medicaid began providing telemedicine medicalservicesin 1024 Whilewhite maleshave thehighest suiciderates, suicide 1017 1021 Thesecost increasesare attributed to expanded 1018 Datafrom2012 shows thatsuicideinTexas isthe 1023 Althoughthereisnoone causeof 1020 In2012, 3,032 1022 1019 Data 1014 In In
1015
Best Practices 283 . Data from 2012 shows 2012 from Data is Texas suicide in that cause the second leading of among male death and adults adolescents is the and ages 15-34, cause of leading third adult among young death females ages 25-35.
1025, 1026 1025,
1027 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 National Suicide Prevention Lifeline: 1-800-273-TALK (8255) 1-800-273-TALK Lifeline: Prevention Suicide National 1-888-628-9454 del Suicidio: de Prevencion Red Nacional (8255) 1-800-273-TALK Hotline: Suicide Prevention Veterans (LGBTQ) or questioning transgender bisexual, (for lesbian, gay, Hotline Trevor 1-866-488-7386 youth): LMHA of all Texas a list For LMHAs also operate crisis hotlines. Texas go to http://www.dshs.state.tx.us/mhsa/lmha-list/ numbers, crisis hotline The United States Interagency Council on Homelessness describes Housing First First InteragencyStates The United describes Housing Homelessness Council on quickly as possible as housing affordable permanent, that offers as “an approach the and then provides homelessness, experiencing for individuals and families Best Practice: Housing Practice: Best First Housing · · · · · cuts across all ethnicities, ages, races and genders. races ages, ethnicities, across all cuts Suicide in Texas is a serious public health concern concern health public a serious is Texas Suicide in through addressed effectively that could be and one prevention and coordinated comprehensive Council Suicide Prevention The Texas practices. local suicide between effort is a collaborative agencies to and state coalitions prevention plan prevention suicide an effective implement an include activities council’s The in Texas. trainings, suicide prevention website, informational bilingual conference, suicide prevention an annual public awareness and packets, information of list has published a The council campaigns. prevention, relate to suicide that statutes Texas also offers free The council reporting. services and prevention about suicide resources downloadable visit the information more For and intervention. at http://www. website Prevention Suicide Texas . texassuicideprevention.org Prevention for Suicide The American Foundation suicide is another Chapter (AFSP) Central Texas AFSP is Texans. for available resource prevention understanding dedicated to nonprofit a national advocacyeducation, through research, suicide and outreach. The and preventing opportunities, volunteer on suicide prevention, information AFSP website provides suicide a surviving individuals for support and grants research resources, educational at http://www.afsp.org/centraltexas can be found information More loss. experiencing anyone to available hotlines 24-hour toll-free, the following DSHS lists crisis: emotional a suicidal or Best Practices 284 address other needs, such as mentalhealth needs. housing provides astable platform that enables people experiencing homelessness to program, refer totheTexas Environment section. andadditionalservices offeredthoughthe more informationaboutthe HCBS-AMH program.Forauthorities toprovide housing vouchers topeople intheHCBS-AMH it is likely thatTDHCA willcoordinatehousing assistance withpublichousing still in the planning phases, andTDHCA’s specific involvement isunclear. However, is so theirneedscanbemet outsideofaninpatientpsychiatric hospital.HCBS-AMH will provide awidevariety ofhome and community-based servicestothese individuals needacuteinpatientservices.in inpatientfacilitiesaftertheynolonger HCBS-AMH service needsofasmallnumber mental healthconsumerswhoreceive extended care operatedby DSHS, program. HCBS-AMH, will addressthecommon (HCBS-AMH) development oftheHome and Community-Based Mental Services—Adult Health supportive housing opportunities. Funds for the1915(i)waiver are being used forthe amendment totheTexas Medicaid programtosupportthedevelopment ofpermanent -2015 legislative appropriations request for state matchfunds for a 1915(i)state plan serious mentalillness. DSHSwas grantedanexceptional itemrequest initsFY2014 working toincrease the availability ofpermanentsupportive housingforpeoplewith In collaborationwithTDHCA, theDepartmentofStateHealth Services(DSHS) is Based-Practices-EBP-KIT/SMA10-4510. at For more information on permanent supportive housingseetheSAMHSAresources · · · · · · · According to SAMHSA, the coreelements of permanent supportive housingare: According component in promoting recovery for people with behavioral healthconditions. in communitylife. PSH isacost-effective, evidence-basedpracticethat isa key who experiencechronic homelessness, tolive independentlyandparticipate ofsupport services that enable vulnerable tenants,to arange especially people Permanent supportive housing(PSH) is permanent, affordable housing linked Permanent needed to keep their housing and avoid returning to homelessness” supportive services and connections to the community-based supports people Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas experiencing homelessness also have a mentalhealth condition. temporary housing and repeated use ofpublic acute caresystems. Research has demonstrated thatpermanent housing can cost less thanlongstays in not required to remain in housing. First, servicesareoffered andmade available; however, participationinservices is http://store.samhsa.gov/product/Permanent-Supportive-Housing-Evidence- Available services andsupports. ofaccessto housing. Immediacy Full underfederal and state rights of tenancy law. Integration with the surrounding community. Affordability. Functional and servicesstaff. separation of housing management A highdegree of choice offered to tenants. Supportive Housing 1032
1030 1029 Permanent 1028 Many people WithHousing 1031
Best Practices 285
1033
1035 Federally funded Federally has shown research than 80 more that of percent Oxford House residents avoided relapse. legislative session, legislative rd During the 83 1036 DSHS provides DSHS provides 1037 The program has proven both treatment-effective treatment-effective both has proven The program 1034
1039 1038 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 ord House ord xf In 2011, SAMHSA included the Oxford House on the National Registry of Evidence- Registry National on the House the Oxford included SAMHSA In 2011, Practices. based Programs and and cost-effective for individuals attempting to achieve long-term recovery from long-term recovery achieve to individuals attempting for and cost-effective that research has shown funded Federally mental illness. and co-occurring addiction relapse. avoided residents House of Oxford 80 percent more than these houses with a start-up loan of $4,000, which is which of $4,000, loan start-up a houses with these years of full within two in House the Oxford by paid back each day. per bed roughly $2.60 DSHS expends receipt. per $14.29 is around resident the by per bed paid The cost of the expenses an equal share member pays as each day, house. the to maintain The Oxford House model has seen significant growth in growth has seen significant model House The Oxford in and 2013, in opened Houses Oxford Twenty-eight Texas. of one average rate at an are opening Houses Oxford 2014 Oxford growing fastest the Texas week, making house per program, success of the the proven Due to state. House in Texas and is anticipated nationally growth continued coming years. during the Oxford House Inc. runs a national network of individual Oxford Houses that serve as as serve that Houses individual Oxford of network a national runs Inc. Oxford House All Oxford use issues. substance from individuals in recovery housing for supportive “1) the group charter conditions: established the following to adhere must Houses the Oxford of policies and procedures the self-run following democratically be must and 3) the group self-supporting, be financially group must Manua,l 2) the House drugs.” to using alcohol or illicit who returns resident any immediately expel must O over $1.1 million was appropriated to expand the Oxford Oxford expand the to appropriated million was $1.1 over state. across the model House and of the houses 63 in Texas, Houses 115 Oxford Of the DSHS. by 482 of the beds are contracted The first Oxford House opened in Texas in 1991. As of May 2014, there were 115 2014, of May Texas in 1991. As in opened House Oxford The first DSHS contracts beds throughout Texas. of 871 available with a total Oxford Houses for the provision in Texas located Houses of the Oxford half with approximately House Inc. locates Oxford areas. metropolitan Texas in five services of residential DSHS-fundedcompleted successfully who have individuals housing for substance to an who are at risk of returning and employed, currently are not use treatment, who sobriety. compromise could that environment Introduction 286 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas
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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 Appendices Appendices 288 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Appendices 289 31 34 35 43 44 45 59 60 28 29 61 65 66 69 70 71 74 74 75 83 83 84 86 86 88 61 90 95 96 97 92 97 99 100 101 102 103 103 104 104 105 107 108 109 110 110
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 community centers compared to percent of persons readmitted to a state psychiatric hospital within 30 days. days. 30 within hospital psychiatric state a to readmitted ofpersons percent to compared centers community Costs Premium Monthly Averages Categories All and Averages Plan Silver Texas: in Marketplace Federal 4. Figure Credits Tax After Costs Premium Monthly by Separated ofIndividuals Percentage Texas: in Marketplace Federal 2014 5. Figure Process Evaluation Sunset 6. Figure Timeframe Evaluation Sunset 7. Figure 2013 ofNovember as Areas Shortage Professional Health Mental Designated Federally 8. Figure Enterprise Services Human and Health 9. Figure Regions Services Human and Health 10. Figure Agency by Request System HHS 11. Figure Demonstration Care Integrated Eligibles Dual Texas 2. Figure Differences SSDI and SSI 3. Figure List of List Figures Eligible Dual Fully and Enrollment Medicare Texas 1. Figure Figure 12. Methods ofMethods Financing 12. Figure Programs Care Managed Medicaid/CHIP Texas 14. Figure 2014 Levels: Income Annual & Texas in Coverage Subsidized 15. Figure Services Health Behavioral Medicaid-Funded 16. Figure 2011 Expenditures, and Beneficiaries Medicaid Texas 17. Figure Enrollment CHIP 18. Figure Services CHIP 2016-2017: FY Request Appropriations Legislative 19. Figure Programs CHIP and Medicaid for Measures ofCare Quality Health Behavioral Selected 20. Figure 2003-2015 Spending Annual Spending: Health Behavioral Public Texas 21. Figure funds) (all Request Appropriations Legislative 2016-2017 FY and Appropriations 2015 – 2014 FY Expenditures, State 2013 FY 22. Figure Services Health Mental Community for Needs Unmet 23. Figure 2014 May FYTD – 2012 FY – Served Adults by List Waiting Adult ofImpact 24. Figure 2014 May FYTD – 2012 FY – Served Children by List Waiting ofChild Impact 25. Figure 2014 Levels: Income Annual & Texas in Coverage Subsidized 26. Figure Population Priroity LMHA 27. Figure Figure 13. Medicaid Funded Programs Across HHSC Agencies HHSC Across Programs Funded Medicaid 13. Figure Figure 28. Map of LMHAs and 39 Service Regions Regions Service 39 and ofLMHAs Map 28. Figure Figure 30. Utilization/Cost for Adult Community Mental Health Services Health Mental Community Adult for Utilization/Cost 30. Figure Services Health Mental Community Receiving Adults for Measures ofCare Quality Selected 31. Figure Adolescents and Children for ofCare Level Recovery and Resiliency Texas 32. Figure Figure 29. Texas Resiliency and Recovery Level of Care for Adults for of Level Recovery and Care Resiliency Texas 29. Figure Figure 33. Utilization/Cost for Child and Adolescent Community Mental Health Services Health Mental Community Adolescent and Child for Utilization/Cost 33. Figure Services Health Mental Community Receiving Adolescents and Children for Measures ofCare Quality Selected 34. Figure Services Crisis 35. Figure Figure 36. Utilization/Cost for Adult Community Mental Health Services Health Mental Community Adult for Utilization/Cost 36. Figure Measures ofCare Quality 37. Figure Figure 38. NorthSTAR Mental Health Benefits Health Mental NorthSTAR 38. Figure Population By Services ofNorthSTAR Utilization 39. Figure Services NorthSTAR for COSTS 2013 FY 40. Figure NorthSTAR for Measures ofQuality Selected Care 41. Figure Figure 42. State Mental Health Hospitals: 2014* Hospitals: Health Mental State 42. Figure 2012 FY Texas, in Hospitals State at Types, Bed by Beds, Health ofMental Number 43. Figure Hospitals State for Costs and Utilization 44. Figure ofNumber DSHS-funded at services transitional and services outpatient crisis accessing persons 45. Figure
Figure 46. Contracted Community & Private Hospitals, Allocated Funds and Number ofNumber and Beds Funds Allocated Hospitals, Private & Community Contracted 46. Figure Appendices 290 Figure 94. Youth Discharged and linked to Community Services, including Behavioral Health treatment, Figure 93. Specialized Treatment Programs in Texas Figure 92. TJJD Secure Facilities Figure 91. Common Juvenile Justice Definitions Figure 90. Terms and Concepts Figure 89. Referrals and Dispositions of TJJD youth in 2012 and 2013 Figure 86. Substance Use Service Descriptions Figure 85. Specialized Mental Health Programs Figure 84. Health Service Level of Figure 83. Behavioral Health Related Divisions within TDCJ Figure 82. TDCJ Operating Budget for FY 2013 Figure 88. Figure 87. Special Programs for Offenders with Behavioral Health Conditions Figure 81. Figure 80. Common Criminal Justice Definitions Figure 79. 83rd Session Criminal Justice and Mental Health Legislation Figure 78. DBS Services Figure 77. Utilization Disability of Determination Services in Texas Figure 76. Disability Claims Process for SSI and SSDI Benefits Figure 75. Outcomes for Individuals utilizing Vocational Rehabilitation Services Figure 74. Characteristics Individuals of utilizing ECI Services Figure 73. Percentage Enrolled by Reason for Eligibility Figure 72. Program Cost Trends - Average Monthly Cost Per Individual for Dads Waiver and Institutional Programs Figure 71. Percentage Peopleof Enrolled in Dads Programs with a Behavioral Health Diagnosis
Figure 70. Total Cost Programsof Serving Individuals with Disabilities (Data on costs for behavioral health services in Figure 69. Residential Programs Utilization and Costs of for Persons with Disabilities Figure 68. Institutional Care Eligibility and Behavioral Health-Related Services Disabilities Figure 67. State Supported Living Center Census Data Figure 66. Utilization and Costs for DADS HCS Waivers Figure 65. Community-Based Waiver Eligibility and Behavioral Health-Related Services Disabilities Figure 64. Child Care Operations in Texas Figure 63. APS Investigation Process Figure 62. Prevention and Early Intervention Programs and Services and their Costs and Availability in Texas Figure 61. Psychotropic Medication Prescriptions Figure 60. Disproportionality in the CPS System Figure 59. Confirmed Child Fatalities Due to Abuse or Neglect Figure 58. Child Mortalities in Texas Figure 57. Health Insurance Programs for Former Foster Care Children Figure 56. CPS Investigation Process Figure 55. Child Protection Courts and Covered Regions Figure 54. Care Selected Quality of Measures for Youth Substance Use Services Figure 53. Selected Quality Careof Measures for Adult Substance Use Services Figure 52. Utilization and Costs for Youth Substance Use Services Figure 51. Utilization and Costs for Adult Substance Use Services Figure 50. Available Substance Use Services Through DSHS Figure 49. Daily Census Snapshot for Civil and Forensic Commitments in State Mental Health Hospitals 2001-2014 Figure 48. Comparison Competencyof Restoration Programs** Figure 47. Placement Determination For Competency Restoration Programs Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas care management and support services in FY 2013 these programs is not available)
214 211 210 208 207 207 197 192 191 190 189 187 192 194 186 184 180 179 177 175 172 171 164 164 162 162 160 160 157 155 147 146 140 142 138 136 136 133 131 129 121 121 120 119 118 114 113 111 Appendices 291 215 217 224 227 231 233 239 248 252 270
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 95. Youth with Behavioral Health Conditions and Juvenile Justice Involvement Served in the Community, FY 2013 FY Community, the in Served Involvement Justice Juvenile and Conditions Health Behavioral with Youth 95. Figure Figure 96. Average Expected Length of Stay in Various Community Programs 621 Programs Community Various in ofStay Length Expected Average 96. Figure Methods Delivery Service Health Mental 97. Figure Education Special for Support State Declining 98. Figure Regions Center Service of Education Map 99. Figure Support Behavior Positive & Instructional of School-wide Continuum 100. Figure 2002-2013 from Expulsions School Public Texas 101. Figure of Assistance Housing Types 102. Figure 2013 in Funding TDHCA’s 103. Figure Model Clinical Traditional vs. Model Focused Recovery 104. Figure Appendices 292 DRS -Division for Rehabilitation Services DHHS -U.S. Department of Health and Human Services DFPS -Texas Department of Family and Protective Services DDS -Division of Disability Determination Services DBS -Division for Blindand Visually Impaired Services DBMD -Deaf-Blind with Multiple Disabilities [waiver program] DARS -Texas Department of Assistive and Rehabilitative Services DAHS Health -Day Services Activity DAEP -Disciplinary Alternative Education Program DADS -Texas Department of Agingand Disability Services CSU -CrisisStabilization Unit CSBG -Community Services Block Grant -CommunityResource Coordination Group CRCG CPS- Certified Peer Specialist CPS -ChildProtective Services Service Provider COSP -Consumer-Operated COPSD - Co-occurring Psychiatric andSubstance Use Disorder COPE -Collaborative OpportunitiesforPositive Experiences COG -Council of Governments CMS -Centers for Medicare and Medicaid Services CLASS -Community Living Assistance and Support Services [waiver program] CIT -Crisis Intervention Team CIS - Communities in Schools CINS -ConductinNeed of Supervision CIL -CenterforIndependent Living HealthCIHCP - County Indigent Care Program CHIP -Children’s Health Insurance Program CFP -Certified Family Partner CEU -ContinuingEducation Unit CDC -Centers for Disease Control and Prevention - Criss ColeRehabilitation Center CCRC CCL -ChildCareLicensing CBT -Cognitive Behavioral Therapy -Community-Based AlternativesCBA CAS CANS Needs and Strengths [assessment] -Child and Adolescent -BrainInjury Screening Questionnaire BISQ AYBR -Amy Young Barrier Removal [program] ASSET Successful Systems Enriching Texas -Achieving [initiative grant] ASD -Autism Spectrum Disorder ASCA ARS -Alternative Response System ProtectiveAPS -Adult Services Needsand Strengths Assessment ANSA -Adult AMFI -AreaMedian Family Income AFSP -AmericanFoundation for Suicide Prevention ACA Acronyms of List Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas -CommunityAttendant Services -PatientAct Protection and Affordable Care -American School Counselor Association Appendices 293 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 Qualified Health Center Qualified - Home and Community-Based Services—Adult Mental Health [program] Health Services—Adult Mental and Community-Based - Home - Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition Disorders, Mental Manual for and Statistical - Diagnostic - Health Maintenance Program Maintenance - Health - Electroconvulsive Therapy - Electroconvulsive - Food and Drug Administration and Drug - Food - Employee Assistance Plan Assistance - Employee - Fund for Veterans’ Assistance Assistance Veterans’ for - Fund - Incompetent to Stand Trial to - Incompetent GAD Disorder - Generalized Anxiety GAFof Functioning Assessment - Global General AccountingOffice GAO- U.S. GRO[facility] Operations Residential - General Assistance Homebuyer HBA - Texas Services and Community-Based HCBS - Home HCBS-AMH Set Data and Information Effectiveness Healthcare HEDIS - Services and Human HHS- Health HHSC Commission Human Services and - Health Program and Services Housing HHSP - Homeless [program] Payment Premium Insurance HIPP - Health HMO Credit [program] Tax HTC - Home Fund Trust HTF - Housing and Urban Development of Housing Department HUD - U.S. Development Clubhouse Center for ICCD - International Care Facility ICF - Intermediate disabilities developmental and IDD - intellectual ActEducation Disabilities with IDEA - Individuals Plan Education IEP - Individualized