Meeting the Mental Health Needs of Texans: The State of Mental Health Challenges and Innovations in Texas

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Meeting the Mental Health Needs of TexansThe
State of Mental Health Challenges and Innovations
in Texas

• Sam Shore, LMSW
• Director, Mental Health Transformation
• Mental Health and Substance Abuse Division

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Overview

• Identify key data points that indicate the mental
  health needs and challenges of Texans
• Describe Innovations In Policy, Programs and
  Practices that are being tested, or widely
  deployed, to address the needs of Texans

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• Needs and Challenges

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Mental Illness Strikes More Americans Each Year
Than Other Serious Illnesses
Serious Mental Illness
CVD
Mental Illness
Diabetes
Cancer
Asthma
CDC BRFSS, SEER Cancer Statistics Review,
1975-2002, Prevalence, Severity, and
Co-morbidity of 12-Month DSM-IV Disorders  Arch
Gen Psychiatry.  Vol. 62, June 2005
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Need Met for Community Mental Health Services in
TexasADULT
2010 Adult Population (18 years) 18,789,238
2010 Estimated Number with Serious and
Persistent Mental Illness 488,520
FY2010 Number Served in DSHS-Funded Community
Mental Health Services (including
NorthSTAR) 156,880 (33.6)
Sources 2010 Adult (18)/Child (9-17) Population
from Demographic Analysis Unit, Research
Division, HHSC, based on population projections
for 18 by the Texas State Data Center at the
University of Texas (San Antonio). 2010 Estimate
of Adults with Serious Persistent Mental
Illness based on methodology from Federal
Register, Volume 64, Number 121, Thursday, June
24, 1999, Notices, pages 33890-33897. 2010
Estimate of Children with Severe Emotional
Disturbance based on methodology from Federal
Register, Volume 63, Number 137, Friday, July 17,
1998, Notices, pages 33661-38665. FY2010 Number
of Adults/Children Served with Resiliency
Disease Management (Service Package 1-4)
including NorthSTAR.
Prepared by Decision Support Unit, Mental
Health Substance Abuse Division, DSHS.
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Need Met for Community Mental Health Services in
TexasCHILDREN
2010 Child Population (9-17 years) 3,094,475
2010 Estimated Number with Severe Emotional
Disturbance 154,724
FY2010 Number Served in DSHS-Funded Community
Mental Health Services (including
NorthSTAR) 44,787 (28.9)
Sources 2010 Adult (18)/Child (9-17) Population
from Demographic Analysis Unit, Research
Division, HHSC, based on population projections
for 18 by the Texas State Data Center at the
University of Texas (San Antonio). 2010 Estimate
of Adults with Serious Persistent Mental
Illness based on methodology from Federal
Register, Volume 64, Number 121, Thursday, June
24, 1999, Notices, pages 33890-33897. 2010
Estimate of Children with Severe Emotional
Disturbance based on methodology from Federal
Register, Volume 63, Number 137, Friday, July 17,
1998, Notices, pages 33661-38665. FY2010 Number
of Adults/Children Served with Resiliency
Disease Management (Service Package 1-4)
including NorthSTAR.
Prepared by Decision Support Unit, Mental
Health Substance Abuse Division, DSHS.
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Adults and Children Waiting for DSHS-Funded
Community Mental Health Services Increasing
Source DSHS Mental Retardation and Behavioral
Health Outpatient Warehouse (MBOW),
10/07/10. Prepared by Decision Support Unit,
Mental Health Substance Abuse Division, DSHS.
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Smoking among BH Population

• Persons with behavioral health conditions,
  defined as mental illness and/or substance abuse
  disorders, accounted for 44 of all cigarettes
  smoked in the United States (Lasser, et.al.,
  JAMA,2000)
• Adults with BH disorders account for 25 of
  population and consume almost 2X the cigarettes
  as general pop. (SAMHSA/NSDUH, March 20, 2013)
• Adults with BH disorders are twice as likely to
  be smokers

