Mental Health and Substance Abuse Services

1
Mental Health and Substance Abuse Services

• Mimi Martinez McKay, M.A., M.L.I.S.
• Chief of Staff/Information Services Director
• mimi.mckay_at_dshs.state.tx.us

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Scope of Duties

• Legislative Liaison
• Stakeholder Communications
• Web Services Administrator
• Information Services Director
• DDRAC Coordinator
• PDFT Contract Administrator
• NASADAD Liaison
• Other duties as assigned!

3
Overview

• DSHS/MHSA overview
• System Improvement
• DSHS Legislative Update
• Drug Demand Reduction Advisory Committee
• Partnership for a Drug Free Texas

4
DSHS Overview
Texas Department of State Health Services (DSHS)
became operational on September 1, 2004 in
accordance with HB2292.
Health Department
Mental Health Agency
Substance Abuse Agency
5
DSHS Overview

• Mission
• To improve health and well-being in Texas
• Fiscal Year 2008 Budget
• 2,750,231,703
• Full-Time Positions
• 12,206

Page 5
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DSHS Organizational Structure
Page 6
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MHSA Overview

• Mission
• Provide statewide leadership, direction and
  oversight for services to help Texans prevent
  mental health or substance abuse problems, build
  resiliency and facilitate recovery in their home
  or community.
• Fiscal Year 2008 Budget (total funding)
• Community Mental Health Services 482,316,409
• Mental Health Hospital Services 373,730,280
• Substance Abuse Services 164,575,118
• Division includes 11 state hospitals, and has
  service contracts with 39 mental health centers,
  and 270 substance abuse providers.
• Full-Time Positions
• 7,734

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Division Summary

• Substance Abuse Prevention, Intervention, and
  Treatment Services
• Inpatient Psychiatric Services (State Hospitals)
• Community-Based Mental Health Services
• Projects for Assistance in Transition from
  Homelessness (PATH)
• NorthSTAR Community-Based Mental Health,
  Substance Abuse and Co-Occurring Services
• South Texas Health Care System
• Texas Center for Infectious Disease (TCID)

9
Economic Impact of Substance Abuse in Texas
Source Decision Support Unit, MH SA, DSHS.
10
Need Met for Substance Abuse Treatment in
TexasADJUSTING FOR POVERTY
2008 Texas Population (age 12) 19,844,757
2008 Estimated Number with Chemical
Dependency 1,855,364
SFY2008 Number Served in DSHS-Funded Substance
Abuse Treatment Programs (including
NorthSTAR) 52,129 (5.8)
Who Are Also Poor 892,882
Source Decision Support Unit, MH SA, DSHS.
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Substance Abuse Prevention and Early Intervention
Services

• Primary Prevention
• HIV Early Intervention and Outreach
• Outreach, Screening, Assessment and Referral
  Services (OSAR)
• Tobacco Prevention and Control
• Pregnant and Post-partum Intervention for Women
  (PPI)

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PREVENTION OUTCOMESOutcomes Positive among Youth
in DSHS-Funded Substance Abuse Prevention Over
Time
Percent of Youth Completing SA Prevention
Number of Schools Participating in SA Prevention
Source DSHS Behavioral Health Integrated
Provider System (BHIPS).
13
PREVENTION OUTCOMESPercentage of Texas Youth Who
Used Substances in the Past Month Decreasing
Over Time
Source Texas School Survey of Substance Use,
DSHS.
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Substance Abuse Treatment Services

• Detoxification
• Intensive and Supportive Residential (adult and
  youth)
• Outpatient (adult and youth)
• Opioid Replacement Therapy
• Co-Occurring Psychiatric and Substance Abuse
  Disorders (COPSD) Services
• Specialized Female Services

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TREAMTMENT OUTCOMESClinical Outcomes Positive
among Adults Completing DSHS-Funded Substance
Abuse Treatment Over Time
Source DSHS Behavioral Health Integrated
Provider System (BHIPS).
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TREATMENT OUTCOMESClinical Outcomes Positive
among Youth Completing DSHS-Funded Substance
Abuse Treatment Over Time
Source DSHS Behavioral Health Integrated
Provider System (BHIPS).
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Current and Emerging Challenges

• Changing trends in drug use patterns
• Cost pressures on treatment providers
• Workforce development
• Availability of specialized services
• Ensuring a continuum of care

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Trends In Substance Abuse

• Alcohol is the primary drug of abuse in Texas
• Of particular concern is heavy consumption of
  alcohol, or binge drinking, which is defined as
  drinking five or more drinks at one time. In
  2008, 12 percent of all secondary students said
  that when they drank, they usually drank five or
  more beers at one time, and 13 percent reported
  binge drinking of liquor
• In 2008, 27 percent of all clients admitted to
  publicly funded treatment programs had a primary
  problem with alcohol