Service Plan Individualized Family IFSP - Disease Mental for IMD - Institution District School ISD - Independent ISS - In-School Suspension IST Program Education Alternative Justice - Juvenile JJAEP Recovery and Trauma Diversion - Jail JDTR Board Budget LBB - Legislative Queer Bisexual, Transgender, Gay, - Lesbian, LGTBQ [program] Credit Tax Housing Income Low LIHTC - - Delivery System Reform Incentive Pool Pool Reform Incentive System DSRIP - Delivery EAP Practice EBP - Evidence-Based ECT [program] Childhood Intervention ECI - Early and Treatment Diagnosis Screening, and Periodic - Early EPSDT ESG - EmergencyGrants Solutions FDA [program] Care Children Foster - Former FFCC [program] in Higher Education Care Foster - Former FFCHE Percentage Assistance Medical FMAP - Federal Guideline Poverty FPG - Federal Level Poverty FPL - Federal - Federally FQHC School to Attend Failure - FTAS FVA - Texas Department of State Health Services Services Health State of Department Texas - DSHS Disability - Intellectual Manual - Diagnostic DM-ID DSM-V Appendices 294 SSA- Social Security Administration SNAP -Supplemental Nutrition Assistance Program SMVF -Service Members, Veterans, and Family Members SHARS -SchoolHealth and Related Services Council SHAC - School Health Advisory SEL -SocialandEmotional Learning SED -Severe Emotional Disturbance SAPIT - Substance Abuse Prevention, Intervention, and Treatment SAMHSA -Substance Abuse andMental Health Services Administration RTC System ofCare -Recovery-Oriented ROSC RHP -Regional Healthcare Partnership andDisease Management RDM -Resiliency - Post-TraumaticPTSD Stress Disorder PSH -Permanent Supportive Housing -PreventionPRC Resource Center PRA -Project Rental Assistance [demonstration program] PPO PPCD -Pre-schoolProgram for Children with Disabilities PHC -Primary Home Care PHA -PublicHousing Agency PEI -Prevention and Early Intervention PE -PASRR Evaluation PCP PASRR Suspension OSS -Out-of-School OIO -OfficeoftheIndependent Ombudsman OCR -Outpatient Competency Restoration OCD NNTY -National Network for Youth Transition NGRI -Not Guilty By Reason of Insanity NCTIC -National Center for Trauma Informed Care NCTSN -National Child Traumatic Stress Network Early Childhood NCEC -Non-Categorical NAMI -National Alliance on Mental Illness MTFCY - Medicaid for Transitioning Foster Care Youth MRSA- Medicaid RuralService Area MOU -Memorandum of Understanding MHPAEA - Mental Health Parity Equity Act andAddiction MHFA -Mental Health First Aid MH -Mental Health MDD MDCP -Medically Dependent Children Program MCOT - Mobile Crisis Outreach Team CareOrganization MCO- Managed MAYSI -Massachusetts Youth Screening Instrument LTSS -Long-Term Services and Supports LSSP -LicensedSpecialist inSchool Psychology LOC -Level ofCare LMHA -Local Mental Health Authority Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas - Primary Care Physician - Preferred provider organization - Residential Treatment Center - Obsessive-compulsive Disorder - MajorDepressive Disorder - Pre-Admission Screening and Resident Review - Pre-Admission Appendices 295 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 - World Health Organization Health - World - Texas Juvenile Justice Department Justice Juvenile - Texas - Texas Veterans Commission Veterans - Texas - Texas Youth Commission Youth - Texas - Transition-Age Youth Youth - Transition-Age - Significant Traditional Provider Traditional - Significant - Uncompensated Care - Uncompensated - U.S. Department of Veteran Affairs of Veteran Department - U.S. - Wellness Recovery Action Plan Recovery WRAP® - Wellness [waiver] Services Empowerment YES -Youth UC VA Network Service Integrated VISN - Veterans Rehabilitation VR - Vocational Organization Service VSOVeterans - WHO - Shared Services Arrangement Services Shared SSA - Insurance Disability Security - Social SSDI Income Security SSI - Supplemental Center Living State Supported SSLC - and Seclusion to Restraint Alternatives of Texas - State STARS STP Supports and Interventions Behavioral Positive - School-wide SWPBIS Families for Needy Assistance - Temporary TANF TAY Brain Injury TBI - Traumatic Assistance Rental TBRA - Tenant-Based Initiative Support Behavior TBSI - Texas TCOOMMI Mental Impairments - Medical or on Offenders with Office Correctional Texas Association Chiefs Police - Texas TCPA Justice Criminal of Department TDCJ - Texas Affairs and Community of Housing Department - Texas TDHCA of Insurance Department TDI - Texas Education Agency TEA - Texas TIC - Trauma-Informed Care TJJD Commission Probation Juvenile - Texas TJPC Partnership and Healthcare Medicaid TMHP - Texas Initiative Recovery TRI - Texas ResiliencyRecovery and TRR - Texas TVC program] [waiver Living Home - Texas TxHmL TYC Appendices 296 Texans CareforChildren:http://texanscareforchildren.org/ Child Welfare LeagueofAmerica:http://www.cwla.org/ mentalhealth/ Child Welfare InformationGateway: http://www.childwelfare.gov/systemwide/ Child Via Hope –Texas Mental Health Resource:http://www.viahope.org/ Pillars ofPeer Support:http://www.pillarsofpeersupport.org/ services/peer.php Institute forRecovery andCommunityIntegration:http://www.mhrecovery.org/ Georgia Certified Peer Specialist Project:http://www.gacps.org/ Copeland CenterforWellness andRecovery: http://copelandcenter.com/ Certified Peer Texas Workforce Commission:www.twc.state.tx.us tx.us Texas DepartmentofHousing andCommunityAffairs(TDHCS):www.tdhca.state. Texas (TEA):www.tea.state.tx.us EducationAgency Texas Juvenile Justice Department(TJJD): www.tjjd.texas.gov Texas DepartmentofCriminalJustice (TDCJ):www.tdcj.state.tx.us tx.us/index.shtml Texas DepartmentofAssistive andRehabilitative Services(DARS): www.dars.state. Texas DepartmentofAgingandDisability Services(DADS): www.dads.state.tx.us Texas DepartmentofFamily andProtective Services(DFPS):www.dfps.state.tx.us Texas DepartmentofStateHealth Services(DSHS):www.dshs.state.tx.us dex.shtml Texas www.hhsc.state.tx.us/in Health andHumanServicesCommission(HHSC): - Agency Additional Resources Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/index.shtml National Institute ofMental Mental Health, Health: ChildandAdolescent http:// org/ National Federation ofFamilies forChildren’s Mental Health: http://www.ffcmh. National ChildTraumatic StressNetwork: http://www.nctsnet.org/ Initiative: http://www.buildingbridges4youth.org/index.htmlBuilding Bridges cy-Documents.aspx Success-for-All-Children/Transition-Aged-Youth/Transition-Aged-Youth-Poli- Bazelon CenterforMental Health Law: http://www.bazelon.org/Where-We-Stand/ Children’s Welfare Websites Ment Specialists al He alth Appendices 297 - - h alt l He al tions Ment and ompetency C aniza Org ustice Justice mily amily inguistic Linguistic nd F and 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 al Rights onsumer http://nccc. National Center for Cultural Competence: University Georgetown georgetown.edu of health care: Elimi- Enhancing the delivery Health. for Mental Foundation Hogg integrated and linguistically centered a culturally nating health disparities through - : http://www.hogg.utexas.edu/uploads/documents/FinalRe approach health care port%20-ConsensusStatementsRecommendations.pdf - NAMI Multicultural Action Center: http://www.nami.org/Template.cfm?Sec tion=Multicultural_Support&Template=/TaggedPage/TaggedPageDisplay.cfm&T Cultur PLID=56&ContentID=25443 Health: http:// & Human Services: Office of Minority Department of Health U.S. www.minorityhealth.hhs.gov Health- Culture, Race, Mental Office Supplemental Report on Surgeon General’s U.S. and Ethnicity: www.surgeongeneral.gov/library/mentalhealth/cre Partner (TA Health Mental for Child and Family Partnership Assistance Technical ship): http://www.tapartnership.org/COP/CLC/default.php Criminal/Juvenile Health and Mental Criminal Justice Center. Justice Council on State Governments - Consensus Project: http://csgjusticecenter.org/mental-health-projects/re port-of-the-consensus-project/ http://www.ncmhjj.com Justice: and Juvenile Health National Center for Mental Transformation: http:// and Justice Health GAINS Center for Behavioral SAMHSA’s gainscenter.samhsa.gov/ Appleseed: http://www.texasappleseed.net/ Texas Coalition: http://www.texascjc.org/ Criminal Justice Texas http://www.texaspolicy.com/ Foundation: Public Policy Texas C http://www.mytce.org/ for Empowerment: Catalyst Texas http://www.viahope.org/ – Texas: Via Hope Antonio: http://www.prosumersinternational.org/ Prosumers of San http://www.mentalhealthamerica.net/ America: Health Mental http://www.mhatexas.org/ Texas: America – Health Mental Illness: http://www.nami.org/ National Alliance on Mental http://www.namitexas.org/ Illness – Texas: National Alliance on Mental Center: http://www.power2u.org/ National Empowerment Civil http://www.bazelon.org Law: Health Mental Center for L. Bazelon David Judge tx.org/ disabilityrights https://www. Rights Texas: Disability Texans Care for Children: http://texanscareforchildren.org/ for Children: Care Texans http://tnoys.org/ Services: Youth of Network Texas Appendices 298 Ment Intellectu council.org/cs/center_for_integrated_health_solutions National CouncilonCommunity Behavioral Healthcare: http://www.thenational- Integrated Behavioral Health Project(IBHP):http://www.ibhp.org/ Hogg Foundation forMental Health: http://www.hogg.utexas.edu/index.php IntegratedMental HealthAdvancing Solutions(AIMS)Center: http://aims.uw.edu/ ademy.ahrq.gov/ Academy forIntegratingBehavioral Health andPrimaryCare:http://integrationac- Integr Subst U.S. DepartmentofHousing andUrbanDevelopment: http://www.huduser.org/ Texas DepartmentofHousing &Community Affairs:https://www.tdhca.state.tx.us/ Technical Assistance Collaborative: http://www.tacinc.org/ National AlliancetoEndHomelessness: http://www.endhomelessness.org/ department/permanent-supportive-housing-initiative Neighborhood Housing andCommunityDevelopment: http://www.austintexas.gov/ Coalition forSupportive Housing: http://www.csh.org/csh-in-the-field/texas Housing dataoutcomes/urs Health ServicesUniformReportingSystem OutputTables: //www.samhsa.gov/ 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 Texas StateofMindPolicy Institute: http://www.texasstateofmind.org United-States-2010/SMA12-4681 Health http://store.samhsa.gov/product/Mental-Health- ServicesAdministration: Mental Health,UnitedStates,2010. Available throughtheSubstance UseandMental Gener 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/about/staff/ Early Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas al He ance Childhood al a ted Ph ysic Inf alth al Use orma Disability with C onditions tion on and al and Ment Ment Ment al He C o-occurring al He al He alth alth alth Care and Appendices 299 - pment Develo orce orce Schools Workf Wellness h alt in h alt 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 l He al l He al ecovery ecovery exas Education Agency: http://www.tea.state.tx.us/ R http://www.power2u.org/ Center: National Empowerment National Council on Alcoholism and Drug Dependence, Inc.: http://www.ncadd.org/ index.php/recovery-support/overview http://www.recoveryinnovations.org/index.html Innovations: Recovery SAMHSA: http://www.samhsa.gov/newsroom/advisories/1112223420.aspx Migrant Health Promotion Training and Support for Promotores(as): http:// Training and Support for Promotores(as): Promotion Migrant Health - www.migranthealth.org/index.php?option=com_content&view=arti cle&id=67&Itemid=65 http://promotorasinmentalhealth.com/ Health: in Mental Promotoras http://www.rural-preparedness. Preparedness: USA Center for Rural Public Health org/index.aspx?page=fd089d35-bd02-4b2a-9ad7-15fc31c99b55 forceactionplan.pdf - http://an Development: Workforce Health The Annapolis Coalition on Behavioral napoliscoalition.org/ the men- Developing of Health, National Institutes US National Library of Medicine : http://www.ncbi.nlm.nih.gov/pubmed/21190075 tal health workforce with of People Employment Promoting Law, Health Bazelon Center for Mental - Illness: http://www.bazelon.org/portals/0/Where%20We%20Stand/Com Mental - munity%20Integration/Olmstead/Getting%20to%20Work.pdf?utm_source=Get - ting+to+Work+Report+&utm_campaign=Getting+to+Work+Report&utm_medi um=email as) Promotores( Ment prepared Development Workforce SAMSHA, An Action Health Plan for Behavioral The Annapolis Coalition: http://www.samhsa.gov/workforce/annapolis/work by Center for Health and Health Care in Schools: http://www.healthinschools.org/ Care and Health Center for Health http://www.cisoftexas.org/ Schools (CIS) of Texas: Communities in - http://www.txbehaviorsupport.org/de Networks: Support (TBS) Behavior Texas fault.aspx?name=homepage T Service Centers: http://www.tea.state.tx.us/regional_services/esc/ Education Texas Project: http://smhp.psych.ucla.edu/ UCLA Health School Mental Health: on School Mental Center Assistance of Maryland Technical University http://csmh.umaryland.edu/ Ment http://thenadd.org/ Diagnosed: the Dually for Association National The A Guide Disability: Intellectual with for People Services Accessible Health Mental http://3dn.unsw.edu.au/sites/default/files/ddn/page/Accessible%20 for Providers: Mental%20Health%20Services%20for%20People%20with%20an%20ID%20-%20 A%20Guide%20for%20Providers_current.pdf Appendices 300 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:Shareexperiencesandsupportsfor veterans: http://makethe- Veter University ofColoradoDenver Telemental Health Guide:http://www.tmhguide.org/ American Telemedicine Association:http://www.americantelemed.org/ Telemedicine dshs.state.tx.us/mhsa/suicide/Suicide-Prevention.aspx Texas DepartmentofStateHealth Services, Texas SuicidePrevention: http://www. Texas SuicidePrevention ResourceCenter:http://www.sprc.org/states/texas Texas SuicidePrevention: http://www.texassuicideprevention.org/ SAMHSA –SuicidePrevention: http://www.samhsa.gov/prevention/suicide.aspx Preventing-Suicide-A-Toolkit-for-High-Schools/SMA12-4669 Preventing Suicide:Atoolkit forHighSchools:http://store.samhsa.gov/product/ tion/full-report.pdf http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-preven- General:2012A ReportoftheSurgeon NationalStrategyforSuicidePrevention: Suicide Prevention Via Hope Recovery Institute: http://www.viahope.org/programs/recovery-institute https://www.dshs.state.tx.us/substance-abuse/ROSC/(ROSC): Texas DepartmentofStateHealth Services, Recovery-oriented systems ofcare Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas ans Services and Telehe alth Appendices 301 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 Glossary: Common Behavioral Health Behavioral Common Glossary: Terms Act 1115 of Social Security under section CMS and states : A waiver that allows 1115 Waiver services. Medicaid of delivery programs to ensure in designing more flexibility Acute: and is intense and of short rapidly or condition that develops Refers to a disease duration. youth has engagedAdjudication: Is a finding that a conduct or “conduct in in delinquent court. in adult “conviction” It is similar to a need of supervision.” body language. facial expression or by manifested especially as or emotion, Affect: Feeling an income below have that are affordable for people who units Housing Affordable housing: is often considered to be 30% or less income of a specific area. Affordable the median family monthly income. of a person’s - of or in addition to convention health care that is used instead therapy: Mental Alternative al mental health services. and apprehension about something. nervousness, A sense of fear, Anxiety: from feelings of uneasiness to disorders: A group of chronic disorders ranging Anxiety obsessive-compulsive disorders include panic disorder, Anxiety immobilizing bouts of terror. disorder. and generalized anxiety disorder (PTSD), phobias, stress post-traumatic disorder, Behavioral at risk of, or currently living health care: Continuum of services for individuals behavioral use disorders or other substance with, one or more mental health conditions, health disorders. through rewards, behaviors focusing on changing unwanted Behavioral therapy: Therapy is a process of Desensitization, or exposure therapy, reinforcements and desensitization. - the unwant discomfort or fear and overcoming that arouses anxiety, confronting something ed responses. - The kind of medication a psychi medication. Biomedical treatment: Treatment involving treated; also referred to as prescribes varies with the disorder and the individual being atrist psychopharmachology. episodes of major Bipolar disorder: A mood disorder in which a person alternates between depression and mania. meals and transportation, to at basic care, such as Boarding home: A business that provides where the residents are unrelat- are elderly, and/or a disability three residents who have least ed to the owner. in which a medical participating in, or being a health-care system Capitated: Relating to, an HMO) regardless of treatment required. fee per patient (as by a set is given provider A person who has special training to help people with mental health conditions. Caregiver: may Caregivers required to be, mental health professionals. be, but are not can Caregivers family members and mentors. psychiatrists, psychologists, teachers, include social workers, Case manager: An individual who organizes and coordinates services and supports for and advocate [Also service coordinator, persons with mental health needs and their families. facilitator.] Appendices 302 DM-ID (Diagnostic Manual –IntellectualDisability): Atextbook ofdiagnoses ofmental als usetheDSM-V toconfirmdiagnosesformental illnesses. istic symptoms ofdifferent mentalillnesses. Physicians and other mentalhealthprofession- lished by theAmericanPsychiatric descriptions Associationthatgives general andcharacter DSM-V (Diagnostic andStatistical ManualofMental Disorders, FifthEdition):Abookpub- ods ofnormalorslightlyelevatedmood. Cyclothymia: Amooddisordercharacterizedby periodsofmilddepressionfollowed by peri- authorization. delivered toanyone experiencing amentalhealthcrisis. This servicedoesnot requireprior to prevent admissionofanindividualtoamorerestrictive environment. Thisservicemay be duce symptoms ofsevere and persistent mentalillnessorseriousemotional disturbance and Crisis intervention services:Interventions provided inresponsetoacrisisorderre - oration. toselforothers,danger orthathishermental orphysical healthisatriskofseriousdeteri- health, orasituationinwhichanindividualbelieves thatheorshepresentsanimmediate toselforothersimmediate danger orisatriskofseriousdeterioration ofmentalorphysical Crisis: Asituationinwhich,duetoamentalhealthcondition,anindividualpresents fundamental componentofCOSPs ispeersupport. tal Health Authorities (LMHAs),suchaspeersupport,outreach,educationandadvocacy. A erned by individualsinrecovery thatdeliver servicesthroughsubcontractswithLocalMen - Consumer-operated serviceproviders: Independentorganizationsoperatedandgov ment orsupportforamentalhealthcondition. Consumer: Apersonwhoisobtaining, orhasobtained, conventional oralternative treat- ted by orrunningaway anadult,suchastruancy fromhome. committed by anadult,couldresultinonlyafine,orconductthatisnot aviolationifcommit- Conduct inneedofsupervision(CINS):Generallyconductcommitted by aminorthat,if Counseling isintendedtobebrief,time-limitedandfocused. that helppeopleidentifyandmodifymaladaptive thoughtpatterns, beliefs, andbehaviors. Cognitive behavioral therapy(CBT):Acombinationofcognitive andbehavioral therapies feelings andbehaviors thatmay betroublesome,self-defeating,orself-destructive. Cognitive therapy:Aimstoidentifyandmodifydistorted thinkingpatterns thatcanleadto Chronic: Referstoadiseaseorconditionthatpersists over alongperiodoftime. inpatient andoutpatientmentalhealthsubstance useservices. federal poverty level sothatlow-income childrencanhave accesstohealthcare,including governments 0–19 andisavailable forchildrenaged withincomeupto200percentofthe AswithMedicaid, CHIPisjointlyfundedbyof theSocialSecurityAct. thestate andfederal Children’s Health InsuranceProgram(CHIP):CHIPwas createdin1997underTitleXXI ing andhave passedacertificationexam. other peoplewithsimilardiagnoses. Certified peerspecialists have received approved train- mental illnessorsubstance useenablesthemtoprovide assistance andrecovery supportto Certified Peer Specialist (CPS):Individualswhosepersonalexperienceandstruggles with stances. exam. Afamilypartnerprovides informationandsupporttoother parentsinsimilarcircum- public mentalhealthsystem andhave received approved trainingandpassedacertification tal, emotional orbehavioral healthdisordersandhave hadpersonalinvolvement withthe Certified Family Partner (CFP):Individualswithexperienceparentingachildmen isters Medicare, Medicaid, andtheStateChildren’s Health InsuranceProgram. Centers forMedicare andMedicaid (CMS):TheU.S. Services thatadmin- federalagency Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas - - - Appendices 303 - 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 disorders in persons with intellectual disabilities. This manual was developed cooperatively