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Adverse Childhood ExperiencesThe impact of
trauma on health outcomesMany chronic
diseasesin adults are determineddecades
earlier, in childhood.
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(No Transcript)
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Their risk factors are alsoreliable markers for
antecedent problems.In my end is my
beginning. T.S. Eliot -
Quartets
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Dismissing them as bad habits
orself-destructive behavior totallymisses
their function.
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What is conventionallyviewed as a problem is
actually a solution to an unrecognized prior
adversity.
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The risk factors underlyingthese adult diseases
areeffective coping devices.
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Premature mortality and excess morbidity are
typically the result of a small number of common
diseases.
ACE Parental Loss
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Evidence from ACE Study SuggestsThese chronic
diseases in adults are determined decades
earlier, by the experiences of childhood.
Affective Response
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Evidence from ACE Study Suggests
Risk factors for these diseases are
initiated during childhood
or adolescence . . .
Seeking to Cope
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Evidence from ACE Study Suggests
..... and continue
into adult life.
Outcome social and biomedical damage
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Another possible outcome.
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Evidence from ACE Study SuggestsAdverse
childhood experiences are the most basic cause of
health risk behaviors, morbidity, disability,
mortality, and healthcare costs.
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• Challenges

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Texas Health Regions
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State Mental Health Facilities
Approximately 10 beds per 100,000 population
(2008)
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Texas Community Center Service Areas
Source Texas Council of Community MHMR Centers,
Inc.
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Bridging the Quality Chasm
Recovery/Resilience Promising and Evidence Based
Practice Information Technology
The behavioral health care that we know to be
effective
The behavioral health care that Americans receive
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Challenges

• Increasing Population
• In last decade Texas grew by more than entire
  population of Vermont and Arkansas combined (U.
  S. Census)
• Increase in diversity - culturally and
  linguistically
• Uninsured Individuals
• Texas has highest number of uninsured in all of
  the 50 states
• Lack of insurance is disincentive to seek care
  early - people are further in their disease when
  they seek help
• Workforce Shortages
• 60 of licensed professionals in the state are
  located in Houston, San Antonio and Ft. Worth
  (DSHS survey of LMHAs excluding NorthSTAR)
• In rural areas one licensed professional may be
  covering six or more counties-not uncommon (DSHS
  survey of LMHAs excluding NorthSTAR)
• Provider population is aging

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Mental Health HPSAs
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• Innovations

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Innovations in Programs and Practices

• Focus on Recovery and Resiliency (wellness and
  strengths versus illness and deficits internal
  activation)
• Person Centered Recovery Planning
• Wrap Around Planning
• Use of evidence based and promising practices
• Trauma-informed care and trauma-specific tx

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Innovations in Programs

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

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Innovations in Use of Technology

• Information Technology
• Electronic Health Record
• Data Sharing and interoperable Systems
• Use of Technology to Improve Access to Services
• Telemedicine for Psychiatric Services
• Training
• Distance Learning
• Online Resource for Educators to I.D. and respond
  to signs and symptoms of suicide risk

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Innovations in Financing

• Center for Medicare and Medicaid Services (CMS)
• Money Follows the Person (MFP)
• Demonstration to Maintain Independence and
  Employment (DMIE)
• 1915 (c) Medicaid Waiver for Children's Services
  Youth Empowerment Services (YES)
• Medicaid Incentives for Prevention of Chronic
  Disease (MIPCD)
• 1115 Transformation Waiver

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The 1115 Transformation Waiver

• Five year demonstration waiver (2011-2016)
• Managed care expansion
• Allows statewide Medicaid managed care services
• Includes pharmacy carve-in and dental managed
  care
• Under the waiver, historic Upper Payment Limit
  (UPL) funds and additional new funds are
  distributed to hospitals and other providers
  through two pools
• Uncompensated Care (UC) Pool
• Costs of care provided to individuals who have no
  third party coverage for the services provided by
  hospitals or other providers (beginning in first
  year).
• Medicaid Shortfall - The unreimbursed cost of
  Medicaid inpatient and outpatient hospital
  services furnished to Medicaid patients.
• Delivery System Reform Incentive Payments (DSRIP)
• Support coordinated care and quality improvements
  through 20 Regional Healthcare Partnerships
  (RHPs) to transform care delivery systems
  (beginning in later waiver years).

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Delivery System Reform Initiatives

• Category 1 Infrastructure
• Examples telemedicine, improve service
  availability (hours, locations, mobile clinics),
  increase access to crisis stabilization,
  workforce enhancement
• Category 2 Innovations
• Examples Targeted interventions for special
  populations, integration of primary care and
  behavioral health, peer support, improve
  transition from inpatient
• Category 3 Outcomes
• Related to Cat 1 or 2 projects. Examples Reduce
  preventable readmissions, improve management of
  chronic conditions

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1115 Funding Distribution
DY Demonstration Year

• FY 2011 UPL hospital payments 2.8 billion per
  year.