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Trends In Substance Abuse

• Increase in inhaling heroinnot just Cheese
  (heroinTylenol PM) but use of other
  diphenhydramine products such as Benedryl to
  produce powder from the Tar.
• Problems with inhaled heroin continue to
  increase, especially among youths and young
  adults.
• Suboxone (buprenorphine naloxone) as treatment
  option for young heroin clients.
• Proportion of Black crack users continues to
  decrease.
• Decreased availability and increased price due to
  late 2008 gang moratorium and Colombians not
  fronting cocaine on consignment to Mexican
  traffickers.

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Trends in Substance Abuse (Cont)

• Methamphetamine availability down and price up.
• Mexican limits on importation of pseudoephedrine
  have dropped from 140 tons in 2005 to 12 tons in
  2007
• Small meth labs starting up again

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TX-Mexico Border concerns

• magnitude of the substance abuse and mental
  health problem on the Border is of serious
  concern.
• Concern that people in need of substance abuse
  and mental health services will become more
  closeted and afraid to ask for help due to
  repercussions related to the safety of their
  families and/or immigration issues.
• Increasing numbers of youth involved in drug
  trafficking and fewer options for them. Choosing
  whether or not to become involved in drugs and
  gangs is less a choice and instead a decision
  based on threats and fear.

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Data Source

• Jane Maxwell, Ph.D.
• Center for Excellence in Drug Epidemiology
• Gulf Coast Addiction Technology Transfer Center
• http//www.utexas.edu/research/cswr/gcattc/documen
  ts/Texas2009_002.pdf
• E-Mail jcmaxwell_at_mail.utexas.edu

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System Improvement

• Clinical Management Behavioral Health System
  (CMBHS)
• Access to Recovery (ATR)
• Texas Recovery Initiative (TRI)
• Licensure

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Clinical Management Behavioral Health System
(CMBHS)

• CMBHS will
• Integrate clinical management tool for Substance
  Abuse and Mental Health service providers
• Capture demographic, service and clinical data
  for Substance Abuse and Mental Health clients
• Track service utilization and client progress
• Facilitate State and Federal reporting
  requirements

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Who Can Use CMBHS?

• All Mental Health Substance Abuse Treatment
  providers contracted with DSHS Mental Health and
  Substance Abuse division.
• CMBHS will serve as a connection point to other
  publicly-funded behavioral health service systems
  and related programs.
• Clients will not currently have direct access to
  information in CMBHS. A future expansion may
  provide this service.

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Substance Abuse Treatment Providers and CMBHS

• CMBHS will replace BHIPS, DSHS legacy system for
  managing substance abuse treatment.
• CMBHS is web-based. Providers need only a
  computer with Internet access to use the system.
• Training began earlier this month, with rollout
  to providers by region.
• Helpdesk services will be available to all CMBHS
  users.

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CMBHS Provider Benefits

• Efficient, seamless administrative and clinical
  processes for gathering, updating, and sharing
  client information.
• Convenient and accessible from any computer that
  has a browser and Internet connection, allowing
  access from almost any location.
• Free of charge to community Mental Health and
  Substance Abuse treatment providers who provide
  services under contract to DSHS.

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CMBHS Client Benefits

• A person seeking services will experience more
  streamlined intake, admission, assessment,
  diagnosis, treatment plan development, treatment
  and discharge processes by
• Reducing time for staff to perform administrative
  tasks and gather basic client information
• Using a single process that assesses a persons
  need for mental health and/or substance abuse
  treatment
• Creating a single client record that can be
  shared, eliminating need to create and maintain
  multiple client records
• Allowing access to previous health records that
  can help identify what types of treatment have
  been most effective in the past and facilitate
  current treatment plans.

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When Will CMBHS Be Ready For Use?

• CMBHS will begin an incremental rollout to
  Substance Abuse and NorthSTAR providers beginning
  in August.
• Region 7 Substance Abuse Providers, 08/10/09
• Region 6 Substance Abuse Providers, 09/08/09
• NorthSTAR Substance Abuse Providers, 10/05/09
• Region 3 Substance Abuse Providers, 11/02/09
• Region 5 Substance Abuse Providers, 12/01/09

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When Will CMBHS Be Ready For Use?