cooperatively developed was This manual disabilities. intellectual with in persons disorders - Associa Psychiatric the American and Dually-Diagnosed of the Association National the by tion. - voca parent training, education, counseling, including special treatment: Treatment Day 4 hours for at least therapy and recreational crisis intervention skill building, tional training, a day. health care expenses before insurance for pay must Deductible: The amount an individual Often insurance plans are based its contract share. pay begins to (or a self-insured company) amounts. on yearly deductible being contradict impression that is maintained despite belief or Delusion: An idiosyncratic as reality. is generally what accepted ed by - that: (a) is attribut of an individual chronic disability a severe, disability: Developmental impairments; or combination of mental and physical impairment physical able to a mental or (b) age to continue indefinitely; 22; (c) is likely individual attains before the is manifested areas of major limitations in 3 or more of the following functional (d) results in substantial self-direction, language, and expressive mobility, learning, life activity: self-care, receptive self-sufficiency;capacity for independent living, or economic the individual’s and (e) reflects indi- or generic services, of special, interdisciplinary, need for a combination and sequence duration and or extended that are of lifelong forms of assistance or other vidualized supports, are individually planned and coordinated. findings physical often characterized by Disease: An impairment of health or functioning that are common among a number of individuals who ultimately symptoms and specific a diagnosis of the disease in question. receive is or function of the body or mind that of the normal structure Disorder: An interruption symptoms. findings or specific of physical set a characteristic by manifested a particular group of people in a particular of Overrepresentation Disproportionality: group or system. at one time, such as a specified amount of medication. Dose: A quantity to be administered The has co-occurring conditions. Dually diagnosed: This term refers to an individual who use disorder and a mental health a substance has both term is often used when an individual disabilities or intellectual one or more developmental condition, or an individual living with use disorder or mental health condition. and a substance loss of interest feelings of sadness, disorder: A mood disorder characterized by Dysthymic disturbed altered appetite, and some or all of the following: or pleasure in usual activities, decreased ability to concentrate and feelings of hopelessness. lack of energy, sleep patterns, disorder. than those of major depressive are less severe Symptoms from the students Exclusionary discipline: Disciplinary practices in schools that remove classroom. - technique using electrical stim controversial A highly therapy (ECT): Electroconvulsive and some forms of ulation of the brain to treat some forms of major depression, acute mania schizophrenia. either as part of, or employers by plan (EAP): Resources provided assistance Employee care preventive typically provide EAPs health plans. separate from, employer-sponsored various health care screenings and wellness activities. measures, in the “normal” range, symptoms. without manic or depressive Mood Euthymia: Appendices 304 Plan benefitfor states toestablish Health Homes tocoordinate careforpeoplewith Medicaid Health HomesAct createdanoptional : Section2703oftheAffordable Care Medicaid State lets you compareprices, coverage levels, andother details forhealthinsuranceplans. allows apersonto shopandenrollforahealthplan.TheHealth InsuranceMarketplace also exchange,Act and isaccessibleonline.It was developed asaresultoftheAffordableCare Health InsuranceMarketplace: TheHealth InsuranceMarketplace, alsocalledthehealth bilitative Services(DARS). ment ofAgingandDisability Services(DADS) andTexas DepartmentofAssistive andReha- Services (DSHS),Texas DepartmentofFamily Protective Services(DFPS),Texas Depart- including theTexasand HumanServicesCommission(HHSC), DepartmentofStateHealth Health (HHS)Enterprise:referstostate undertheHealth andHumanServices agencies actually present. Hallucination: Theperception ofsomething, thatisnot suchasasoundor visualimage, recidivism orrelapsewhencomparedtoareleasedirectly intosociety. while still providing believed toreducetheriskof monitoringandsupport;thisisgenerally of ahalfway houseistoallow thepersonstobeginprocessofreintegrationwithsociety, from aprimaryinstitution suchasaprison,hospitalorrehabilitationfacility. Thepurpose mental illness, orindividualsconvicted ofafelony areplacedimmediatelyaftertheirrelease Halfway house:Aresidentialcenterorhomewheredrugusers, sexoffenders, personswith Services arefurnishedthroughanetwork ofproviders. insurer andprovider ofacomprehensive set ofhealthcare servicestoanenrolledpopulation. careplanthatactsasboth maintenanceorganization):Atypeofmanaged HMO (health distress andpossiblymodifytheirbehavior. sional usestheemotional interactionsofthegroup’s memberstohelpthemget relieffrom ences andwhomeet regularlywithamentalhealthprofessional.Theprofes Group therapy:Therapy involving groupsofusually4to12peoplewhohave similarexperi- hospitals forcareoftheirpatients. ated rate,andthatgroupisresponsibleforcompensating itsphysicians andcontractingwith ciation. Thehealthplancompensates themedicalgroupforcontractedservicesatanegoti- contracts withphysicians organizedasapartnership, professionalcorporationorother asso- Group-model healthmaintenanceorganization(HMO):Acaremodelinvolving Geneticgenes.: Inherited;passedfromparentstooffspringthrough company. Whenthepatentexpires, other version. manufacturerscanproduceitsgeneric have thesame medicaleffect.Somedrugsareprotected by patentsandsupplied by onlyone a brand-namecounterpart,withthesame active ingredients, strength anddosage formand Generic: Drugsthatdonot have abrandnamebutaretypicallyrequiredtobeequivalent fatigue, restlessness, irritabilityandsleepdisturbance. feelings ofanxiety foraperiodofatleast sixmonthsandaccompaniedby symptoms suchas Generalized anxiety Ananxiety disordercharacterizedby disorder(GAD): consistent to benot guiltyby reasonofinsanity (NGRI). been determined not tohave thecapacitytostand trial,or2)thepatienthasbeendetermined 1)thepatienthasbeenadmittedcategories: toahospitalby judicialorderbecausetheyhave Forensic commitment: Patients on aforensic commitment fallinto one ofthe following two over-the-counter drugs. protecting thepublichealthby assuringthesafety, efficacy, andsecurityofprescription and Food andDrugAdministration whoseresponsibilitiesinclude (FDA): Afederalagency ence, andpatientvalues. Evidence-based practices(EBP):Integrationofbest researchevidence,clinicalexperi- Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas - Appendices 305 -
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 ing, such as getting dressed, taking medication, preparing meals, habilitation, attendant care, habilitation, attendant dressed, taking medication, preparing meals, ing, such as getting respite, managing money and more. specialized therapies, feelings of intense Disorder (MDD): A mood disorder characterized by Major Depressive a few weeks. beyond and hopelessness that persist sadness elevated mood and agitation. hyperactivity, of intense mental and physical Mania: Feelings Manic-depression: See bipolar disorder. health services that comprehensive for delivering Managed care: An organized system to an individual what services will be provided the managedallows care entity to determine managed care controls health care for a prearranged Generally, financial payment. in return The health plan of specialists. and overuse hospitalization and discourages unnecessary costs operates under contract to a payer. Managed care organizations (MCOs): An organization that combines the functions primarily available Services are of care and administration. of health insurance, delivery contracting with the MCO. of providers through a network The systematic coordination of primary and behavioral health coordination of primary and behavioral Integrated health care: The systematic person. services addressing the needs of the whole 17 at the time he or she yet 10 years old but not defendant: A person who is at least Juvenile conduct” or “conduct in need of supervision.” an act defined as “delinquent committed as community mental health (LMHAs): Also known Authorities Health Local Mental state, called the local services to a specific geographic area of the LMHAs provide centers, allocate coordinate, policy, to plan, develop the state service area. LMHAs are required by the local service area. resources for mental health services in and develop or settings in institutional be provided May Services and Supports (LTSS): Long-Term with activities of daily liv include assistance This may services. through community-based who have chronic conditions. Health Home providers integrate and coordinate all primary, all primary, and coordinate integrate providers Home Health conditions. chronic have who person. whole to treat the supports and services long-term health, and behavioral acute, for Medicaid opportunities Services Based provides (HCBS): and Community Home the community with own home or goal of preventing services in their to receive beneficiaries institutionalization. adequate and (USC regular, Homeless who lacks a fixed, An individual 42 §11302(a)): residence. nighttime more than 30 when a household pays exists burden burden: A housing cost cost Housing housing. deductions toward and before taxes income percent of its total as quickly as possible offers permanent, affordable housing An approach that first: Housing the supportive provides and then families experiencing homelessness, for individuals and their needed to keep supports people to the community-based services and connections to homelessness. returning housing and avoid in a hospital or other medical treatment that is provided Inpatient care: The term refers to stay. one overnight at least facility and requires Intermediate care facility/developmentally (ICF-IDD): Intermediate Care Facilities and developmental, personal care, habilitation, 24-hour is a facility that provides disabled clients whose primary need is for de- disabled to developmentally health services supportive need for skilled nursing a recurring but intermittent have services and who may velopmental services. that specifies the behavioral A plan developed Individualized Education Plan (IEP): who receive for the students the school district by to be provided supports and interventions special education services. Appendices 306 tions andsupports have onthe individualsorcommunities. Outcome measure : Ameasurethat identifiestheresultsor impact thatservices, interven- pulsions). thoughts, feelings, ideasorsensations (obsessions)orrepetitive, ritualizedbehaviors (com- Obsessive-compulsive disorder(OCD):Ananxiety disordercharacterized by recurrent not integratedwithprimarycare services. health servicesareprovided careorganization andis throughabehavioral healthmanaged Kaufman counties. Thisservicedelivery modelisreferredtoasa“carve-out,” asbehavioral health servicestotheeligibleresidentsofDallas, Ellis, Collin,Hunt,Navarro, Rockwall and NorthSTAR careapproachtothedelivery ofbehavioral: apubliclyfundedmanaged crossing thespacebetween twoadjacentneurons. Neurotransmitters: Chemicalsthattransmitinformationfromoneneuron toanother by combined withanantidepressant. Mood stabilizer: Lithiumand/or ananticonvulsant fortreatment ofbipolardisorder, often disorder. I andbipolarIIdisorders, cyclothymic disorder, major depressive disorderanddysthymic ed asoneormoreepisodesofmania,hypomania, depression,orsomecombinationofbipolar Mood disorders:Disordersinwhichtheessentialfeatureisadisturbance ofmoodmanifest - how tosupportindividualsexperiencingamentalhealthcrisis. and addictions, includingriskfactorsandwarning signs. Thetrainingalsooffers strategies on Mental Health First Aid(MHFA): Anin-persontrainingtolearnaboutmentalillnesses mood, abilitytorelateothers ordailyfunctioningandcausesthepersondistress. Mental healthcondition: Ahealthconditionthatdisrupts aperson’s thinking,feelings, peer professionals, pharmacists andmany other professionals. clinical socialworkers, psychiatric nurses, mentalhealthcounselors, professionalcounselors, mental healthconditions. includespsychiatrists, Thisbroadcategory clinicalpsychologists, who offersservicesforthepurposeofimproving an individual’s mentalhealthortotreat Mental healthprofessionals: Amentalhealthprofessionalisacarepractitioner promote healthy behaviors andlifestyles. meet oflifeevents andtransitionsby thechallenges creatingandreinforcingconditionsthat Mental healthprevention: Aproactive processthatempowers individualsandsystems to make acontributiontohisorhercommunity. can copewiththenormalstresses oflife,canworkproductively andfruitfully, andisableto Mental health:Astate ofwell-beinginwhichtheindividualrealizeshisorherown abilities, and monitoringofpotential sideeffectsofpsychotropic medications. Medication therapy:Prescription, administration, andassessmentofdrugeffectiveness the patient’s support,maintenanceandtreatment. responsible forthepatient’s support;and(3)isunabletoreimbursethestate forthecosts of Medically: anindividualwho:(1)possessesnoproperty;(2)haspersonlegally indigent tions, ofsymptoms, monitoringandmanagement andsideeffects. Medication trainingandsupportservices: Includeseducationondiagnosis, medica- courses oftheirlives; smalldeductiblesandco-payments arerequired. over of65. theage Most costs arepaidviatrust fundsthatbeneficiariespay into over the Medicare: Afederalinsuranceprogramservingindividualswithdisabilities andpersons dren andfamiliespeoplewithdisabilities. Medicaid: Afederal-state fundedhealthinsuranceassistance programforlow-income chil- Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Appendices 307 - 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 all medical care and referring the individual to more specialized physicians for additional to more specialized physicians all medical care and referring the individual specialties: group practice, family practice, the following are included in PCPs care. Typically and pediatrics. internal medicine, obstetrics/gynecology outcomes positive that shows intervention or treatment Promising practice: A prevention of rigorous level scientific evaluation as evidenced-based practice. the same have but does not capable of medications: Medications Psychiatric/psychotherapeutic/psychotropic or manage that are used to treat and behavior a psychiatric affecting the mind, emotions or challenging behavior. symptom treatment and prevention diagnosis, A medical doctor who specializes in the Psychiatrist: of mental illness. emo - A health care professional who diagnoses and treats mental, nervous, Psychologist: conditions. tional and behavioral are so impaired mental health condition in which thought and emotions A severe Psychosis: reality. that a person loses contact with external for mental health concerns in which a mental health A treatment method Psychotherapy: can Psychotherapy professional and a consumer discuss needs and feelings to find solutions. experi- past how and understand help individuals change patterns their thought or behavior ences affect current behaviors. Agency entity that is responsible for the operation (PHA): A governmental Public Housing programs. of subsidized housing and rental assistance Rapid cycling: Experiencing changes in mood from mania to major depression, or mixed or months. days within hours, states, and including neurotransmitters A molecule that recognizes specific chemicals, Receptor: resides. the cell on which the receptor into and transmits the message hormones, Health care that does not require an overnight stay in a hospital or health or in a hospital stay an overnight require does not care that Health care: Outpatient facility. care rapid heartbeat of terror, feelings people have disorder in which disorder: An anxiety Panic cause. without reasonable suddenly and repeatedly breathing that strike and rapid - estab Care and Affordable States federal statute A United Protection Act (ACA): Patient of overhaul regulatory significant the most characterized as that is 2010 23, lished in March in 1965. and Medicaid of Medicare since the passage healthcare system the U.S. and practice that combines stable : An evidence-based housing supportive Permanent affordable living arrangementsservices designed to to flexible health and human with access conditions. health with behavioral for people recovery promote managementPharmacological of med- of administration services: Includes supervision symptoms. and assessment of of effects and side effects of medication, ication, monitoring per year. evaluation Includes one psychiatric fear of Examples of phobias include fear of something. Phobia: An intense or irrational flying, dogs and injuries driving, water, highway tunnels, escalators, heights, closed-in places, blood. involving Stress Disorder (PTSD): a A mental health condition that is triggered by Post-Traumatic include flashbacks, may experiencing it or witnessing it. Symptoms — either terrifying event thoughts about the event. and uncontrollable anxiety, severe nightmares, over an individual’s (PCP): The PCP is responsible for monitoring Primary care physician Appendices 308 Supported employment: Aservicethat provides individualized assistance inchoosing and Stigma: Anegative stereotype aboutagroupofpeople. schools. tial servicestopeoplewithintellectual anddevelopmental disabilities; formerlycalled state institutionsState SupportedLivingCenter (SSLC):Large thatprovide 24-hour- residen facility. with acuteorchronicmentalillness;alsocalleda healthhospitalorastate psychiatric State hospital:Ahospitalrunby thestate forthecareandtreatment ofpatientsaffected adolescents whichcausesevere disturbances inbehavior, thinkingandfeeling. EmotionalSerious Disturbance (SED):Agroupofpsychiatric disordersinchildrenand disability orareover 65. nue, not SocialSecuritytaxes. SSIisforpeoplewithlimitedincomeandwhohave aqualifying Security Income(SSI): Afederalsupplementalincomefundedby taxreveSocial - general Social Securitytaxes. Security, andhave paidenoughmoneyintotheSocialSecurityprogram.SSDIisfundedby uals ortheirfamilymemberswhohave adisability, have worked inajobcovered by Social Security DisabilitySocial Insurance(SSDI):Afederalsupplementalincomeforindivid- elderly patients, andprovides long-termnursingcare,rehabilitation,andother services. Skilled NursingFacility: Licensedhealthcarefacilitythatserves chronicallyill,usually individual. Signs: Indicationsofillnessthatareobserved by theexaminerratherthanreportedby the tite andmood.People experiencingdepressionoranxiety oftenhave aserotonin deficiency. Serotonin: Aneurotransmitter thatmost likely contributestotheregulationofsleep, appe- chemical. or restrict (restrain) movement ofindividuals. Restraints may bephysical, mechanical,or andRestraint:Seclusion Techniques usedby administrators andstaff toisolate(seclude) tration ofinstruments toassesstreatmentprogress. resources andservicescoordinationofwiththeindividual,aswelladminis Aformofservicethatincludesbasicfacilitationaccessto Routine casemanagement: facility. Residential treatment:Behavioral healthservicesprovided ataresidentialhealthcare difference between thatamountandthemarket rentforthespecificunit. tenants topay approximately 30percent oftheirincometoward rent.Asubsidypays the near market rateforspecifiedhousingunits. Typically, rentalassistance fundsallow eligible Rental assistance: Rentalassistance fundshelptenantswithlow incomesaffordrentator rary improvement. Relapse: Thereoccurrenceofsymptoms ofadisease; adeterioration inhealthafteratempo- similar totheMedicaid serviceoftargeted casemanagement. ilar tobasicservicecoordinationandhashighercaseloads, is rehabilitative casemanagement educational andother appropriatesupportservices. issim- Whereroutinecasemanagement tegrated supporttopeopleincludingassistance inaccessingmedical,social,psychological, AformofservicethatprovidesRehabilitative avariablelevel casemanagement: ofin- live aself-directedlife,andstrive toreachtheirfullpotential. Recovery: throughwhichindividualsimprove Aprocessofchange theirhealthandwellness, torelapseintoaprevious typeofbehavior.Recidivism: Thetendency Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas - Appendices 309 - 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 Sources: ofInstitute Medicine ofInstitute National Health Mental of Services Human and Health Dept. U.S. (SAMHSA) Administration Services Health Mental Abuse Substance and Recovery Resilience Texas dictionaries medical Various obtaining employment at integrated work sites in the community of the consumer’s choice. consumer’s of the community sites in the work at integrated employment obtaining em- keeping in individuals assist that will staff identified by provided supports