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1115 Transformation Progress

• 20 Regional Healthcare Partnerships (RHPs),
  anchored by a public hospital or related entity
  have submitted DSRIP projects
• 1,335 DSRIP projects were proposed (9.9 billion
  91 of available DSRIP funds)
• Projects received from 224 hospitals, 38
  community mental health centers, 20 local health
  departments, and 18 physician practices (included
  12 affiliated with academic health science
  centers)
• Projects include infrastructure (e.g., expand
  specialty care capacity) and innovation (e.g.,
  patient navigation, chronic care management)
• All 20 regions submitted behavioral health
  category projects (320).
• Behavioral health projects are estimated to
  represented over 16 percent of the total value of
  Category 1 and 2 projects (preliminary data)

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What is MIPCD?

• Medicaid Incentives for Prevention of Chronic
  Disease (Sec 4108 ACA)
• Competitive five year federal grant opportunity
  from Centers for Medicare and Medicaid Services
  (CMS). No state match required.
• Funds demonstration projects that use
  evidence-based incentives to help Medicaid
  clients adopt healthy behaviors, improve outcomes
• Projects must address at least one of the
  following goals
• tobacco cessation,
• controlling or reducing weight,
• lowering cholesterol,
• lowering blood pressure, or
• avoiding onset of diabetes or improving
  management of diabetes.

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MIPCD State Projects
STATE TOBACCO CESSATION WEIGHT LOSS LOWERING CHOLESTEROL LOWERING BLOOD PRESSURE DIABETES MANAGEMENT OR PREVENTION
CA X X
CT X
HI X X
MN X X
MO X X
NV X X X X
NH X X
NY X X X
TX X X X X X
WI X
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What is WIN?

• Wellness Incentives and Navigation (WIN)
  Texas MIPCD Project
• 9.9 million grant
• Medicaid State Health Services partnership
• Project imbedded in HHSC delivery system
• Randomized Controlled Trial in Harris Service
  Delivery Area for Medicaid Managed Care
• 1,250 participants

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Target Population

• Medicaid Managed Care (STARPLUS) members, ages
  21 55 who
• Live in the Harris service delivery area (Harris,
  Austin, Waller, Fort Bend, Montgomery, Wharton,
  Brazoria, Galveston and Matagorda Counties)
• Are not receiving Medicare
• Have either
• serious mental illness, OR
• behavioral chronic health conditions

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Why WIN?

• Risk - People with behavioral health conditions
  are significantly more likely to suffer chronic
  physical disease, and to die at a younger age.
  (29 years earlier than other Texans.)
• Cost Behavioral health conditions contribute
  significantly to higher medical costs
  (readmissions, ER visits, etc.)
• Opportunity - STARPLUS is Texas Medicaids
  dominant health care delivery system for adults
  with disabilities. Significant potential for
  large scale change, if successful.

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Research Structure

• Randomized trial
• Intervention, Control and Comparison Groups
• Intervention and Control Groups in the Harris SDA
• Comparison Groups reside outside of Harris
• Why a comparison group?
• Even in randomized trials, there can be bias in
  terms of who agrees to enroll
• Allows comparison of study participants to the
  larger STARPLUS population

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Indicators

• Development and achievement of personal health
  goals
• Improved health as measured by
• Changes in blood pressure
• Changes in weight and BMI
• HbA1c control
• Improved health care use (e.g., reduced
  potentially preventable inpatient admissions,
  readmissions, and emergency dept. visits)
• Better adherence to treatment such as
• Initiation and maintenance of treatment for
  alcohol dependence
• Initiation and maintenance of treatment for
  depression
• Appropriate use of asthma medications
• Comprehensive diabetes care

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WIN Interventions

• Person-centered wellness planning with
  professional health navigators, who are trained
  in Motivational Interviewing (MI) techniques.
• Wellness Recovery Action Planning training
  (WRAP) to enable participants with more severe
  mental illnesses to take full advantage of
  wellness planning.
• Flexible wellness account to support specific
  health goals defined by the participant in the
  individual wellness plan. (1150 / yr.,
  administered through the navigator)

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Flexible Purchases Examples

• Devices that promote wellness goals (e.g.,
  digital scale, BP monitor, mobile device and / or
  app for physical activity, etc.)
• Transportation to wellness activities (e.g.,
  support groups, gym, etc.)
• Subscriptions or memberships to promote wellness
  (e.g., YMCA, fitness magazine)
• Behavioral Interventions not currently covered by
  STARPLUS (e.g., relaxation, visualization, etc.)
• Individual wellness education
• Family-based Wellness Training and Interventions
• Nutritional or Medical Food
• Other items approved by the Harris Project
  Manager

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Thank You!

• Sam Shore, LMSW
• 512-206-5237
• Sam.shore_at_dshs.state.tx.us