• (CMBHS Release One Deployment Continued)
• Region 4 Substance Abuse Treatment Providers,
  January 2010
• Region 2 Substance Abuse Treatment Providers,
  February 2010
• Region 11 Substance Abuse Treatment Providers,
  March 2010
• Region 9 Substance Abuse Treatment Providers,
  April 2010
• Region 10 Substance Abuse Treatment Providers,
  May 2010
• Region 8 Substance Abuse Treatment Providers,
  June 2010
• Region 1 Substance Abuse Treatment Provider, July
  2010

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Connecting CHMBHS to Other Systems
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Access to Recovery(ATR)

• Federal SAMHSA Grant awarded 2004
• 22.8 million for three years
• Federal target 8,928 clients served 15,000
• Voucher issued to client rather than contract
  with provider
• 30 participating drug courts in 13 counties
• Second ATR Meth Grant awarded 2007
• 13.5 million for three years
• Federal target 6,038 clients
• Focus on methamphetamine use
• Partnership with Governors Office/Criminal
  Justice Division

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Substance Abuse Services Performance Improvement

• The Texas Recovery Initiative (TRI)
• Partnership between DSHS and the substance abuse
  treatment and recovery communities
• Identify opportunities and methods for improving
  the quality and effectiveness of services
  provided to adult population
• Process to date has included a series of
  community meetings, creation of a task force and
  the presentation of a set of summary findings for
  service improvement and recommendations

34
Texas Recovery Institutes Next Steps

• Emphasize integration in all efforts.
• Make public health messages readily available to
  individuals seeking recovery.
• Expand existing infrastructure through peer case
  management at the treatment level, community
  recovery services at the OSAR level and seek
  additional funding for additional wrap-around
  ancillary services to support recovery.

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Proposed Facility Licensure Rules Revision

• Chemical Dependency Treatment Facility Licensure
  Rules, TX Administrative Code, Chapter 448 are
  under review for revision
• A stakeholder meeting for input and feedback on
  the preliminary revised Chapter 448 draft was
  held in Austin on July10th
• Input from that meeting is being used to revise
  the rules draft

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Proposed Facility Licensure Rules Revision

• The subsequent revised Ch. 448 rules draft is
  expected to be available today (7/31)
• http//www.dshs.state.tx.us/hfp/hottopics.shtm
• Current Ch. 448 rules are available here
• http//www.dshs.state.tx.us/hfp/rules.shtmsubsta
  nce

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Proposed Facility Licensure Rules Revision

• Another stakeholder meting on the draft rules
  will be held on Friday, Aug. 7
• from 900 a.m. to 400 p.m.
• UT Austin JJ Pickle Research Center Campus
• PRC Commons Center
• Building 137, Room 1.102 (Big Tex)
• 10100 Burnet Rd.
• Austin, TX 78753

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Proposed Facility Licensure Rules Revision (cont)

• Stakeholder meeting 3
• Date September 11, 2009
• Time 900 am 400 pm
• Location UT Commons Center J.J. Pickle Campus

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Proposed Facility Licensure Rules Revision

• Contact for questions on the proposed rules
  revisions
• Jack Montague
• Manager, Substance Abuse Compliance Group
• Regulatory Division
• TX Dept. of State Health Services
• [phone], ext. 2126
• jack.montague_at_dshs.state.tx.us

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Counselor Licensure Rules

• A joint meeting between TAAP, ASAP, TDCJ,
  DSHS/MHSA and DSHS/Regulatory will convene this
  fall
• Contact Cynthia Humphrey, ASAP Executive
  Director, chumphrey_at_asaptexas.org

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Contact Information for LCDC Programs

• Licensed Chemical Dependency Counselor Program
  800/832-9623, option 5
• 512/834-6677 FAX
• lcdc_at_dshs.state.tx.us
• http//www.dshs.state.tx.us/lcdc
• Mailing address
• Stewart Myrick, Team Lead, LCDC Program
• Texas Department of State Health Services
• P.O. Box 149347 (MC-1982)
• Austin, TX 78714-9347
• 512-834-4565
• stewart.myrick_at_dshs.state.tx.us

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• 2009 Legislative Update

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Exceptional Items Community Mental Health
ServicesTotal Request
Amount Requested 85,536,497
Amount Received 56,200,000

• Includes funding for
• Crisis Expansion - 0
• Transitional Services - 25,698,282
• Intensive Ongoing Services - 29,301,718
• Veterans Mental Health Training and Coordination
  1,200,000
• Cognitive Processing Training for
  LPHAs - 500,000
• Web-based eligibility 500,000
  
• Regional Conferences with Partners
  Across Texas 200,000

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Exceptional Items Community MH Services
Maintenance of Critical ServicesTotal Request
Amount Requested 26,800,000
Amount Received 7,977,486