It includes to of a job coach include the services This may job as necessary. another and finding ployment job site. individual at the support the the patient by disorder experienced other of a disease or An indication Symptom: are occurring together, that, when signs and symptoms of physical A collection Syndrome: specific condition. of a characteristic collaboration that involves and framework philosophy of Care: An organizational System services and access and of improving and youth for the purpose families, across agencies, serious emo- services for youth with a of coordinated community-based expanding the array and their families tional disturbance on that includes the abuse or dependence A medical condition use disorder: Substance alcohol or drugs. agencies in order evaluation of state periodic Advisory The Sunset Council’s review: Sunset it operates efficient- needed and whether still functions are an agency’s whether to determine ly and effectively. care services. health The use of technology to deliver Telemedicine/Telehealth: that is experienced of circumstances or set series of events, Occurs from an event, Trauma: or threatening and that has lasting harmful or emotionally an individual as physically by or spiritual social, emotional, functioning and physical, effects on the individual’s adverse well-being. that specifically addresses the approach: Treatment interventions Trauma-informed and are designed to facilitate healing. A trauma-in consequences of trauma on an individual formed approach has the following principles: safety, trustworthiness, peer support, collab- trustworthiness, principles: safety, formed approach has the following support should and choice. Trauma-informed voice, empowerment, oration and mutuality, and gender issues. also consider cultural, historical, or jolt to the head or a penetrating blow a bump, Brain Injury (TBI): Caused by Traumatic the normal function of the brain. head injury that disrupts is responsible for the health care A public or private organization that payer: Third-party entity. expenses of another : Somebody formerly in the armed forces. Veteran as- services: Services that include job finding, development, rehabilitation Vocational of job experience to as well as provision skills, sessment and enhancement of work-related individuals. Appendices 310 Map ofservicedelivery areasforSTAR andSTAR+PLUS (Retrieved fromhttp://www.hhsc.state.tx.us/medicaid/managed-care/plans.shtml.) Texas Medicaid Managed Care Plans Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Appendices 311 Managed Care Company Care Managed HealthPlan Superior Texas, of Healthcare Molina Amerigroup, HealthPlan Superior Texas, of Healthcare Molina HealthPlan Superior Texas, of Healthcare Molina Amerigroup, - Commu UnitedHealthcare Texas, of Healthcare Molina Amerigroup, Plan nity HealthPlan Superior Texas, of Healtcare Molina Cigna-HealthSpring, - Commu UnitedHealthcare Texas, of Healthcare Molina Amerigroup, Plan nity HealthPlan Superior Amerigroup, Plan Community UnitedHealthcare HealthPlan, Superior Cigna-HealthSpring Amerigroup, Plan Community Healthcare United Amerigroup, UnitedHealthcare Cigna-Healthspring, UnitedHealthcare HealthPlan, Superior HealthPlan Superior Amerigroup, Managed Care Company Care Managed Plans, Health First Community Amerigroup, Health, Better Aetna HealthPlan Superior HEALTHfirst Parkland Texas, of Healthcare Molina Amerigroup, Superior Texas, of Healthcare Molina Plan, Premier First Paso El HealthPlan Texas, of Healthcare Molina Choice, Health Community Amerigroup, Plan Community UnitedHealthcare Plan, Health Children’s Texas Superior Texas, of Healthcare Molina Plan, Health Children’s Driscoll Plan Community UnitedHealthcare HealthPlan, Texas, of Healthcare Molina Choice, Health Community Amerigroup, Plan Community UnitedHealthcare Plan, Health Children’s Texas HealthPlan Superior Star, FirstCare Amerigroup, - Health Superior Plan, Health Children’s Driscoll Plan, Health Christus Plan Plan Health Children’s Cook Amerigroup, Heatlh, Better Aetna Health Seton Plans, Health Sendero Texas, ofShield Blue Cross Blue HealthPlan Superior Plan, Superior Amerigroup, Superior White, & Scott Amerigroup, Superior FirstCare, Amerigroup, 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 Service Area Service Bexar Dallas Paso El Harris Hidalgo Jefferson Lubbock Nueces Tarrant Travis Texas MRSA Northeast Texas MRSA Central Texas West MRSA Bexar Dallas Paso El Harris Hidalgo Jefferson Lubbock Nueces Tarrant Travis Texas MRSA Northeast Texas MRSA Central Texas West MRSA Service Area Service STAR+PLUS Service Areas STAR+PLUS STAR Service Areas STAR Appendices 312 Services conservatorshiporextended foster care. 22)intheDepartmentofFamilyfor childrenandyoungadults(uptoage Protective by Health andHumanServicestoprovide medicalandbehavioral healthservices Superior HealthPlan Network carecompany (Superior)isthesolemanaged selected STAR HEALTH Areas Children’s Health InsuranceProgram(CHIP)orChildren’s Medicaid Service Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas MRSAWest Texas CentralMRSA Texas NortheastMRSA Texas Travis Tarrant Nueces Lubbock Jefferson Hidalgo Harris El Paso Dallas Bexar Service Area Molina Healthcare, Superior HealthPlan Molina Healthcare, Superior HealthPlan Molina Healthcare, Superior HealthPlan Blue Cross and Blue Shield of Texas, Sendero, Seton, Superior Aetna, Amerigroup, Cook Children’s Christus, Driscoll, Superior FirstCare, Superior United Amerigroup, Community Health Choice, Molina, Texas Children’s, Molina Healthcare, Superior HealthPlan United Amerigroup, Community Health Choice, Molina, Texas Children’s, El Paso First, Superior Amerigroup, Molina, Parkland Aetna, Amerigroup, Community First, Superior Managed Care Company Appendices 313 ommission ommission C ervices Services an Hum and h alt 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 Advises HHSCof the acute care services and on the implementation and DADS with intellectual for individuals redesign system and supports services long-term disabilities. and developmental Advises HHSC to hospital and equitable payments adequate, reasonable, to ensure hospitals. role of rural essential and to address the providers Established during the 2009 legislative session to help improve the coordination improve session to help 2009 legislative during the Established children. services for of state Advises HHSC programs providing in many services directed consumer regarding services. health mental supports and and services long term Helps in developing, implementing, and administering family support policies policies family support and administering implementing, developing, in Helps Develops for children. programs care and health long-term and related commissioner. and executive the legislature for recommendations Charged needed to integrate development and planning initial with addressing 1, 2014. September managed health services into behavioral care by Medicaid changes create a truly needed to will address systemic Phase II recommendations system. integrated Assists the executive commissioner in developing rules and policies for the developing commissioner in executive the Assists commission. Intellectual and Developmental Disability System Redesign Advisory Com- Redesign System Disability Intellectual and Developmental http://www.hhsc.state.tx.us/about_hhsc/AdvisoryCommittees/iddsrac. mittee: shtml · http://www.hhsc.state.tx.us/about_ Advisory Committee: Payment Hospital hhsc/AdvisoryCommittees/hpac.shtml · - http://www.hhsc.state.tx.us/about_hhsc/Advi Council on Children and Families: soryCommittees/Council.shtml · - http://www.hhsc.state.tx.us/about_hhsc/Advi Consumer Direction Workgroup: soryCommittees/cdw/index.shtml · Children’s Policy Council: Policy Children’s http://www.hhsc.state.tx.us/si/cpc/index.shtml · http://www.hhsc.state. Advisory Committee: Integration Behavioral Health tx.us/about_hhsc/AdvisoryCommittees/bhiac.shtml · ) (HHSC HHSC Council: http://www.hhsc.state.tx.us/about_hhsc/hhsc_council.shtml · Advisory Committees Committees Advisory He as Tex Appendices 314 · about_hhsc/AdvisoryCommittees/STAR-kac.shtml STAR CareAdvisory Committee: KidsManaged http://www.hhsc.state.tx.us/ · der-rates/ Committee: http://www.hhsc.state.tx.us/about_hhsc/AdvisoryCommittees/bor SB 1220Medicaid RatesandExpendituresAdvisory andCHIPBorder · state.tx.us/about_hhsc/AdvisoryCommittees/HCT/default.shtml Qualifications for Health Care Translators andInterpreters: http://www.hhsc. · tx.us/providers/pi/piac/ Promoting IndependenceAdvisoryCommittee (PIAC):http://www.dads.state. · hhsc/AdvisoryCommittees/PPAC.shtml Physician Payment AdvisoryCommittee: http://www.hhsc.state.tx.us/about_ · visoryCommittees/MCAC.shtml Medical CareAdvisoryCommittee: http://www.hhsc.state.tx.us/about_hhsc/Ad- · hhsc.state.tx.us/about_hhsc/AdvisoryCommittees/med-chip-qbp/ Medicaid/CHIP Quality-Based Payment AdvisoryCommittee: http://www. · tx.us/about_hhsc/AdvisoryCommittees/MedicaidCHIP_RAC.shtml Medicaid andCHIPRegionalAdvisoryCommittees: http://www.hhsc.state. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas managed careprogram. managed on the development andimplementation of theSTARAdvises KidsMedicaid 19.CHIP enrolleesunder age capita expenditures and total professional services expenditures forMedicaid and border regionandother areas ofthe state incapitation rates, fee-for-service per regarding eliminating the disparities between theTexas-Mexico HHSC Advises translators. on various items related to qualifications for healthcare interpreters and Advises U.S. Supreme Court’s Olmstead appropriate care settings for persons with disabilities. Created in response to the in the development ofa comprehensive, effectivelyAdvises workingplantoensure policies. about technical issues regarding physicianthe committee payment and HHSC Functions as asubcommittee Committee ofthe Medical toadvise CareAdvisory programs. director on proposedrules that involve Medicaid oraffect policy Medicaid-funded Federally mandated to review andmake recommendationsto state Medicaid care organizations,accountability of managed health careproviders andfacilities. benchmarks for quality performance, quality of careoutcomes, efficiency, and onMedicaid andCHIPreimbursement systems, HHSC Advises standards and the program to HHSC. public input on MedicaidAccepts and CHIP andprovides recommendationson Decision. - Appendices 315 - - Disability and Aging Aging ADS) 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 rtment o f rtment Depa
State-mandated advisory committee assists HHSCassists evaluate reimburseable to committee advisory State-mandated type of programs receiving as monitor as well processes, and delivery services services. these and rule changes for the sanctions for licensure recommendations Provides AdministratorProgram. Licensing Nursing Facility Created during 2013 Texas legislative session to examine the effect of domestic to examine the effect of domestic session legislative Texas 2013 during Created health to improve and ways and children of mothers health on the violence victims. violence for domestic services Initiative. Well AdvisesTexas the Aging implementing on Charged with developing a comprehensive five-year strategic plan to address five-year Chargeda comprehensive with developing developmental intellectual or other illnesses, with chronic of children the needs or serious mental illness. disabilities Informs state leadership of the needs of people with brain injuries and their their and with brain injuries of people of the needs leadership state Informs families. Provides recommendations and ongoing input on the statewide implementation and ongoing recommendations on the statewide input Provides managed care. Medicaid and operation of Advises of policythe development on eligible to ensure recommendations acute consumer-directed person-centered, quality, consumers receive Medicaid setting. integrated in an and supports long-term services care and - http://www.hhsc.state.tx.us/about_hhsc/Ad Advisory Committee: Telemedicine visoryCommittees/TelemedicineAdvisoryCommittee.shtml · as Tex (ATW): http://www.dads.state.tx.us/ser Advisory Committee Well Aging Texas http://www. (NFAAAC): Advisory Committee Administrator Nursing Facility dads.state.tx.us/news_info/council/nfaac/ · - Violence: http://www.hhsc.state.tx.us/about_hhsc/Advi on Domestic Force Task soryCommittees/tfdv/ · (D Services vices/agingtexaswell/about/committee/index.html · Task Force for Children with Special Needs: http://www.hhsc.state.tx.us/about_ for Children Force Task hhsc/AdvisoryCommittees/TaskForce.shtml · Traumatic Brain Injury Advisory Council: http://www.hhsc.state.tx.us/hhsc_ Brain Traumatic projects/abj/Council.shtml · http://www.hhsc.state. Managed Committee: Care Advisory State Medicaid tx.us/about_hhsc/AdvisoryCommittees/smmcac.shtml · Committees/STARPLUS-qc.shtml · http://www.hhsc.state.tx.us/about_hhsc/Advisory Council: Quality STAR+PLUS Appendices 316 · ddrac/ Drug DemandReduction AdvisoryCommittee: http://www.dshs.state.tx.us/sa/ · DSHS Council:www.dshs.state.tx.us/council/default.shtm · Mental andSubstance UseDisorders:https://www.dshs.state.tx.us/mhsa/cap/ Council onPlanning&Advising(CAP) forthePrevention &Treatment of Texas · bei.shtml forEvaluationBoard ofInterpreters: http://www.dars.state.tx.us/councils/BEI/ · shtml State IndependentLivingCouncil:http://www.dars.state.tx.us/councils/silc/silc. · ECI AdvisoryCommittee: http://www.dars.state.tx.us/councils/eci/eci.shtml · shtml Rehabilitation CouncilofTexas: http://www.dars.state.tx.us/councils/rct/rct. · Council: http://www.dars.state.tx.us/councils/darscouncil/dc.shtml Texas DepartmentofAssistive (DARS) andRehabilitative Services DARS · http://www.dads.state.tx.us/providers/pi/mfp_demonstration/committee.html Money Follows thePerson Demonstration AdvisoryCommittee (MDPDAC): · edemployment/pi/index.html Employment First Task Force: http://www.dads.state.tx.us/providers/support- Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas implementation of a drug demand reduction strategy. with creating and coordinating relating to reducing drug demand. Charged Provides information for theGovernor, Legislature and publicaboutissues forum for public input into rules, policies, and budget priorities. in developing rules andpolicies forDSHS.Assists DSHS and HHSC Provides a treatment, recovery and resilience support services inTexas. ofmental and substanceallocation and adequacy use disorderprevention, Monitors, reviews, evaluatesand makes recommendationsregarding the become certified interpreters in Texas. Is responsiblefortesting and certifying the skill level of individuals seekingto of the State Plan for Independent Living. Is anequal partner with DARS inthe development, approval, andimplementation and implementationofpoliciesthatconstitute thestatewide ECI system. theDARS Advises DivisionforEarlyChildhoodIntervention Services ondevelopment vocational rehabilitation services and eligibilityrequirements. on policy Advises Helps develop rules and policiesfor the Department. implementation of the demonstration project throughout thefive-year period. Participates in thedesign of the operational protocol andmonitors standards, responsibilities, andexpectations as any adult. other working-age expectation thatindividualswith disabilities areabletomeet thesame employment Promotes competitive employment ofindividualswithdisabilities andthe Department of
S t a te He alth Services (DSHS) Appendices 317 nd Protective Protective and mily amily F 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 rtment o f rtment Depa Created in 2004 as part of the HHS Transformation HHS of the in 2004 as part Created Provides assistance to the DSHS Council in supporting and delivering coordinated in supporting and delivering DSHS Council to the assistance Provides programs. school health The purpose of the SHCC is to ensure health care services and facilities are health SHCC is to ensure the of The purpose planning Based on these activities. planning through health to all Texans available and the legislature the governor to recommendations makes the SHCC activities, Plan (TSHP). Health State the Texas through Works with DSHS in development and implementation of state plan for the state of implementation and DSHS in development with Works Grant. Block Services and Health Health Preventive Defines core public health services a local health entity should provide in a county in entity should provide health a local health services public Defines core for identifies initiatives and state health in the public or municipality; evaluates available to local health sources funding identifies improvement; need areas that policypublic health recommendations and makes priorities; establishes entities; annually. Advisespromotores/ of training and regulation concerning DSHS on rules workers. health community Advises rules and in establishing Commissioner DSHS and the HHSC Executive and diagnosis, the assessment, to improve of grant funds for the use priorities of the report to the in the review and assists abuse and neglect of child treatment Governor. Advises on technical and administrative issues that directly affect local mental local mental directly affect that issues Advisesand administrative technical on and of initiatives, and coordination evaluation authority responsibilities, health Reviews related to local rules contracts. responsive and flexible of development operations. health authority mental as Tex DFPS Council: https://www.dfps.state.tx.us/About_DFPS/Council/ · : www.dshs.state.tx.us/schoolhealth/ Advisory Committee School Health Texas shadvise.shtm · (DFPS) Services Council: http://www.dshs.state.tx.us/chs/shcc/ Coordinating Health Statewide · State Prevention Health Advisory Committee: https://www.dshs.state.tx.us/ Advisory Committee: Health State Prevention Advisory-Committees.aspx · - : www.dshs.state.tx.us/phfpcom Committee and Policy Funding Public Health mittee/ · Promotor(a) Community Health Worker Training & Certification Advisory Training Worker Health Community Promotor(a) : www.dshs.state.tx.us/mch/chw.shtm Committee · : www.dshs.state.tx.us/mch/medcares.shtm/ Advisory Committee MEDCARES · - http://www.dshs.state.tx.us/mh : Committee Advisory Network Authority Local community/lanac/ · Appendices 318 He Health Recommendations Impacting Mental Texas Sunset Advisory Commission Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Require HHSC to create an approval process and standard criteria for all system websites. Interactions with the Public. Issue 12: HHSC’s Uncoordinated Approach to Websites, Hotlines, and Complaints Reduces the System’s Effectiveness of into managed care organizations statewide. behavioral health Medicaid eligibility and Requireensure services full integration the state to of assist with maintenance of updated model, including associated legislative funding changes. Transition behavioral health services for both Medicaid and indigent populations in the Dallas area from NorthSTAR to an Issue 9: NorthSTAR’s Outdated Approach Stifles More Innovative Delivery Behavioral of Health Services in the Dallas Region. a pilot project. ment of Require incentive-based payments by managed care HHSC to promote organizations, increased use of including develop- health care.major initiatives for improving the quality of Require HHSC to develop a comprehensive, coordinated operational plan designed to ensure consistent approaches in its Issue 6: The State is Missing Opportunities to More Aggressively Promote Health Care. Methods to Improve the Quality of history guidelines for checks it will continue to perform, and complete background checks within 10 days. Require OIG to no longer conduct criminal history checks for providers already reviewed by licensing boards, develop criminal Require HHSC to streamline the Medicaid provider enrollment and credentialing process. age Participation in Medicaid. Issue 5: Fragmented Provider Enrollment and Credentialing Processes Are Administratively Burdensome and Could Discour create a single entity to oversee these related responsibilities. Eliminate the Pharmaceutical and Therapeutics Committee and transfer its functions to the Drug Utilization Review Board to managed care. Adapt processes for the state’s prescription drug program, audits, and advisory committees to reflect the state’s transition to evaluate the Medicaid program on an ongoing basis. Require data, HHSC to regularly evaluate the appropriateness of automate its data reporting processes, and comprehensively Program and Provide Sufficient Oversight. Issue 4: HHSC Has Not Fully Adapted Its Processes to Managed Care, Limiting the Agency’s Ability to Evaluate the Medicaid Medicaid functions at HHSC.Consolidate administration of Future Transitions to Managed Care at Risk. Issue 3: Fragmented Administration Medicaid of Leads to Uncoordinated Policies and Duplicative Services and Could Place plan to guide HHSC and the committee in setting up the new structure. a transition a transition plan and