System Transformation in Texas: Agenda for Dave Wanser Ph.D. Deputy Commissioner for Behavioral and Community Health Department of State Health Services

Current Behavioral Health Care System “For too many Americans, the services and supports they need remain fragmented, disconnected, and often inadequate, frustrating the opportunity for recovery…. Instead of ready access to care, the system presents barriers that all too often add to the burden of mental illness (and substance abuse) for individuals, their families, and our communities.” Achieving the Promise: Transforming Health Care in America

The Texas Approach to Transformation Overarching goal is to improve the mental health of all Texans and meet the President’s NFC goals. Overarching goal is to improve the mental health of all Texans and meet the President’s NFC goals. New Freedom Commission Goals are shared by those participating on the TWG: New Freedom Commission Goals are shared by those participating on the TWG: The Governor’s Office; Department of State Health Services; Texas Health and Human Services Commission (Medicaid); Department of Family and Protective Services; Criminal Justice Department; Juvenile Probation Commission; Texas Youth Commission; Consumers; Family Members; Texas Education Agency; Aging and Disability Services; Workforce Commission; Veteran’s Administration; etc. The Governor’s Office; Department of State Health Services; Texas Health and Human Services Commission (Medicaid); Department of Family and Protective Services; Criminal Justice Department; Juvenile Probation Commission; Texas Youth Commission; Consumers; Family Members; Texas Education Agency; Aging and Disability Services; Workforce Commission; Veteran’s Administration; etc.

TWG Agency Resources Spent on Mental Health

The Texas Approach to Transformation The grant funding is seen as a catalyst to jump start some of the efforts of framing the public health approach. The 2 primary areas of focus: The grant funding is seen as a catalyst to jump start some of the efforts of framing the public health approach. The 2 primary areas of focus: Developing and supporting local behavioral health collaboratives Developing and supporting local behavioral health collaboratives Using cutting edge technology to change work processes across agencies Using cutting edge technology to change work processes across agencies Improvement of the system will be targeted to the IOM Quality Chasm principles: Improvement of the system will be targeted to the IOM Quality Chasm principles: Apply evidence to health care delivery; Apply evidence to health care delivery; Use information technology; Use information technology; Align payment policies with quality improvement; Align payment policies with quality improvement; Prepare the workforce. Prepare the workforce.

Child Abuse or Neglect Physical abuse Physical abuse Sexual abuse Sexual abuse Abandonment Abandonment Adverse Childhood Experiences as a means to Understand the Public Health Approach Trauma in Child’s Household Substance Abuse Parental divorce Mentally ill or suicidal household member Violence to mother Imprisoned household member

Effects of Trauma Difficulty controlling anger Difficulty controlling anger Hallucinations Hallucinations Depression Depression Panic reactions Panic reactions Anxiety Anxiety Adverse Childhood Experiences Health Risk Behaviors Smoking Obesity Suicide Alcoholism Drug abuse Sexually transmitted disease Self-injury Eating disorders

Disease and Disability Heart disease Heart disease Cancer Cancer Chronic lung disease Chronic lung disease Emphysema Emphysema HIV/AIDS HIV/AIDS Adverse Childhood Experiences Long-Term Consequences Social Problems Homeless Prostitution Delinquency, violence and criminal behavior Re-victimizations: rape; domestic violence Unemployment Intergenerational transmission of abuse

Adverse Childhood Experiences & Attempted Suicide

Behavioral Health Issues Impact Costs and Outcomes in Other Systems 75% of children placed in foster care have parents with behavioral health problems 75% of children placed in foster care have parents with behavioral health problems 75% of kids in the juvenile justice system have behavioral health problems 75% of kids in the juvenile justice system have behavioral health problems 30% of kids in the juvenile justice system will end up in the adult justice system 30% of kids in the juvenile justice system will end up in the adult justice system 46% of all ER visits have behavioral health issues as a basis or contributing factor 46% of all ER visits have behavioral health issues as a basis or contributing factor 30% of all truancy is related to behavioral health problems 30% of all truancy is related to behavioral health problems

Potential of a Public Health Approach: What we will make a priority of all agencies Focus on prevention and early intervention and adopt a family based approach Focus on prevention and early intervention and adopt a family based approach Implement national outcome measures and focus on how cultural issues impact disparities in access and outcome. Implement national outcome measures and focus on how cultural issues impact disparities in access and outcome. Expand the use of cutting edge technology Expand the use of cutting edge technology Demonstrate successful integration of physical and behavioral health Demonstrate successful integration of physical and behavioral health Seek public/private partnerships Seek public/private partnerships Work to develop and maintain a shared transformation agenda with stakeholders at both the state and local level Work to develop and maintain a shared transformation agenda with stakeholders at both the state and local level Change minds, change systems, change behavior Change minds, change systems, change behavior

Texas Transformation Texas Transformation 1. Texans understand mental health is essential to overall health 1. Texans understand mental health is essential to overall health Build capacity of primary care providers to identify, treat and refer across disciplines Build capacity of primary care providers to identify, treat and refer across disciplines Use local behavioral health collaboratives to leverage policy change Use local behavioral health collaboratives to leverage policy change 2. MH care is consumer and family driven 2. MH care is consumer and family driven Reduce barriers to treatment and reduce stigma with new program and purchasing models Reduce barriers to treatment and reduce stigma with new program and purchasing models 3. Disparities are eliminated 3. Disparities are eliminated Inter-operability of data systems creates a roadmap for opportunities Inter-operability of data systems creates a roadmap for opportunities Leveraging lessons learned from other initiatives, e.g. work with faith community Leveraging lessons learned from other initiatives, e.g. work with faith community 4. Early screening, assessment and referral are common practice 4. Early screening, assessment and referral are common practice Use of technology Use of technology ACE framework shared by member agencies ACE framework shared by member agencies Behavioral health/ primary care and public/private partnerships Behavioral health/ primary care and public/private partnerships 5., 6. Excellent care is delivered and research accelerated, technology is utilized 5., 6. Excellent care is delivered and research accelerated, technology is utilized Demonstrate return on investment Demonstrate return on investment System wide use of evidence based frameworks and practices System wide use of evidence based frameworks and practices

A Borrowed Approach to Community Collaboration Community collaboratives have been very effective in mobilizing communities to address issues in access to healthcare for underinsured populations Community collaboratives have been very effective in mobilizing communities to address issues in access to healthcare for underinsured populations Membership consists of business leaders, elected officials, community leaders, consumers. Providers Membership consists of business leaders, elected officials, community leaders, consumers. Providers Follows a structured and facilitated process for needs assessment, planning and implementation Follows a structured and facilitated process for needs assessment, planning and implementation Linkages to other local collaboratives through statewide framework leverages political impact. Linkages to other local collaboratives through statewide framework leverages political impact.

Use Technology to Transform the Mental Health System

Federated Data System