• Includes funding for
• Cost increases for medications, salaries, fuel,
  vehicles, lab, increase in healthcare costs,
  utilities, etc

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Exceptional Items Mental Health Hospital
ServicesTotal Request
Amount Requested 85,308,524
Amount Received 63,078,000

• Includes funding for
• Maintain Current Service Level - 35,000,000
• Stipends for Psychiatry - 850,000
• Building Equipment Repair Replacement
  27,228,000

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Exceptional Items MHSAInformation Technology
Total Request
Amount Requested 16,316,153
Amount Received 0

• Includes funding for
• Clinical Management System for Behavioral Health
  Care Services (CMBHS)
• Increase Information Technology Support at
  Hospitals
• Increase electronic client record system capacity
  and bandwidth
• Automated medicated dispensing system

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Exceptional Items Substance Abuse ServicesTotal
Request
Amount Requested 81,669,715
Amount Received 0

• Includes funding for
• Treatment Rate Increase
• Increase Prevention Services
• Expand Detoxification Services
• Enhance Medicaid Benefits
• Recovery Support and Service Coordination
  Services
• OSAR Expansion
• Services for Persons with Co-occurring Mental
  Illness
• Medication Assisted Treatment

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Substance Abuse Adult Medicaid Benefit

• Article IX, Sec. 17.15 of SB 1
• Sec. 17.15. Medicaid Substance Abuse Treatment.
  Out of funds appropriated above in Goal B,
  Medicaid, the Health and Human Services
  Commission shall, beginning January 1, 2010,
  provide coverage for comprehensive substance
  abuse treatment services under Medicaid to
  persons who are at least 21 years of age, have a
  substance abuse disorder, and otherwise qualify
  for Medicaid. The commission may delay
  implementation pending federal approval. The
  commission shall analyze data relating to the
  provision of those treatment services and provide
  the data to the Legislative Budget Board in a
  format and at times requested by the Legislative
  Budget Board. The commission may not provide
  those treatment services if the Legislative
  Budget Board determines that the treatment
  services have resulted in an increase in overall
  Medicaid spending.

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Who is Eligible for SA Medicaid Benefit and its
Potential Array of Benefits

• All Medicaid recipients in Texas
• Traditional fee for service delivery system and
  managed care
• Clinical assessment, residential levels of care,
  ambulatory detox, case mgt, outpatient,
  medication assisted treatment are being reviewed
  by HHSC and DSHS
• Benefits must be approved by CMS prior to
  implementation

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Details about SA Medicaid Benefit and
Implementation Plan

• The rider may allow some greater flexibility in
  terms of benefit array, timeliness for cost
  effectiveness study. 
• HHSC (lead agency) and DSHS are co-managing roll
  out.  There are standing workgroups to address
  the implementation issues, which include
• decisions of IT systems, service delivery system
  (fee for service vs. managed care),  benefit
  design/medical policy and CMS approval of
  benefits, utilization management, provider
  education, recruitment and enrollment in
  Medicaid, recipient education, staffing/oversight,
  how it will relate with and the effect on the
  SAPT block grant and DSHS provider contracts,
  and cost effectiveness evaluation component. 

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SA Medicaid Benefit Implementation Plan (cont.)

• HHSC and DSHS have been meeting regarding
  questions on IT systems, benefit design and
  provider network. 
• Tentative implementation date 
• Around April-May 2010
• Detailed project plan
• There are many moving parts and interdependencies
  in this plan. There will be frequent updates to
  the provider community to keep all apprised.

52
Relevant Bills

• HB 1232 - The Department of State Health Services
  shall establish a local behavioral health
  intervention pilot project for children in Bexar
  County.
• HB 2196 - The executive commissioner of the
  Health and Human Services Commission shall
  establish a workgroup to recommend best practices
  in policy, training, and service delivery to
  promote the integration of health and behavioral
  health services in this state.
• SB 1325 - relating to the creation of a mental
  health intervention program for military
  veterans.
• HB 1233 - relating to the court-ordered
  administration of psychoactive medication to
  certain criminal defendants.