detailed legislative work oversight committeeRequire and the development of formation of established along functional lines and with a 12-year Sunset date. Consolidate the five HHS system agencies into one agency called the Health and Human Services Commission with divisions Agencies Is Not Yet Complete. Issue 1: The Vision for Achieving, Better, More Efficiently Run Services Through Consolidation Health of and Human Services alth and Human Services C ommission (HHSC) - Appendices 319 ervices (DSHS) Services h alt te He te a t 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 Issue 1: Resolving the Current Crisis in the State Mental Health Hospital System Requires Requires System Hospital Health Mental State the in Crisis Current the Resolving 1: Issue Now. Starting Action, the inform to training develop to of Appeals Court the with work to DSHS Criminal Require ofguide a developing including inpatient alternative treatment, health mental inpatient to alternatives about judiciary options. treatment policies resources human streamline and review immediately should Commission Services Human and Health the and DSHS mental with contracting by capacity expanding continue and staffed, appropriately are hospitals health mental state ensure to possible. whenever communities local in providers health ofoversight and management the evaluating system, hospital Continue health mental state the ofpart as of review Sunset larger the to system services human and alternatives, health the organizational possible including offall the in completed be 2014. Mental Community Outcomes-Focused Integrated, Deliver to Struggled Has DSHS 2: Issue Services. Abuse Substance and Health functions. assessment and screening, hotline, abuse substance and health mental integrate to DSHS Require narrow than rather needs capacity targeted on authorities health mental local for efforts equity funding focus to DSHS Require funding. capita per new creating including facilities, treatment health behavioral community-based for regulations overhaul to DSHS Require iftypes license necessary. - re-estab and statute from committees advisory two removing by process input stakeholder health behavioral DSHS’ Improve committee. advisory existing another lishing Their Limiting Purpose, Strategic Lack Committees Advisory Numerous DSHS’ 8: Issue Resources. Wasting and Effectiveness active re-establish to DSHS ofeight direct and statute Remove from committees advisory DSHS’ needed. as rule in functions committee ofall evaluate regularly to and policies committee advisory groups. internal advisory its its revise and review to DSHS Direct Health Basic Providing and Health Public Protecting Continue Should State The 9: Issue Review. Further Await Structure DSHS’ on Decisions but Services, ofcontinuation on decision the ofcompletion the until structure and functions DSHS’ Postpone of review Sunset the system. services human and health the Require HHSC to create policies governing hotlines and call centers throughout the health and human service system. service system. human and health the throughout centers call and hotlines governing policies create to HHSC Require system the throughout complaints for of escalation point a as office ombudsman’s HHSC of the authority and role the Clarify information. complaint standard collect to and be Could Needs, Special With Children for Force Task Interagency the Including Committees, Advisory HHSC’s 13: Issue of Restrictions. Statutory Free Managed Better and Combined to commissioner executive the allow and dates, Sunset with those including statue, from committees advisory Removed rule. in committees advisory needed re-establish Families, and on Children Council the Council, Policy Children’s the Needs, Special With Children for Force Task the Remove committee advisory one create to commissioner executive the direct and statue from Consortium of System Care Texas the and issues. children’s on efforts advisory coordinate better to rule in f o rtment Depa Appendices 320 Department f o Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Department of human services system. Postpone the health DADS’ and the Sunset review of decisions on continuation of functions and structure until completion of Structure Await Sunset’s the HHS System Overall. Analysis of Issue 8: Texas Has a Continuing Need for DADS’ Services, but Decisions on the Agency’s Reporting System for all providers. Direct DADS information available on the Quality to improve the quality and consistency of Require DADS long-term care providers in to maintain a consumer information site on the quality of Texas. For Helping the Public Select Long-Term Care Providers. Issue 6: DADS’ Consumer Information Website Lacks Clear and Consistent Information programs, including data on violations and deficiencies found during inspections Require DADS to compile basic information and data on day habilitation facilities providing services to persons in DADS facilities. community-based IDD waiver and intermediate care facility providers should include in their contracts with day habilitation Require DADS to develop, in rule, requirements for contract provisions regarding basic safety and service requirements that its Day Habilitation Facilities. Issue 3: DADS Lacks Effective Means for Ensuring Its Clients Receive Adequate Care in community clients and the fees for those services. Amend statute to require DADS to establish, in rule, services an SSLC the array of can provide to open small specialized group homes for people with high medical needs. Require DADS and HHSC, in rule, to add a reimbursement level that incentivizes providers to IDD in the community. Require DADS to expand crisis intervention teams to provide increased supports to people with and Medical Needs Require Extra Support. Issue 2: To Transition From SSLCs to the Community, People With Higher Behavioral than August 31, 2022. Require DADS to close the five SSLCs determined by the SSLC Closure Commission no later determine an additional five centers to close. Establish the State Supported Living Center Closure Commission to evaluate the SSLCs and Require DADS to close the Austin SSLC by August 31, 2017. Care,of Texas Continues to Operate 13 SSLCs. Issue 1: Despite Declining Enrollment, Skyrocketing Costs, and Questionable Quality unit and add additional critical turnover.functions to better support employees and systematically identify root causes of Direct DFPS to consolidate its existing workforce management functions under one operational Leave.Many Staff Issue 1: Efforts to Reduce Turnover CPS Caseworkers of Fail to Address Key Reasons F Aging amily and Protective and Disability Services (D Services (DFPS) ADS) Appendices 321 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 Direct DFPS to dedicate certain existing caseworker positions to create a mentoring program to program mentoring a create to positions caseworker existing certain dedicate to DFPS Direct caseworkers. CPS new support better ensuring and quality casework measuring better by performance caseworker evaluating for system its revise should CPS reasonable. are expectations performance ofperformance judging for tool a as regional CPS appropriate, when ofway systematic a develop should DFPS turnover, using management. Management Day-to-Day on Focus to Ability CPS’ Affects Culture Crisis A 2: Issue Work. Difficult Its Perform Successfully to Needed Activities process. planning business annual an implement to CPS Direct CPS the to response in implement to plans it changes on 2014 October in Commission Sunset the to report to DFPS Direct changes. needed impede may that barriers statutory any and progress, in currently assessment operational handbook procedures and policy CPS the update and review comprehensively to DFPS Direct procedures. policies and updated clear, ensure to process policymaking its to approach systematic a develop and a including performance, regional monitoring and evaluating to approach comprehensive systematic, a develop to CPS Direct ofimplementation verify to process improvement. for recommendations State’s the Reform to Efforts Its in Risks and Challenges Significant Faces DFPS 3: Issue System. Care Foster - transi agency’s the guide to plan implementation redesign care foster long-range a maintain and develop to DFPS Require efforts. tion ofimplementation broader before cost and data system redesign. evaluate should DFPS care foster and quality provider monitoring and measuring to approach consistent a develop should DFPS systems. redesigned and legacy the both in indicators risk identifying ofSafety the Ensure Best to Strengthened Be Must Efforts Enforcement DFPS’ 4: Issue Care. Regulated in Children pursuing first without violations licensing care child high-risk for penalties administrative assess to agency the Authorize sanctions. administrative non-monetary specific a require and efforts, enforcement licensing care child guide to rule in policy enforcement an develop to DFPS Require available. publicly be to methodology How Address Adequately to Information Comprehensive Capture Not Does CPS 5: Issue Children. Protecting Is It Well ofevaluation and collection its ofimprove to DFPS Direct measure additional an adding by data ofuse the standardizing and clarifying case unsure perpetrator, alleged the to linked recidivism process. review investigation fatality child its broadening and findings, Safety Family-Based to families referring for policy consistent and clear a develop should DFPS provided. services specific to linked measures outcome develop and Services Intervention Early and ofImportance the Elevate Should DFPS 6: Issue Prevention Its Effectiveness. Program Evaluate to Data Existing Use Better and Efforts a develop and programs intervention early and prevention its for plan strategic comprehensive a develop to DFPS Require ofoutcomes the report and efforts programs. its prevention its focus better to data existing to use strategy and Intervention Post-Partum Pregnant DSHS’ and programs visiting home HHSC’s Transfer DFPS. to programs Education Risk Drug and Awareness Parenting Process Collection Fee Antiquated an and Flexibility Administrative ofLack A 7: Issue Costs. Regulatory Recover to Ability DFPS’ Limit rule. in set be to fees authorize and caps fee administrative and licensing statutory agency’s the Eliminate Appendices 322 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas the Sunset review of the health and human services system.the Sunset review of Postpone DFPS’ functions and structure until the completion of the decision on continuation of Part an Overall Health and Human Services of Assessment of Agencies. Issue 9: Consider Organizational Aspects Related to Family and Protective Services as and direct DFPS to clearly define in agency policy the appropriate use advisory of committees and informal workgroups. advisory committees,Require rules governing the use of ensuring committees meet standard structure and operating criteria, Imposes a Higher Burden on DFPS in How It Obtains Stakeholder Input. Issue 8: Its TheWork Critical Nature of to Protect Children and Vulnerable Adults Direct DFPS to transition to online child care licensing fee collections. Appendices 323 http:// SAMHSA Shoveling up II: The Shoveling http://www.blogs.va.gov/ SAMHSA, MacArthur Achieving the promise: Transforming mental health care health care mental Transforming the promise: Achieving (P.L.111-148). in PPACA provisions health insurance Private Essential Health Benefits: Mental health and substance use disorders disorders substance use health and Mental Health Benefits: Essential http://www.texaspolicy.com/center/effective-justice/reports/right- Retrieved from http://www.whitehouse.gov/the-press-office/2013/06/03/ Retrieved . Geneva, World Health Organization Organization Health World . Geneva, Promotion Health Mental Strengthening http://www.communitycatalyst.org/doc-store/publications/EHB_SUD_Memo_ http://www.statehealthfacts.org/comparemaptable.jsp?cat=5&ind=278 Frequent utilization of behavioral health services in various service systems: systems: service in various health services of behavioral utilization Frequent (DHHS Publication No. SMA 03-3832). Retrieved from http://govinfo.library.unt.edu/ SMA 03-3832). Retrieved No. (DHHS Publication 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 165(6), 663-665. 165(6), Retrieved from http://kff.org/health-reform/state-indicator/health-insurance-exchanges/ Retrieved http://www.samhsa.gov/newsroom/advisories/1203082519.aspx . Retrieved . Retrieved of youth needs health behavioral to the responds system justice juvenile how to improve collaborate from May). (2009, University. at Columbia AddictionCenter on National Abuse and Substance from http://www.casacolumbia.org/ and local budgets. Retrieved state substance abuse on federal, impact of articlefiles/380-ShovelingUpII.pdf health problems mental with serious children How July). (2011, Law. Health Mental Center for Bazelon from http://www.bazelon.org/LinkClick. fix it. Retrieved to how and in our schools treated are aspx?fileticket=N7Q53i3SdBo%3d&tabid=134 of Journal American The Illness. Serious Mental of Costs the Economic (2008). Assessing T.R. Insel, Psychiatry. DC: in the USA Suicide (2012). Washington, Data. on 2010 Based Suicidology. Association of American Suicidology. Association of American of Association National Illness. Mental with Serious in People and Mortality (2006). Morbidity B. Mauer, http://www. from Retrieved Council. (NASMHPD)Medical Directors Directors Mental Health Program State nasmhpd.org/docs/publications/MDCdocs/Mortality%20and%20Morbidity%20Final%20Report%20 8.18.08.pdf (2003). Health. on Mental Commission New Freedom World Health Organization. Organization. Health World 220), 2001. no. sheet (Fact system corrections for prescription 30). The right Texas in the ill mentally the September M. (2011, Levin, from Retrieved slides]. [PowerPoint Committee Services Stakeholder the Psychiatric to presented update. Paper project improvement Performance Central Initiative), Indicator Improvement Illness, on Mental Force Task Health Mental the Mayor’s (part of TX Austin, Health, services expenditures, mental health per capita agency health mental State (n.d.). Foundation. Family Kaiser from Retrieved FY2010. in are persons mentally ill More May). AdvocacyTreatment (2010, Association. National Sheriffs’ Center & from http://treatmentadvocacycenter.org/ states. Retrieved of the survey hospitals: A prisons than jails and storage/documents/final_jails_v_hospitals_study.pdf March). Services Administration. (2012, Health Mental and Abuse Substance prescription-mentally-ill-texas-corrections-system March). (2012, S. Stone, report in America, final mentalhealthcommission/reports/FinalReport/downloads/downloads.html [VideoHealth on Mental National Conference The (2013). Blog. from House The White file]. Retrieved www.whitehouse.gov/blog/2013/06/03/national-conference-mental-health Convened. Conference Health Landmark Mental (2013). Health. Mental and Abuse Substance from Retrieved 21(3). News, on Conference the National on Background June 03). (2013, Secretary. of the Press Office House The White from http://www.whitehouse.gov/the-press-office/2013/06/03/ The White House. Retrieved Health. Mental background-national-conference-mental-health Vantage Summits. Health Mental Community nationwide launch VA House, White 11). July R. (2013, Petzel, from Affairs. Retrieved of Veterans Department U.S. the from Dispatches Point: VAntage/9815/white-house-va-launch-nationwide-community-mental-health-summits/ on Conference the National on Background June 03). (2013, Secretary. of the Press Office House The White The White House. Health. Mental October). (2012, Catalyst. Community from Retrieved advocacy. reboot_10_1_12.pdf Marketplaces, decisions for State Insurance Health creating (2014). Foundation. Family Kaiser J. The Henry 2014. enrollment Summary Marketplace: Insurance Health (2014). and Human Services. of Health Department from http://aspe.hhs.gov/health/reports/2014/ forperiod. Retrieved report enrollment the initial annual open MarketPlaceEnrollment/Apr2014/ib_2014apr_enrollment.pdf decision, 2014. expansion on the Medicaid of state action Status (2014). Foundation. Family Kaiser J. The Henry from http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid- Retrieved under-the-affordable-care-act/#note-2 do not in states that poor adults Uninsured gap: The coverage (2014). Foundation. Family Kaiser J. The Henry background-national-conference-mental-health 15). April Service. (2010, Research Congressional 7 8 9 10 11 12 Endnotes 1 2 4 5 6 3 13 Ibid. 14 15 http://www.samhsa.gov/samhsanewsletter/Volume_21_Number_3/national_conference.aspx 16 17 18 20 21 22 23 24 19 Appendices 324 47 46 http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf 45 44 43 42 41 40 39 Ibid. 38 37 Ibid 36 35 Ibid 34 33 32 31 30 29 28 27 26 25 Ibid. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 52 Ibid. 51 50 49 48 Centers for Medicare and Medicaid Services. (n.d.) from Centers for Medicare and Medicaid Services. (n.d.). theinitialannual open enrollmentreport period. Retrieved for from U.S. Department of Health andHuman Services. (2014). Health insurance marketplace: Summary enrollment SebeliusKathleen201211150621.pdf of Health and Human Services. Retrieved from: R. Perry. (2012, November 15). Letter to Kathleen secretary of U.S. Sebelius, former Department sect01b.pdf Disability Insurance program, 2012. (2012).The United States Social Security Administration. Annual statistical report on theSocial Security security-disability-insurance-ssdi-beneficiaries-ages-18-64/ beneficiaries, ages 18-64.Retrieved from http://kff.org/medicare/state-indicator/total-disabled-social- The Henry J. Kaiser Family Foundation. (2014). Total disabled Social Security Disability Insurance (SSDI) program. Retrieved from (2013).The United States Social Security Administration. Annual report of theSupplemental Security Income medicaid/state-indicator/total-ssi-beneficiaries/ The Henry J. Kaiser Family Foundation. (2014). Total SSIbeneficiaries.Retrieved http://kff.org/from FinancialAlignmentInitiative/Downloads/TXMOU.pdf Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/ for Medicare-Medicaid enrollees.financial alignmentmodel Medicare &MedicaidServices and the state of Texas regarding afederal-state partnership to test acapitated Centers for Medicare & Medicaid. (n.d.). Medicaid-Coordination-Office/FinancialAlignmentInitiative/Texas.html www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare- Centers for Medicare & Medicaid. (2014). FinancialModelstoSupportStatesEffortsinCareCoordination.html Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/ http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid- Centers for Medicare & Medicaid. (2014). FinancialAlignmentInitiative/Downloads/TXProposal.pdf Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/ from CentersforMedicare and Medicaid website: http://www.cms.gov/Medicare-Medicaid- Millwee, B. (2012). Texas dualeligible integrated care demonstration project: Application. kff.org/medicare/state-indicator/dual-eligible-beneficiaries/ The Henry J. Kaiser Family Foundation. (2014). Number of dualeligible beneficiaries. Henry J. Kaiser Family Foundation website: both Medicaid andMedicare. Retrieved people eligible for fromthe examination of services and spending for Coughlin, T., Waidmann, T., &Watts, M. (2009, April). medicare/state-indicator/distribution-of-medicare-beneficiaries-by-eligibility-category-2/?state=TX The Henry J. Kaiser Family Foundation. (2012). Retrieved fromhttp://www.medicare.gov/Pubs/pdf/10050.pdf Centers for Medicare and Medicaid Services. (2014). Medicare &you 2014 rules. Retrieved from Faegre Baker Daniels LLP. website: http://www.faegrebd.com/20772 Swain, F. S., &Zook, D. R.(2013). aspx?id=131 Congressional Research Service. Retrieved from Sarata, A. K. (2010). Mental Health Parity andthe PatientAct of2010. Protection and Affordable Care http://www.nashp.org/sites/default/files/LTSS_SCAN-FINAL-9-29-10.PDF based services.for State Health Policy, Briefing: APublicationofthe NationalAcademy 1-9 Justice, D.Act: New options (2010). for Implementing the Affordable Care Medicaid homeand community poor-adults-in-states-that-do-not-expand-medicaid/ expand Medicaid. Ibid. HC_2014_02_TDINavigatorRules.pdf ahead with registration; timelines post achallenge. Center for PublicPolicy Priorities. (2014). Final navigators rules much improved: TDIandnavigators moving Texas Well and Healthy. (n.d.).Retrieved from state.tx.us/pdf/ba83r/sb1795.pdf Texas House Research Organization. (2013). Bill analysis: SB Retrieved1795. from http://www.hro.house. www.healthcare.gov/how-do-i-choose-marketplace-insurance/plans-categories/ https://www.healthcare.gov/what-key-dates-do-i-need-to-know/#part=1 Retrieved fromhttp://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured- http://ssa.gov/oact/ssir/SSI13/ssi2013.pdf HHS, Labor and Treasury Departments release final MentalHealth Parity Retrieved from http://www.ssa.gov/policy/docs/statcomps/di_asr/2012/ Memorandum of Understanding (MOU) between TheCenters for Texas financial alignment demonstration. Retrieved from http:// Financial alignment initiative. Retrieved from http://www.kff.org/medicaid/upload/7895-2.pdf http://texaswellandhealthy.org/tag/navigators/ http://governor.state.tx.us/files/press-office/O- https://www.naphs.org/resourcemanager/handlerresource. Texas: Medicare enrollment. Retrieved http://kff.org/from Retrieved from:http://forabettertexas.org/images/ Marketplace insurance categories. Important health insurance Marketplace dates. Retrieved The diversity of dualeligible beneficiaries: An Retrieved from http://www.cms.gov/Medicare-
(CMS Product No. 10050). Retrieved from Retrieved fromhttps:// Retrieved . Retrieved from http:// Appendices 325 http://
http://www. Retrieved from Retrieved Retrieved from Retrieved http://www.capitol.state. https://www.hhsc.state.tx.us/news/ Presentation to House Committee on Human Services: on Committee to House Presentation Texas Medicaid patient-centered medical home report. report. medical home Medicaid patient-centered Texas Presentation to the Senate Committee on Health and on Health Committee to the Senate Presentation . Retrieved from http:// . Retrieved Eligibility act: care Affordable forit means & what expansion Medicaid . Retrieved you Retrieved from Bill. Retrieved Appropriations S.B.General 1 Retrieved from National Association of State Mental Health Program Directors’ Health State Mental of Association from National Retrieved [PowerPoint slides]. Retrieved from slides]. Retrieved [PowerPoint http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical- 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.healthcare.gov/what-if-my-state-is-not-expanding-medicaid/ Centers for Medicare and Medicaid Services. (n.d.). Services. and Medicaid for Medicare Centers http://www.nasmhpd.org/docs/publications/NASMHPDMedicaidExpansionReportFinal.pdf website: gap. coverage to close the funds care health federal should accept Texas (2014). and Healthy. Well Texas from http://texaswellandhealthy.org/wp-content/uploads/2014/05/Printable-One-Pager-on- Retrieved Health-Coverage-Gap.pdf participation in the lack of state the How despair: more promises; broken Dashed hopes; (2014). J. Miller, Health Mental from American Retrieved mental illness. punish Americans with will expansion Medicaid website: http://www.amhca.org/assets/content/AMHCA_DashedHopes_ Association Counselors Report_2_21_14_final.pdf A national crisis. cuts: mental health State (2011). Illness. Alliance on Mental National www.medicaid.gov/AffordableCareAct/Provisions/Eligibility.html from . Retrieved guidelines poverty 2014 (2014). Services. and Medicaid for Medicare Centers medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Downloads/2014-Federal- Poverty-level-charts.pdf (n.d.). Services. Medicaid and for Medicare Centers from National billions. Medicaid of snubbing Texas’ of decry snubbing official 23). Health May (2013, W. Goodwyn, from http://www.npr.org/2013/05/23/186303141/health-officials-decry-texas- Retrieved Public Radio. snubbing-of-medicaid-billions decision, 2014. expansion on the Medicaid state action of Status (2014). Foundation. Family Kaiser J. The Henry from http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid- Retrieved under-the-affordable-care-act/ gap. coverage to close the funds care health federal should accept Texas (2014). and Healthy. Well Texas from http://texaswellandhealthy.org/wp-content/uploads/2014/05/Printable-One-Pager-on- Retrieved Health-Coverage-Gap.pdf effect: of impacts waterfall The Transformative (2013). J. & Harding, N., Maududi, C., E., Lentz, J. Miller, on states. expansion Medicaid http://www.nami.org/Content/NavigationMenu/State_Advocacy/State_Budget_Cuts_Report/ NAMIStateBudgetCrisis2011.pdf and Health Care by the as amended 111-148), P.L. Care and Affordable Protection (PPACA, Act The Patient as the in this paper referred to is collectively 111-152), ActReconciliation Education (HCERA, P.L. of 2010 Care Affordable (ACA). 2010 Act of in States states. for ill: An opportunity the chronically homes for Health (2010). D. & Rodin, S. Silow-Carrol, from http://www.commonwealthfund.org/Newsletters/ . Retrieved Policy Health in State Innovations Action: States-in-Action/2011/Jan/December-2010-January-2011/Feature/Feature.aspx status (effective CMS proposal home health State June (2014). Services. and Medicaid for Medicare Centers from Retrieved 2014). Assistance/Health-Homes-Technical-Assistance/Downloads/HH-MAP_v34.pdf home implementation health Medicaid Services Administration. (2013). Health Mental and Abuse Substance from www.integration.samhsa.gov/about-us/CIHS_Presentation_ Retrieved later. A year in Missouri: Slides_062713.pdf (2013). Services Commission. and Human Health Texas from http://www.hhsc.state.tx.us/reports/2013/SB7-Medicaid-Patient-Centered.pdf Retrieved and Human Services Health to the Senate Presentation (2014). Services Commission. and Human Health Texas SB 7 implentation Committee: (2014). Services Commission. and Human Health Texas from Retrieved slides]. Act [PowerPoint Care Affordable and the Human Services: Medicaid II Article Appropriations to the House Presentation (2014). Services Commission. and Human Health Texas from Retrieved slides]. [PowerPoint Waiver in the 1115 projects healthcare Behavioral Subcommittee: tx.us/BillLookup/History.aspx?LegSess=83R&Bill=SB1 and Community- Home communication: Personal 8). July (2014, Services. State Health of Department Texas Program (HCBS-AMH) Health Based Services—Adult Mental presentations/2014/SB-7-implementation.pdf Commission. (2014). Services and Human Health Texas from www.hhsc.state.tx.us/news/ slides]. Retrieved [PowerPoint initiatives Managed Care Medicaid presentations/2014/Managed-Care-Initiatives.pdf II Article Appropriations to the House Presentation (2014). Services Commission. and Human Health Texas slides]. [PowerPoint Waiver in the 1115 projects healthcare Behavioral Subcommittee: www.hhsc.state.tx.us/news/presentations/2014/House-Appropriations-Committe-DSRIP-BH.pdf Appropriations to the House Presentation (2014). Services Commission. and Human Health Texas from http://www.hhsc. Retrieved slides]. [PowerPoint health coordination on Article II: Mental Subcommittee state.tx.us/news/presentations/2014/Mental-Health-Coordination.pdf (2013). Online. Legislature Texas 53 60 61 62 54 55 56 57 58 59 63 64 65 66 67 Ibid. 68 69 http://www.hhsc.state.tx.us/news/presentations/2014/House-Appropriations-Committe-DSRIP-BH.pdf 72 https://www.hhsc.state.tx.us/news/presentations/2014/affordable-care-act.pdf 73 77 70 71 74 75 Ibid. 76 Appendices 326 94 93 92 Ibid. 91 Ibid. 90 89 Ibid. 88 87 Ibid. 86 85 84 108 107 106 105 104 103 Ibid. 102 Ibid. 101 100 99 98 97 Buckles, 83 82 81 80 79 78 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 95 96 Retrieved fromhttp://www.hindawi.com/journals/aurt/2011/405849/ Disabilities, Statewide Health Coordinating Council. (n.d.). from Aronson, B. (2012, May 8). Interactive: Mapping access tohealth care inTexas. from Texas Department of State Health Services. (2014). Themental health workforce shortage in Texas.Retreived Mental_Health_Crisis_final_032111.pdf health workforce shortages in Texas. Hogg Foundation for Mental Health & Methodist Healthcare Ministries. (2011, March). from Texas Department of State Health Services. (2014). Themental health workforce shortage in Texas. Retreived Health_Crisis_final_032111.pdf workforce shortages in Texas. Retrievedhttp://www.hogg.utexas.edu/uploads/documents/Mental_ from Hogg Foundation for Mental Health & Methodist Healthcare Ministries. (2011). Crisis point: Mental health from Texas Department of State Health Services. (2014). Themental health workforce shortage in Texas. Retreived 32(11), 2005-2012 Texas Health and Human Services Comission. (2012). boardinghome.org/regulating-boarding-homes/ Mental Health America of Greater Dallas. (n.d.). http://www.hhsc.state.tx.us/BoardingHouseModelStandards.pdf Texas Health and Human Services Commission. (n.d.). html boarding inTexas. home reforms Hogg Foundation for Mental Health. (2009). Mental Health America of Texas receives grant topromote boardinghome.org/ Mental Health America of Greater Dallas. (n.d.). ber=100 cfm?legSession=80-0&billtypeDetail=HB&billNumberDetail=1168&startRow=1&IDlist=&unClicklist=&num and HumanServicesCommision. Retrieved fromhttp://www.lrl.state.tx.us/legis/billsearch/docs. Health Associates. Management (2008). 1-6. Association on Intellectual and Developmental Disabilities, Harvey, K. (2012). Trauma-informed behavioral interventions: What worksand what doesn’t. American Rosenberg, R.,W., Kaufmann, update. Smiley,E. (2005). in studies/hcs-class-report.pdf Medicaid waiver programs. Retrieved from http://www.dads.state.tx.us/news_info/publications/ in the Home andCommunity-Based ServicesandCommunity LivingAssistance and Support Services Texas Department of AgingandDisability Services. (2012). Physical andbehavioral healthservices addiction workforce Hoge, M. A.,Stuart, G. W., Morris, J., Flaherty, M.T., Paris, M. J., &Goplerud, E. (2013). Mental health and Health_Crisis_final_032111.pdf workforce shortage in Texas. Retrievedhttp://www.hogg.utexas.edu/uploads/documents/Mental_ from Hogg Foundation for Mental Health & Methodist Healthcare Ministires. (2011) Crisis point: Mental health gov/workplacehealthpromotion/businesscase/ Centers for DiseaseControl and Prevention. (2013). Making a business case . Retrievedhttp://www.cdc. from Health_Crisis_final_032111.pdf workforce shortage in Texas. Retrievedhttp://www.hogg.utexas.edu/uploads/documents/Mental_ from Hogg Foundation for Mental Health & Methodist Healthcare Ministries. (2011) Crisis point: Mental health Retrieved from Health (HCBS-AMH). Texas Department of State Health Services. (n.d). 1915(i) Home andCommunity Based Services –Adult Mental Community-Based Mental Services—Adult Health Program (HCBS-AMH) Texas Department of State Health Services. (2014, September 9). Personal communication: Home and comorbid diagnoses mental healthservices-HB3793. ” Retrieved from Texas Department of State Health Services. (2014). the appropriate and timelyprovision Initial plan for of state.tx.us/chs/shcc/reports/SHP2011-2016/ adults with http://www.texastribune.org/library/data/texas-shortage-health-care-providers/ http://www.dshs.state.tx.us/WorkArea/DownloadAsset.aspx?id=8589985787 http://www.dshs.state.tx.us/WorkArea/DownloadAsset.aspx?id=8589985787 http://www.dshs.state.tx.us/WorkArea/DownloadAsset.aspx?id=8589985787 Advances Advances J .,
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Psychiatric Treatment, in R., Keef, E. (2013). E. R., Keef, autism spectrum disor autism Law, Retrieved fromhttp://www.hogg.utexas.edu/detail/85/policy_grant_mhat. of Retrieved from http://www.hogg.utexas.edu/uploads/documents/ mentalproblems health K., www.dshs.state.tx.us/mhsa/hcbs-amh/ & Law,P., & (2011). Report on Texas boarding houses: Presented to Texas Health A systematic review Texas state health plan2011-2016. 18 Regulating boarding homes.Retrieved from http:// Boarding home regulation. Retrieved from http:// http://www.dshs.state.tx.us/mhsa/hb3793/ der , 21 Journal 4-222. Boarding report: Report tothe homes facility s Texas boarding house model standards. Retrieved from .
Autism Parent report of of in Research Mental Mental of the adults prevalence of Health Researchin with and community psychiatric
learning disabilities: The Texas Tribune. Retrieved Treatment, Retrieved from www.dshs. of psychiatric disorders Crisis point: Mental , 1- 2011, Intellectual 1 0. 0. An Appendices 327 Regular th [Data file]. ninth edition. ninth ninth edition. Psychiatric Psychiatric With peer support, recovery support, recovery peer With http://www.dshs.state.tx.us/ http://www.hhsc.state.tx.us/medicaid/managed- Health and Human Services System consolidated System and Human Services Health , in perspective Medicaid and CHIP Texas from year 2014. Retrieved fiscal audit plan Internal , perspective in Medicaid and CHIP Texas 2A. Summary of base request by strategy, 84 2A.by strategy, request Summary of base . Retrieved from http:// act. Retrieved appropriations General . Retrieved from http:// act. Retrieved appropriations General . Retrieved from http:// act. Retrieved appropriations General Retrieved 2013. Retrieved by county October enrollment Medicaid Achieving the promise: Transforming mental health care health care mental Transforming the promise: Achieving Health and Human Services System: Strategic plan 2015- Strategic System: and Human Services Health http://www.hhsc.state.tx.us/about_hhsc/finance/2014-2015. Retrieved from http://www. Retrieved Today. News Medical http://www.dads.state.tx.us/news_info/publications/legislative/ http://www.dshs.state.tx.us/chpr/fqhcmain.shtm [PowerPoint on Article II [PowerPoint Subcommittee Appropriations to the House Presentation 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 from http://ps.psychiatryonline.org/article.aspx?articleID=1832833 Retrieved 429-441. 65(4), Retrieved from http://www.hhsc.state.tx.us/about_hhsc/strategic-plan/2015-2019/strategic-plan-2015- Retrieved http://www.texasobserver.org/datelinehouston/judge-rules-mentally-ill-prisoners-must-not-wait http://www.hhsc.state.tx.us/research/MedicaidEnrollment/me-results.asp http://www.hhsc.state.tx.us/research/MedicaidEnrollment/me-results.asp Retrieved from from Retrieved Legislature. Texas boardinghomefaciliities-dec2012.pdf Boarding home communication: Personal 15). May (2014, Dallas. of Greater America Health Mental regulation #07-011. Letter Director Medicaid State August). (2007, Services. Medicaid and for Medicare Centers from http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD081507A. Retrieved pdf M. E. A., & Delphinn-Rittmon, Swift, S., S. Ghose, S., A. H., Daniels, R. Dougherty, M., George,Chinman, P., the evidence. illness: Assessing mental with serious for individuals services support Peer (2014). Services, hospitalization, psychiatric peer support, among of relationships An analysis M. (2011). G., & Zhou, Landers, from http://www. Retrieved , 106-112. 47 Health Journal Mental Community stabilization. and crisis countyofsb.org/uploadedFiles/admhs_new/resources/Systems_Change/Peer_Action_Team/An%20 Analysis%20of%20Relationships.pdf Administration.Services Division (2012). Health Mental and Abuse Substance at http://www.samhsa.gov/samhsanewsletter/Volume_20_ SAMHSA 20(3). Retrieved is possible. 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Services Commission. and Human Health Texas http://www.hhsc.state.tx.us/reports/2013/FY14-Internal-Audit-Plan.pdf (2013). Committee. Conference Legislature, 83rd Texas www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2014-15.pdf (2014). Services Commission. and Human Health Texas Retrieved from http://www.txohc.org/PDFsPPs/Texas%20Medicaid_CHIP%20Pinkbook.2013.pdf Retrieved is Medicare/Medicaid? (n.d.) What P. Crosta, www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2014-15.pdf Managed Care of Medicaid April). Expansion (2014, Services Commission. and Human Health Texas from slides]. Retrieved information [PowerPoint session care/mmc/consumer-presentation.pdf (2013). Services Commission. and Human Health Texas Session, agency submission, version 1, Automated Budget and Evaluation System of Texas (ABEST) of Texas System Budget and Evaluation 1, Automated version agency submission, Session, from http://www.hhsc.state.tx.us/LAR/2016-2017/2A-base-request-by-strategy.pdf Retrieved (2013). Committee. Conference Legislature, 83rd Texas 109 110 111 112 Ibid. 113 Ibid. 114 115 116 117 118 Ibid. 119 120 Ibid. 121 122 123 124 125 126 127 128 129 130 131 132 133 137 135 136 134 Appendices 328 162 161 160 159 158 157 156 155 154 153 152 151 150 149 148 147 146 145 144 143 142 141 140 139 138 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Texas Department of State Health Services. (2014, August 14). Presentation to Senate Health andHuman Behavioral%20Health%20System.pdf publicconsultinggroup.com/client/txdshs/documents/Analysis%20of%20the%20Texas%20Public%20 State HealthServices:Analysis of theTexas public behavioral health system. Retrieved from Public Consulting Group. (n.d.).Stateof Texas Health and HumanServices Commission Department of Behavioral%20Health%20System.pdf publicconsultinggroup.com/client/txdshs/documents/Analysis%20of%20the%20Texas%20Public%20 State HealthServices:Analysis of theTexas public behavioral health system. Retrieved from Public Consulting Group. (n.d.).Stateof Texas Health and HumanServices Commission Department of aspx?LinkIdentifier=id&ItemID=8589979882 & Substance Abuse Block Grant Application. Retrieved https://www.dshs.state.tx.us/WorkArea/linkit. Texas Department of StateHealth Services. (2013). FY2014–2015 SAMHSA Community Mental Health Priorities website: http://forabettertexas.org/images/2013_10__PP_Budget_MentalHealth.pdf K. (2013).Ligon, Sizing up the 2014-15 Texas budget: Mental health. services expenditures. Retrieved fromhttp://kff.org/other/state-indicator/smha-expenditures-per-capita/ The Henry J. Kaiser Family Foundation. (2010). Material_0.pdf Retrieved fromhttps://www.sunset.texas.gov/public/uploads/files/reports/DSHS%20Decision%20 Commission. (2014).Sunset Advisory aspx?LinkIdentifier=id&ItemID=8589990636 from Texas Department of State Health Services website: Services Committee: Overview mental health and substance abuse services [PowerPoint slides]. Retrieved Texas Department of State Health Services. (2014, August 14). Presentation to Senate Health andHuman aspx?LinkIdentifier=id&ItemID=8589988644 from Texas Department of State Health Services website: Subcommittee on ArticleII:Overview of newmental health funds in Texas [PowerPoint slides]. Retrieved Texas Department of State Health Services. (2014, June 16). aspx?LinkIdentifier=id&ItemID=8589990636 from Texas Department of State Health Services website: Services Committee: Overview mental health and substance abuse services [PowerPoint slides]. Retrieved Texas Department of State Health Services. (2014, August 14). Presentation to Senate Health andHuman Mental healthandsubstance abuse services. Retrieved from http://www.dshs.state.tx.us/sunset.aspx Texas Department of State Health Services. (2013). DSHS Sunset Self-Evaluation report, September 2013: aspx?LinkIdentifier=id&ItemID=8589990636 from Texas Department of State Health Services website: Services Committee: Overview mental health and substance abuse services [PowerPoint slides]. Retrieved Texas Department of State Health Services. (2014, August 14). 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(2013) medicalnewstoday.com/info/medicare-medicaid/ http://www.hhsc.state.tx.us/news/release/2014/050914-Xerox-Medicaid.shtml http://www.hhsc.state.tx.us/research/MedicaidEnrollment/me-results.asp http://www.dshs.state.tx.us/chpr/fqhcmain.shtm Staff report withdecision material:Department ofState HealthServices. Texas: Patients served by federally-funded federally qualified State Mental Health Agency (SMHA) per capita mental health State Mental Health Agency (SMHA) Chapter 9: Children’s Health Insurance Program. Chapter 9: Children’s Health Insurance Program. Medicaid enrollment by countyOctober 2013. Retrieved HHSC cancelsXerox Medicaid Contract. Retrieved Texas MedicaidandCHIP in perspective , http://www.dshs.state.tx.us/WorkArea/linkit. https://www.dshs.state.tx.us/WorkArea/linkit. http://www.dshs.state.tx.us/WorkArea/linkit. http://www.dshs.state.tx.us/WorkArea/linkit. http://www.dshs.state.tx.us/WorkArea/linkit. 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Retrieved from Texas Health and Human Services and Human Health from Texas . Retrieved Integration Health SB 58 Behavioral Hearing. Joint and Planning Policy Office of Budget, Board-Governor’s Budget 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 www.hhsc.state.tx.us/research/MedicaidEnrollment/ME-Monthly.asp www.txcouncil.com/userfiles/file/HOW/Framework%20for%20the%20Future%20Final%209%205%20 2013.pdf from Retrieved (LMHAs). Authorities Health Local Mental (2014). Services. of State Health Department Texas http://www.dshs.state.tx.us/mhsa/lmha-list/ Health Mental Community SAMHSA FY 2014–2015 (2013). Services. State Health of Department Texas https://www.dshs.state.tx.us/WorkArea/linkit. Retrieved Grant Application. Block Abuse & Substance aspx?LinkIdentifier=id&ItemID=8589979882 of Department Commission and Human Services Health Texas (n.d.). State of Consulting Group. Public from Retrieved . system health public behavioral of the Texas State Health Services: Analysis publicconsultinggroup.com/client/txdshs/documents/Analysis%20of%20the%20Texas%20Public%20 Behavioral%20Health%20System.pdf 2013: September report, Sunset self-evaluation DSHS (2013). Services. of State Health Department Texas from http://www.dshs.state.tx.us/sunset.aspx services. Retrieved abuse Mental health and substance from . Retrieved Services Unit: NorthSTAR Medicaid (2014). Services. of State Health Department Texas http://www.dshs.state.tx.us/mhsa/northstar/northstar.shtm (2013). Authority. Health Behavioral North Texas from decision, 2014. expansion on the Medicaid state action of Status (2014). Foundation. Family Kaiser J. The Henry from http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid- Retrieved under-the-affordable-care-act/ (2013). Centers. of Community Council Texas com/userfiles/file/HOW/Framework%20for%20the%20Future%20Final%209%205%202013.pdf from http://www.statutes.legis.state. Retrieved (1991). B § 552.012. subtit. 