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Partnerships and Stakeholder Engagement

• Texas Education Agency (TEA)
• Education Service Centers (ESC) - expanding role
  of School Health Specialist to include MH
  promotion and substance abuse prevention efforts
• Legislative direction to implement tobacco
  education program in schools
• Drug Demand Reduction Advisory Committee (DDRAC)

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• Drug Demand Reduction Advisory Committee
• (DDRAC)

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Texas Drug Demand Reduction Advisory Committee

• The DDRAC was legislatively mandated to develop a
  comprehensive statewide strategy with
  recommendations to reduce drug demand in Texas.
• 16 state agencies must participate in effort, as
  well as 5 at-large members from different
  geographical areas within the state.
• 3 Subcommittees Workforce, Continuity of SA
  Services/ Data Sharing Media/Communications

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Recommendations of the DDRAC

• Remove exclusion clause for medical expenses from
  Uniform Individual Accident and Sickness Policy
  Provision Law
• Statewide public smoking ban
• Prescription Drug Monitoring
• Mandate comprehensive alcohol and other drug
  reduction strategies targeting college students
• Support the recruitment and retention of quality
  service providers in the field of substance abuse
  prevention and treatment

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Workforce Subcommittee Recommendations

• To develop a strong workforce and provide a
  holistic approach to substance abuse and mental
  health service delivery
• Shift the focus from the number of people
  receiving services to the specific services
  urgently needed to reduce drug demand in Texas.
• Recruit and train a professional workforce to
  fully meet the service needs and provide
  appropriate training and tools.

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Agencies Represented on the Workforce Subcommittee

• Association of Substance Abuse Programs
• Texas Workforce Commission
• Texas Youth Commission
• Department of Family Protective Services
• Southwest Center for the Application of
  Prevention Technologies
• DSHS

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Recruitment and Retention of Service
Professionals

• Rationale
• Texas has an urgent need for qualified and
  well-supported behavioral health professionals
  across disciplines.
• The reported annual staff turnover for Texas
  substance abuse programs was 42 and program
  directors report ongoing difficulty filling their
  open positions.
• Quality service providers in the field of
  substance abuse prevention and treatment
  specializing in criminal justice populations are
  also decreasing and difficult to recruit.

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Action Items July 15, 2009 Workforce Meeting

• Increase the number of substance abuse programs
  in higher education institutions
• Stimulus funding for health care should include
  behavioral health
• Establish an internship program with local
  institutions of higher education
• Make LCDC training a part of the TRI
• Target veterans to receive assistance to be
  trained as substance abuse professionals

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DDRAC Border Symposium

• DSHS, Aug 4th ,1-5pm
• http//www.dshs.state.tx.us/sa/ddrac/symposium.sht
  m
• Unique opportunity for attendees to gain a
  greater understanding of the unique challenges
  facing the border region because of the demand
  for drugs in the United States
• As of today, there have been 9,903 drug war
  related deaths at the US/Mexico Border
• Source UC San Diego Transborder Institute

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DDRAC Border Symposium (cont)

• Speakers include
• Jane Maxwell, Ph.D., UT Addiction Technology
  Transfer Ctr.
• Chilo Madrid, Ph.D., Aliviane NO-AD, Inc.
• Luis Flores, SCAN, Inc.
• Michael Hanson, Border Patrol, Operation Detour
• Guillermo Valenzuela, Director of International
  and Border Affairs for U.S. Congressman Silvestre
  Reyes, Chairman of the House Select Committee on
  Intelligence
• Sergio Nogueira, CEO of Mexican Association of
  Rehabilitation of Alcoholics and Addicts
• Simon F. Sotelo, Executive Director, Quad
  Counties Council on Alcohol and Drug Abuse

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Partnership for a Drug Free Texas
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Partnership for a Drug Free Texas

• Mission To reduce youth drug use in Texas by
  distributing research-based media messages
  created by the Partnership for a Drug-Free
  America and supplementary marketing materials
  developed specifically for Texas.

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PDFT Projects

• Alliance Support
• 1-877-9-NO-DRUG Hotline
• Red Ribbon Rally (October 15!)

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Looking Forward 2009

• Childrens Activity Book
• Currently producing bilingual activity book for
  ages 5-7
• PSA Distribution Changes
• Moving towards digital PSA distribution
• New Drug-Free Texas Website
• Working with Partnership National to syndicate
  content
• Will allow for daily updates by DSHS and PDFT

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Recovery Month

• 2009 marks the 20th Anniversary of Recovery
  Month, which aims to
• highlight societal benefits of substance abuse
  treatment
• laud the contributions of treatment providers
• promote the message that recovery is possible
• encourage citizens to help expand and improve
  availability of effective treatment
• educate public on substance abuse, addiction is a
  treatable disease and recovery possible
• reduce and eventually eliminate public stigma
  associated with substance abuse and recovery

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Recovery Month Events

• Rallies will be hosted in
• San Antonio
• Dallas
• Houston
• El Paso
• More much more information on Recovery Month can
  be found at
• http//www.recoverymonth.gov

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• On behalf of the citizens of Texas, thank you
  for all of the work you do!