7. Code, tit. and Safety Health Texas tx.us/Docs/HS/htm/HS.552.htm#552.012 of Department Commission and Human Services Health Texas (n.d.). State of Consulting Group. Public from Retrieved . system health public behavioral of the Texas State Health Services: Analysis health-carve-in.pdf September). (2013, Centers. of Community Council Texas http://www.ntbha.org/docs/NTBHA_LSAP_SFY14-15_FINAL.pdf (formerlyand Recovery Resilience Texas (2013). Services. of State Health Department The mental RDM): Texas from http://www.dshs.state.tx.us/mhsa/trr/ Retrieved redesigned. system health Medicaid-CHIP-Program-Information/By-State/texas.html eligibility standards income CHIP and Medicaid State (2014). Services. & Medicaid for Medicare Centers from http://www.medicaid.gov/ Retrieved 2014). 1, as of July decisions state based on Groups, MAGI (For AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/Medicaid-and-CHIP-Eligibility-Levels- Table.pdf (n.d). Services Commission. and Human Health Texas Information/By-Topics/Delivery-Systems/Managed-Care/Managed-Care.html M. (n.d.). Thyssen, website: Commission aspx?LinkIdentifier=id&ItemID=8589990636 waitlists LMHA communication: Personal April 29). (2014, Services. Health of State Department Texas L. (2012). D. Lakey, http://www.dshs.state.tx.us/WorkArea/ website: Services of State Health Department from Texas Retrieved DownloadAsset.aspx?id=70651 http://www.dshs. from list summaries. Retrieved Waiting (2014) Services. State Health of Department Texas state.tx.us/mhsa/waitlist/ (n.d.). Medicaid.gov. publicconsultinggroup.com/client/txdshs/documents/Analysis%20of%20the%20Texas%20Public%20 Behavioral%20Health%20System.pdf . 1 § 412.106. part tit. 25, Code, Administrative Texas 1 § 444.413. part tit. 25, Code, Administrative Texas criteria. – eligibility Program Care Health Indigent County (2014). Services of State Health Department Texas from www.dshs.state.tx.us/cihcp/eligibility.shtm Retrieved from www.dshs.state. – 83(R). Retrieved Bill 3793 House (2014). Services. State Health of Department Texas tx.us/mhsa/hb3793 from http://www.statutes.legis. Retrieved (2014). A § 533.0354 subtit. 7. Code, tit. and Safety Health Texas state.tx.us/Docs/HS/htm/HS.533.htm#533.0354 (2013). Online. Legislature Texas billtext/html/HB03793F.htm (2013). Online. Legislature Texas billtext/html/SB00007F.htm (n.d.). Medicaid.gov. [PowerPoint slides]. Retrieved slides]. Retrieved [PowerPoint services abuse substance health and mental Overview Committee: Services website: Services Health of State Department from Texas 183 Ibid. 184 185 186 187 188 189 169 170 171 172 182 190 Ibid. 191 167 168 181 163 164 165 166 173 174 175 176 177 178 179 180 Appendices 330 212 211 210 209 208 207 206 205 204 203 202 201 200 199 198 197 196 195 194 193 Ibid. 192 Ibid. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 218 217 216 215 214 213 indicators: SMHFindicators-1 Texas Department of State Health Services. (2014). quarterly State mental health facilities performance Primer.pdf Managing%20and%20Funding%20State%20Mental%20Hospitals%20in%20Texas%20-%20Legislative%20 Legislative primer. Retrieved from Texas Legislative Budget Board.(2011, February). aspx?LegSess=83R&Bill=SB152 Texas LegislatureOnline. (2013). 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U4zkLIHd8AH-84CgBw&usg=AFQjCNFgoK0YVzXIfyP4vyvjoVyGTDtZSw&sig2=vqBLbuxuDMaPJUR org%2FHealthCareProviders%2FEducation%2FC0BCBehavioralHealt08E03%2FNaranjo.asp&ei=HRb- url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CB4QFjAA&url=http%3A%2F%2Fwww.tha. to stand trial [PowerPoint slides].Retrieved from towardsServices efforts more timely treatment ofpatients determined incompetent Texas Department of State Health Services. (2012). Department of State Health Texas Department of State Health Services (2014, August 22) Personal communication: State Hospitals yWo_Gtg. U4zkLIHd8AH-84CgBw&usg=AFQjCNFgoK0YVzXIfyP4vyvjoVyGTDtZSw&sig2=vqBLbuxuDMaPJUR org%2FHealthCareProviders%2FEducation%2FC0BCBehavioralHealt08E03%2FNaranjo.asp&ei=HRb- url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CB4QFjAA&url=http%3A%2F%2Fwww.tha. to stand trial [PowerPoint slides].Retrieved from towardsServices efforts more timely treatment ofpatients determined incompetent Texas Department of State Health Services. (2012). 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Submitted 422 417 418 Ibid. 419 Ibid. 420 Ibid. 421 423 Ibid. 424 425 426 427 Ibid. 428 415 416 413 Ibid. 414 403 410 411 412 404 395 396 405 406 407 408 409 402 397 398 399 400 401 Appendices 338 458 457 456 455 Ibid. 454 453 452 451 450 449 Ibid. 448 447 446 445 444 443 442 441 440 439 Ibid. 438 437 Ibid. 436 435 434 433 432 431 430 Ibid. 429 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas http://ajp.psychiatryonline.org/article.aspx?articleid=100490 incarcerations: The revolving prison door. American Journal of Psychiatry, 166 (1), 103-109. Retrieved from J.,Baillargeon, Binswanger, I.,Penn, J., Williams, B., &Murray, O. (2009). Psychiatric disorders and repeat shtml Submitted to theSunsetCommission. Retrieved from http://www.dars.state.tx.us/news/sunset_eval_report. Texas Department of Assistive andRehabilitative Services. (2013, September). 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661 671 672 Ibid. 673 674 675 670 662 663 664 665 669 668 666 667 Ibid. 676 677 678 679 680 of Education, Department U.S. Statistics, for Education National Center 243299). (NCES 2014-042/NCJ DC. Washington, Justice. of Department U.S. and Programs, Justice Office of Statistics, of Justice Bureau 681 690 682 683 Ibid. 684 685 686 687 Ibid. 688 689 Appendices 346 727 726 Ibid. 725 Ibid. 724 Ibid. 723 Ibid. 722 Ibid. 721 720 719 718 717 716 715 714 713 712 711 710 709 Ibid. 708 Ibid. 707 Ibid. 706 705 704 703 702 701 700 699 698 697 Ibid. 696 Ibid. 695 694 Ibid. 693 692 Ibid. 691 Ibid. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas austinisd.org/academics/sel Department of Social and Emotional Learning. (n.d.) Social and emotional learning first.https://www. download&gid=867&Itemid= districts. Texas Appleseed. (2009). Breaking rules, breaking budgets: Cost ofexclusionary discipline in 11 Texas school Texans Care for Children. (2013, March 13). Personal communication: Positive Behavior Intervention Support Interior/reports/child_mental_wellbeing.pdf Texans Care for Children. (n.d.). Retrieved fromhttp://www.txbehaviorsupport.org/default.aspx?name=pbs.mission Texas Behavior Support Network. (n.d.). Texas Positive Behavioral Interventions and Support Project. Interior/reports/child_mental_wellbeing.pdf Texans Care for Children. (n.d.). default.aspx?name=about.history Texas Behavior Support Network. (n.d.). About PBIS. Retrieved fromhttp://www.txbehaviorsupport.org/ Retrieved from http://www.txbehaviorsupport.org/default.aspx?name=pbs.mission Texas Behavior Support Network. (n.d.). Texas Positive Behavioral Interventions and Support Project. Interior/reports/child_mental_wellbeing.pdf Texans Care for Children. (n.d.). content/dam/farm/reports/reports/2013/rwjf404627 a study of eleven states. Behrens, D., Lear, J.G. & Price,O.A. (2013). Improving access tochildren’s mental health care: Lessons from index3.aspx?id=4639 Texas Education Agency. (2014). Communities in Schools ofTexas. Retrieved from 15.pdf Bill No. 1.Retrieved from http://www.lbb.state.tx.us/Documents/GAA/General_Appropriations_Act_2014- forthe 2014-15General Appropriations Act Biennium. (2013). Appropriations Bill. Retrieved from Legislative Reference Library. (2011). Conference Committee report 3 index3.aspx?id=4639 Texas Education Agency. (2014). Communities in Schools ofTexas. Retrieved from dshs.state.tx.us/schoolhealth/csh.shtm Texas Department of StateHealth Services. (2012). Coordinated School Health.Retrieved from http://www. Model. Retrieved from Texas Education Agency. (2012). pdf Retrieved from http://www.gpo.gov/fdsys/pkg/CFR-2007-title34-vol2/pdf/CFR-2007-title34-vol2-part300. Education Assistance to States for the Education of Children with Disabilities Rule, 34C.F.R. § 300.8 (2007). www.tea.state.tx.us/index4.aspx?id=2147494988 Texas Education Agency. (2013). pdf Retrieved fromhttp://www.gpo.gov/fdsys/pkg/CFR-2007-title34-vol2/pdf/CFR-2007-title34-vol2-part300. Education Assistance to States for the Education of Children with Disabilities Rule, 34C.F.R. § 300.8 (2007). adulthood. Wagner, M.(1995). Outcomes foryouth with seriousemotional disturbance in secondary school and early from Texas Education Agency. (2014). Special education reports: 2013-2014 Statewide totals www.tea.state.tx.us/index4.aspx?id=2147494988 Texas Education Agency. Texas (2013). Services for students with disabilities ages 3-5.Retrieved fromhttp:// state.tx.us/index2.aspx?id=4456 Texas Education Agency. (2013). School health and related services (SHARS). education-act-cost-impact-local-school-districts districts. Retrieved fromhttp://febp.newamerica.net/background-analysis/individuals-disabilities- New America Foundation. (2013). Individuals with Disabilities Education Act –costimpact on localschool distribution
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Child mental wellbeing. Retrieved from http://txchildren.org/Images/ Child mental wellbeing. Retrieved from http://txchildren.org/Images/ Child mental wellbeing. Retrieved from http://txchildren.org/Images/ Services for TexasServices for students with disabilities ages 3-5. Retrieved from http:// Counseling and mentalhealth services oftheCoordinated School Health (5)2, 90-112. http://www.lrl.state.tx.us/scanned/ApproBills/82_0/82_R_ALL.pdf . Text ofConference Committee report on Senate rd printing H.B. No. printing H.B. 1 General Retrieved fromhttp://www.tea. http://www.tea.state.tx.us/ http://www.tea.state.tx.us/ [Data file]. Retrieved Appendices 347 2011-2012 PEIMS 2011-2012 www.statutes.legis. www.statutes.legis. http://justicecenter.csg.org/ http://justicecenter.csg.org/ Persistent fearcan affect and anxiety Persistent young Trauma-informed care and trauma-informed and trauma-informed care Trauma-informed http://www.developingchild.net 30 Texas school districts disproportionately reply on out of reply disproportionately school districts 30 Texas Retrieved from http://ritter.tea.state.tx.us/adhocrpt/Disciplinary_ Retrieved Retrieved from http://ritter.tea.state.tx.us/adhocrpt/Disciplinary_ Retrieved Retrieved from http://ritter.tea.state.tx.us/adhocrpt/Disciplinary_ Retrieved When my child is disciplined at school: A guide forschool: A guide at child is disciplined When my families. from Retrieved Retrieved from Retrieved to incarceration. Dropout pipeline: school-to-prison Texas’ [Data file]. [Data file]. [Data file]. http://www.texasappleseed.net/index.php?option=com_docman&task=doc_ Texas’ school-to-prison pipeline: School expulsion –the path from lockout to lockout from –the path School expulsion pipeline: school-to-prison Texas’ Texas’ school-to-prison pipeline: School expulsion –the path from lockout to lockout from –the path School expulsion pipeline: school-to-prison Texas’ http://www.texasappleseed.net/index.php?option=com_docman&task=doc_ http://www.texasappleseed.net/index.php?option=com_docman&task=doc_ Retrieved from http://ritter.tea.state.tx.us/adhocrpt/Disciplinary_Data_Products/ Retrieved . Retrieved from http://www. attendance). Retrieved daily (average School finance glossary 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.disabilityrightstx.org/files/JointOSSReportAug7-2012.pdf
Breaking school rules: A statewide study of how school discipline relates to student success and juvenile and juvenile success to student relates school discipline of how study school rules: A statewide Breaking Breaking school rules: A statewide study of how school discipline relates to student success and juvenile and juvenile success to student relates school discipline of how study school rules: A statewide Breaking Breaking school rules: A statewide study of how school discipline relates to student success and juvenile and juvenile success to student relates school discipline of how study school rules: A statewide Breaking from http://www.tea.state.tx.us/chapter37_reporting.html Retrieved Data Standard. from http:// Retrieved to incarceration. Dropout pipeline: school-to-prison (2007). Appleseed. Texas’ Texas percent20Report.pdf www.texasappleseed.net/pdf/Pipeline placement and JJAEP of DAEP counts 2012-2013 products: data Discipline (2013). Agency. Education Texas types [Data file]. reason DAG_Summaries/Download_State_DAG_Summaries.html A & M University. at Texas Institute Policy and the Public of State Governments, Council Center, Justice (2011). website: State Governments The Council of from Retrieved involvement. justice resources/juveniles (2010). Appleseed. Texas from Retrieved dropout. Data_Products/DAG_Summaries/Download_State_DAG_Summaries.html Appendix E: Additional (2012). to discipline. information related Agency. Education Texas state.tx.us/Docs/ED/htm/ED.37.htm October). (2007, Appleseed. Texas percent20Report.pdf http://www.texasappleseed.net/pdf/Pipeline from Retrieved (2011). A. § 37.008 subchapter 37, G., chapter 2, subtitle Edu Code, titl. Tex state.tx.us/Docs/ED/htm/ED.37.htm A & M University. at Texas Institute Policy and the Public of State Governments, Council Center, Justice (2011). website: State Governments The Council of from Retrieved involvement. justice resources/juveniles actions and discipline of students counts 2012-2013 products: data Discipline (2013). Agency. Education Texas groupings by discipline action Data_Products/DAG_Summaries/Download_State_DAG_Summaries.html Thurgood& Appleseed, Texas, Law, for Youth National Center Rights Texas, at Risk, Disability Children (2012). Earl Carl Institute. of Law’s Marshall School Rights Disability from out of school. Retrieved students money behind and pushing school suspension: Leaving website Texas (n.d.) Center. Equity equitycenter.org/resources/school-finance-glossary from Retrieved (2011). A. § 37.008 subchapter 37, G., chapter 2, subtitle Edu Code, titl. Tex = http://www.texasappleseed.net/index.php?option=com_docman&task=doc_view&gid=60&Itemid from www.statutes. Retrieved (2003). § 37.005 A. subchapter 37, chapter G., subtitle Edu Code, titl. 2, Tex legis.state.tx.us/Docs/ED/htm/ED.37.htm actions and discipline of students counts 2012-2013 products: data Discipline (2013). Agency. Education Texas groupings by discipline action download&gid=380&Itemid January). (2009, Appleseed. Texas from http://beta.samhsa.gov/nctic/trauma-interventions services. Retrieved from http:// Retrieved to incarceration. Dropout pipeline: school-to-prison (2007). Appleseed. Texas’ Texas percent20Report.pdf www.texasappleseed.net/pdf/Pipeline actions and discipline of students counts 2012-2013 products: data Discipline (2013). Agency. Education Texas groupings by discipline action Data_Products/DAG_Summaries/Download_State_DAG_Summaries.html (2010). Appleseed. Texas from Retrieved dropout. download&gid=380&Itemid A & M University. at Texas Institute Policy and the Public Governments, of State Council Center, Justice (2011). http://justicecenter.csg.org/ website: State Governments The Council of from Retrieved involvement. justice resources/juveniles lockout path from –the School expulsion pipeline: school-to-prison April). Texas’ (2010, Appleseed. Texas from Retrieved to dropout. Substance Abuse and Mental Health Administration. (n.d.) Health Mental and Abuse Substance Ibid. Child. (2010). Developing on the Council Scientific National 9. No. paper Working and development: learning children’s 755 756 757 758 754 750 751 752 753 747 748 749 745 746 744 733 Ibid. 734 Ibid. 735 736 Ibid. 737 738 Ibid. 739 Ibid. Ibid. 740 741 742 743 731 Ibid. 732 Ibid. 728 729 730 Appendices 348 789 788 787 786 785 784 783 Ibid. 782 781 780 779 Ibid. 778 777 776 Ibid. 775 774 773 772 771 Ibid. 770 Ibid. 769 768 767 Ibid. 766 Ibid. 765 764 763 762 761 760 759 Ibid. Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas Delinquency Prevention website: Delinquency Development Services Group, Inc. (2009). Truancy prevention. Retrieved from Office of Juvenile Justice and Ibid. php?option=com_docman&task=doc_download&gid=934&Itemid adult criminalcourts.Retrieved from Texas Appleseed’s website: Fowler, D. (2013). Criminalization of truancy in Texas: Prosecution of “Failure to AttendSchool” in statutes.legis.state.tx.us/Docs/ED/htm/ED.25.htm Tex EduCodetitl.2 subtitle E.,chapter 25., subchapter A. § 25.094 (2011). Retrieved from net/index.php?option=com_docman&task=doc_download&gid=990&Itemid= Texas Appleseed. (2013). not-/ Retrieved fromthehttp:/www.texastribune.org/2013/08/29/class-disruption-cases-head-principals-office- Serrano, J. (2013, August 29). issueon-campus citations. Schoolofficers cannolonger Texas Retrieved fromhttp://www.texasappleseed.net/images/stories/reports/Ticketing_Booklet_web.pdf Texas Appleseed. (2010). not-/ Retrieved fromthehttp:/www.texastribune.org/2013/08/29/class-disruption-cases-head-principals-office- Serrano, J. (2013, August 29). issueon-campus citations. Schoolofficers cannolonger Texas Tribune. students/ http://www.texastribune.org/texas-education/public-education/school-district-cops-ticket-thousands-of- Thevenot, B. (2010, June 2). School district copsticket thousands of students. download&gid=380&Itemid dropout. Retrieved from Texas Appleseed. (2010). www.texasappleseed.net/pdf/Pipeline percent20Report.pdf Texas Texas’ Appleseed. (2007). school-to-prison pipeline: Dropout toincarceration. Retrieved from http:// download&gid=380&Itemid dropout. Retrieved from Texas Appleseed. (2010). Data_Products/DAG_Summaries/Download_State_DAG_Summaries.html by disciplineaction groupings Texas Education Agency. (2013). Discipline data products: 2012-2013 counts of students and discipline actions download&gid=380&Itemid dropout. Retrieved from Texas Appleseed. (2010). Data Standard. Retrieved from http://www.tea.state.tx.us/chapter37_reporting.html Texas Education Agency. information related to discipline. (2012). Appendix E:Additional download&gid=380&Itemid Dropout. Retrieved from Texas Appleseed. (2010). DAG_Summaries/Download_State_DAG_Summaries.html reason types[Datafile]. Texas Education Agency. (2013). Discipline Data Products: 2012-2013counts of DAEP andJJAEP placement download&gid=380&Itemid dropout. Retrieved from Texas Appleseed. (2010). Data_Products/DAG_Summaries/Download_State_DAG_Summaries.html by disciplineaction groupings Texas Education Agency. (2013). Discipline data products: 2012-2013 counts of students and discipline actions 2013. Retrieved from Juvenile Justice Alternative Education Program. (2014). download&gid=380&Itemid dropout. Retrieved from Texas Appleseed.(2010). state.tx.us/Docs/ED/htm/ED.37.htm Tex EduCodetitl.2, subtitle G., chapter 37, subchapter A.§ 37.008 (2011). Retrieved from gov/services/jjaep.aspx Texas Juvenile and Justice Department. (n.d.). download&gid=380&Itemid http://www.tjjd.texas.gov/publications/reports/JJAEP_2013_Report.pdf Retrieved fromhttp://ritter.tea.state.tx.us/adhocrpt/Disciplinary_Data_Products/ http://www.texasappleseed.net/index.php?option=com_docman&task=doc_ http://www.texasappleseed.net/index.php?option=com_docman&task=doc_ http://www.texasappleseed.net/index.php?option=com_docman&task=doc_ http://www.texasappleseed.net/index.php?option=com_docman&task=doc_ http://www.texasappleseed.net/index.php?option=com_docman&task=doc_ http://www.texasappleseed.net/index.php?option=com_docman&task=doc_ School ticketing implementation guide. Retrieved fromhttp://www.texasappleseed. Texas’ school-to-prison pipeline: Ticketing, arrests, in schools. and use offorce Texas’ school-to-prison pipeline: School expulsion –the path from lockout to Texas’ school-to-prison pipeline: School expulsion –the path from lockout to Texas’ school-to-prison pipeline: School expulsion –the path from Lockout to Texas’ school-to-prison pipeline: School expulsion –the path from lockout to Texas’ school-to-prison pipeline: School expulsion –the path from lockout to Texas’ school-to-prison pipeline: School expulsion –thepath from lockout to [Data file]. [Data file]. http://www.ojjdp.gov/mpg/litreviews/Truancy_Prevention.pdf Retrieved from http://ritter.tea.state.tx.us/adhocrpt/Disciplinary_ Retrieved fromhttp://ritter.tea.state.tx.us/adhocrpt/Disciplinary_ JJAEP programming. Retrieved from Performance assessment report school year 2012- http://texasappleseed.net/index. Texas Tribune.Retrieved from http://www.tjjd.texas.
www.statutes.legis. http://www. 2011-2012 PEIMS Tribune. Appendices 349
http://www.utexas.edu/ (NCH Fact Sheet #5). Retrieved Retrieved #5). Sheet (NCH Fact . program assistance rental Section 811 project http://www.tacinc.org/media/33368/ http://www.fauquier-mha.com/docs/TenYear.pdf The housing crisis forcrisis The housing disabilities. people with http://www.huduser.org/portal/Publications/pdf/HUD- Understanding Supplemental Security Income SSI benefits – 2014 SSI benefits Income Security Supplemental Understanding Texas’ school-to-prison pipeline: Ticketing, arrests, and use of force and use in arrests, Ticketing, pipeline: school-to-prison Texas’ 10-year retrospective study shows progression in American attitudes about attitudes in American progression study shows retrospective 10-year Who can afford to live in a home?: A look at data from the 2006 American at data from a home?: A look in to live Who can afford Breaking rules, breaking budgets: Cost of school discipline in 11 Texas school in 11 Texas school discipline of Cost budgets: rules, breaking Breaking Retrieved use of force & in schools Retrieved Ticking, arrest pipeline: school-to-prison Texas’ Retrieved from http://www.nami.org/Content/NavigationMenu/Find_Support/ Retrieved http://www.texasappleseed.net/images/stories/reports/Ticketing_Booklet_web.pdf http://www.tdhca.state.tx.us/housing-center/docs/12-stratplanFY13-17.pdf Retrieved from The University of Texas at Austin website: at Austin of Texas from The University 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 Journal of Adolescent Health, 32(5), 385-393. Adolescent of Journal Retrieved from http://www.texasappleseed.net/index.php?option=com_docman&task=doc_ Retrieved http://www.nimh.nih.gov/about/director/2011/understanding-severe-mental-illness.shtml from http://www.socialsecurity.gov/ssi/text-benefits-ussi.htm Retrieved Retrieved from http://www.hudhre.info/ Retrieved to congress. report assessment annual homeless The 2010 from http://www.hudhre.info/ Retrieved to congress. report assessment annual homeless The 2010 http://info.sos.state.tx.us/pls/pub/readtac$ext.viewtac http://cdm16064.contentdm.oclc.org/cdm/ref/collection/p266901coll4/id/3722 http://www.nationalhomeless.org/publications/facts/Mental_Illness.pdf Steffen, B. L. (2013). Worst case housing needs 2011: Report to congress. Retrieved from U.S. Department U.S. from Retrieved to congress. Report 2011: housing needs case Worst B. L. (2013). Steffen, website: Development of Housing and Urban 506_WorstCase2011_reportv3.pdf (TBRA) rental assistance Tenant-based (n.d.). Affairs. Community and Housing of Department Texas http://www.tdhca.state.tx.us/home-division/tbra.htm from Retrieved program. Retrieved housing. of service-enriched Definition §1.11. (2010). 1, rule part tit. 10, Code, Administrative Texas from . support #4: Recovery initiative Strategic Services Administration. (2013). Health Mental and Abuse Substance from http://store.samhsa.gov/shin/content/SMA11-4629/06-RecoverySupport.pdf Retrieved E. (n.d.). M., Wilson, Schwartz, Retrieved from US Census Bureau website: http://www.census.gov/housing/census/ Bureau from US Census Retrieved Survey. Community Ibid. The from . Retrieved practice and policy, Research, reduction: Truancy (2012). H. G. L. & Burden, Cumbo, http://www.ccyj.org/uploads/PPO/TRUANCY_Updated_ website: Justice & Youth for Children Center July2012.pdf 2006. Data Collection Civil Rights (2006), Civil Rights Office of for Adolescent of the Society paper in schools: Position punishment (2003). Corporal al. et D.E. Greydanus, Medicine. December). (2010, Appleseed. Texas from Retrieved schools. from attitudes. Public Retrieved analysis: survey (n.d.). Schizophrenia Illness. Alliance on Mental National http://www.nami.org/Content/NavigationMenu/SchizophreniaSurvey/Analysis_Public_Attitudes.htm (2), 121-124. Psychiatry,2 World An overview. Violence and mental illness: H. (2003). Stuart, Illness of Mental Institute from National . Retrieved Mental Illness Severe Understanding (2011). T. Insel, website: Responding to youth with mental health needs: A CIT forhealth needs: with mental to youth Responding (2011). youth Illness. Alliance on Mental National manual. implementation Child_and_Teen_Support/CIT_for_Youth/CITYouthWorkbook_Web.pdf (2010) Appleseed. Texas from (2012). Appleseed. Texas from Retrieved issues. health and other mental depression districts. download&gid=867&Itemid= school reduces San Antonio middle in program discipline Restorative (2013) M. A. & Campetella, R.D., Meckel, suspensions. student news/2013/12/17/restorative-discipline-san-antonio/ 2013-17 plan for years the fiscal Agency strategic (2012). Affairs. Community and Housing of Department Texas from . Retrieved Period and Development. Planning of Community Office Urban Development, and Housing of Department U.S. (2011). documents/2010HomelessAssessmentReport.pdf Administration.Social Security (n.d.). edition. A. (2013). & Zovistoski, N., A. Singer, E., O’Hara, Cooper, website: Collaborative Assistance from Technical Retrieved PricedOut2012.pdf Project communication: Personal 14). August (2014, Affairs. Community and Housing of Department Texas Access Program plans income housing low State of Texas ). 2014 (2014 Affairs. Community and Housing of Department Texas from http://www.tdhca.state.tx.us/housing-center/docs/14-SLIHP.pdf . Retrieved report and annual (n.d.). Affairs. Community and Housing of Department Texas from http://www.tdhca.state.tx.us/section-811-pra/index.htm Retrieved and Development. Planning of Community Office Urban Development, and Housing of Department U.S. (2011). documents/2010HomelessAssessmentReport.pdf homelessness and illness (2006). Mental the Homeless. Coalition for National from 2013-17 plan for years the fiscal Agency strategic (2012). Affairs. Community and Housing of Department Texas from http://www.tdhca.state.tx.us/housing-center/docs/12-stratplanFY13-17.pdf Retrieved period. (2007). America. Health Mental 819 820 821 822 823 790 791 792 793 794 816 817 818 795 Ibid. 796 797 798 Ibid. 799 800 Ibid. Ibid. 801 802 Ibid. 803 804 Ibid. 805 806 807 808 809 810 811 812 813 814 815 Appendices 350 850 847 846 Ibid. 845 844 843 Ibid. 842 841 840 839 838 Ibid. 837 Ibid. 836 Ibid. 835 Ibid. 834 833 832 831 830 829 828 827 826 Ibid. 825 Ibid. 824 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas 858 857 856 Ibid. 855 Ibid. 854 853 852 Ibid. 851 849 848 Ibid. Appropriations Bill. Retrieved from Legislative BudgetBoard. (2013). Legislative Reference Library of Texas. (2009). annual report. Retrieved from http://www.tdhca.state.tx.us/housing-center/docs/14-SLIHP.pdf Texas Departmentof Housing and Community Affairs. (2014). 2014 state of Texas low income housing plan and Health (HCBS-AMH). Department of State Health Services. (2014). content/SMA10-4510/SMA10-4510-05-EvaluatingYourProgram-PSH.pdf Evaluating your program (HHSPublicationNo. SMA 10-4509). Retrieved from Substance Abuse and Mental Health (2010). Services Administration. 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No. printing S.B. 1General Appropriations rd rd printing H.B. No. printing H.B. 1 General http://store.samhsa.gov/shin/ printing S.B. No. printing S.B. 1General Appendices 351 http://www. http://www. http://www. from Retrieved http://www. from Retrieved http://www.tdhca.state.tx.us/housing- Process for utilizing HOME Tenant-Based for Tenant-Based HOME utilizing Process . Retrieved from http:// housing design. Retrieved Visitable Section 8 housing. Section 8 housing. Section 8 housing. . Grant Choice Systems Real of Texas State Section 811 Supportive Housing for Persons with with for Housing Supportive 811 Section Persons executive and presidential laws housing Fair Retrieved from Retrieved limits. income FY 2014 state http://www.tdhca.state.tx.us/housing-center/fair- Mental Health Program for veterans fiscal year 2013 annual report. annual year 2013 fiscal for veterans Program Mental Health http://media.samhsa.gov/co-occurring/topics/military/index.aspx http://www.tdhca.state.tx.us/housing-center/docs/14-SLIHP.pdf http://portal.hud.gov/hudportal/HUD?src=/program_offices/fair_housing_equal_ 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.tdhca.state.tx.us/housing-center/docs/14-SLIHP.pdf Retrieved from http://portal.hud.gov/hudportal/HUD?src=/program_offices/housing/mfh/ Retrieved State of Texas plan for fair from Retrieved choice. housing Texas State of . 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Renewal and Housing Manitoba www.gov.mb.ca/housing/pubs/visitable_housing.pdf (2013, Solutions). and Consulting, & Community Research (with Morningside & Consulting BBC Research October). Texas Department of Housing and Community Affairs. (2013). (2013). Affairs. Community and Housing of Department Texas opp/FHLaws (2013). Solutions). and Consulting, & Community Research (with Morningside & Consulting BBC Research plan for fair from Retrieved choice. housing Texas State of report. annual Disabilities progdesc/disab811 (n.d.). Affairs. Community and of Housing Department Texas from Retrieved . orders 888 889 890 891 Ibid. Ibid. 892 893 Ibid. 894 Ibid. 895 885 886 887 862 883 Ibid. 884 860 861 863 Ibid. 864 865 866 867 869 Ibid. 870 871 Ibid. 872 Ibid. 873 Ibid. Ibid. 874 875 Ibid. 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1915(i) Home and Community Based Services – Adult Mental – Adult Based Services Home and Community 1915(i) Telepsychiatry. Telepsychiatry. http://www.lbb.state.tx.us/Documents/Publications/GEER/
[Data file]. Retrieved from http://webappa.cdc.gov/sasweb/ncipc/ from Retrieved [Data file]. Retrieved from http://www.dshs.state.tx.us/layouts/contentpage. Retrieved www.dshs.state.tx.us/injury/data/suicide-overview/ from http://www.dshs.state.tx.us/mhsa/hcbs-amh/ Retrieved [PowerPoint Slides]. Retrieved from from Slides]. Retrieved [PowerPoint mental health system of the Overview Presentation: from http://www.hhsc.state.tx.us/reports/2013/SB789-Telemedicine.pdf 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 . from http://www.shelterforce.org/article/2755/housing_first/ Retrieved Spring 2012. from http://www.dshs.state.tx.us/chs/vstat/vs12/t17.shtm [Data file]. Retrieved from http://www.dshs.state.tx.us/chs/vstat/vs12/t17.shtm [Data file]. Retrieved . Government%20Effectiveness%20and%20Efficiency%20Report%202012.pdf Abuse Division Substance and Health Mental (2010). Services. State Health of Department Texas report. Force Task of Care Continuity aspx?pageid=35959&id=67427&terms=jail+diversion (n.d.). D. M. Maples, Services website: Health State of Department Texas DSHS-HHSC-combined-MHOverview.pdf competency Outpatient communication: Personal August). (2014, Services. State Health of Department Texas restoration report. evaluation Restoration Competency Outpatient (2014). Health. for Mental Foundation Hogg for with youth and of care children of health reform and systems intersect The (2011). & Stroul, B. J. Wotring, and their families conditions abuse mental health and substance Brief) (Issue . Mental Children’s Center for Technical & National Development and Human for Child Center University Health. from report . Retrieved final grantee planning expansion of care System (2013). of Care. System Texas www.txsystemofcare.org/wp-content/uploads/2014/01/ASSET-Final-Report.pdf Ibid. (2014). Association. Psychiatric American Retrieved from Retrieved and recommendations. Statewide Health Coordinating Council. (n.d.). Council. Coordinating Health Statewide Texas Legislature. Legislature. Texas state.tx.us/chs/shcc/reports/SHP2011-2016/ per and rate deaths suicide injury States 2011, United (2014). and Prevention. for Disease Control Center all ages both sexes, All races, 100,000: mortrate10_us.html evidence-based An illness: public health and mental Guns, (2013). Firearm Policy. for Risk-Based Consortium from http://www.efsgv.org/wp-content/uploads/2014/02/Final- forapproach policy Retrieved federal Federal-Report.pdf [Data file]. forstatistics ICD-10 death state of Texas the (2014). Services. State Health of Department Texas from http://soupfin.tdh.state.tx.us/death10.htm Retrieved Texas age and by sex causes of death leading five 17 Table (2014). Services. State Health Department of Texas residents of Department from Texas Retrieved slides]. suicide [PowerPoint Texas of An overview (2011). J. Hellsten, Services website: Health State Suicide fact Suicide from http://www.nami.org/ (2013). . Retrieved sheet Illness. Alliance on Mental National factsheets/suicide_factsheet.pdf Texas age and by sex causes of death leading 17 five Table (2014). Services. of State Health Department Texas residents fact Suicide from http://www.nami.org/ (2013). . Retrieved sheet Illness. Alliance on Mental National factsheets/suicide_factsheet.pdf from: http://www.dshs. Retrieved suicide prevention. Texas (2013). Services. of State Health Department Texas state.tx.us/mhsa/suicide/Suicide-Prevention.aspx (2013). States InteragencyUnited on Homelessness. Council www.apa.org/monitor/2011/06/telehealth.aspx from www.dshs. Retrieved 2011-2016. health plan state Texas (n.d.). Council. Coordinating Health Statewide state.tx.us/chs/shcc/reports/SHP2011-2016/ (2012). Services Commission. and Human Health Texas . usich_resources/solutions/explore/housing_first/ Shelterforce: First. Housing L. (2012). & Stand, Roman, N., practice/professional-interests/underserved-communities/telepsychiatry impact on Telemedicine’s outcomes: of research Examples (2013). Association. Telemedicine American from http://www.americantelemed.org/docs/default-source/policy/ Retrieved cost and quality. healthcare examples-of-research-outcomes---telemedicine%27s-impact-on-healthcare-cost-and-quality.pdf . on telehealth A new emphasis A. (2011). Novotney, Building, housing: supportive Permanent Services Administration. (2010). Health Mental and Abuse Substance from Retrieved 10-4509). SMA (HHS Publication No. program your Evaluating content/SMA10-4510/SMA10-4510-05-EvaluatingYourProgram-PSH.pdf (2014). Services. Health of State Department (HCBS-AMH).Health Retrieved from http://www.oxfordhouse.org/ 2013. Retrieved year fiscal Annual report (2014). Inc. Oxford House, userfiles/file/doc/ar2013.pdf 1002 1003 1004 1005 1006 1007 1008 1009 1018 1019 1020 1021 1022 1023 1024 1025 1026 1027 1028 1016 1017 1029 Ibid. 1010 Ibid. 1011 1012 Ibid. 1013 Ibid. 1014 1015 1030 Ibid. 1031 1032 1033 Appendices 356 1039 1038 1037 1036 1035 1034 Hogg Foundation forMentalHealth |A Guide toUnderstanding MentalHealth Systems and Servicesin Texas userfiles/file/doc/ar2013.pdf Oxford House, Inc. (2014). Annualreport fiscal year 2013.Retrieved from Oxford House, Inc. (2014, May 1).Personal communication: Oxford house Department of State Health Services. (2014, May 1).Personal communication: Oxford Houses inTexas Retrieved fromhttp://www.dshs.state.tx.us/WorkArea/DownloadAsset.aspx?id=8589979883 Grant andMental Health Block Grant (SABG) (MHBG) behavioral health assessment and intended use plan. Texas Department of StateHealth Services. (2013). Texas FY2014–2015 userfiles/file/doc/ar2008.pdf Oxford House, Inc.(2009). Annual report fiscal year 2008.Retrievedhttp://www.oxfordhouse.org/ from http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=223 SAMHSA’s NationalRegistry ofEvidence-based Programs and Practices, Oxford House Model. Retrieved from . combined Substance Abuse Block http://www.oxfordhouse.org/ 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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