1. State Perspectives on Behavioral Health
Sonja Gaines
Associate Commissioner Texas Health and Human Services
October 28, 2016

2. HHS Transformation Organization Chart Effective Sept. 1, 2016
Executive
Commissioner
Veterans’ Services
Chief Deputy
Exec. Comm.
Aging Services
e-Health
Medical & Social Services (MSS) Division
Mental Health
Coordination
Community Services
Access &
Eligibility Services
Community Access
Eligibility Ops
Disability Determination
Community Care Eligibility
Behavioral Health & Intellectual and Developmental Disability Services
Behavioral Health Services
IDD Services
Health, Developmental & Independent Services
Rehab & Social Services
Health & Developmental Services
Medicaid
& CHIP Services
Program Enrollment
Operations
Policy & Program
Quality
Health Plan Monitoring
Transformation provides new opportunities to broaden coordination efforts both within the HHS System and externally and ultimately be recognized as the face of BH-IDD for the HHS System

3. Behavioral Health-IDD Services Functions
Community Services includes the Behavioral Health-IDD Services Department
Behavioral Health Services: Oversees and contracts for community-based mental health and substance use disorder services for children and adults provided by Local Mental Health Authorities and community-based providers and organizations.
Services such as crisis, out-patient, local inpatient, residential, prevention, intervention, veterans mental health, jail diversion, and peer support.
Intellectual and Developmental Disability (IDD) Services: Oversees IDD services by Local Intellectual and Developmental Disability Authorities.

4. Mental Health Coordination Functions
Office of Mental Health Coordination (MHC) created by S.B. 1-83R (Article II, HHSC Rider 82). The Office has authority to:
Provide broad oversight on public mental health policy.
Coordinate the policy and delivery of mental health services throughout the State of Texas.
Consult and coordinate with other state agencies, local governments, and other entities to ensure a strategic, statewide approach to mental health.

5. Statewide Behavioral Health Strategic Plan & Coordinated Expenditure Proposal
H.B. 1-84R (Article IX, Section 10.04) created the Statewide Behavioral Health Coordinating Council comprised of 18 state agencies charged with developing a:
Five-Year Statewide Behavioral Health Strategic Plan
Coordinated Expenditure Proposal for Fiscal Year 2017
Five-Year Strategic Plan for Fiscal Years includes:
Detailed planned efforts to coordinate behavioral health programs and services offered by Council agencies to eliminate redundancy; perpetuate identified, successful models for mental health and substance abuse treatment; ensure optimal service delivery; and identify and collect comparable data on results and effectiveness
Inventory of behavioral health programs and services by Council agencies
Report of the number of persons served
Coordinated Expenditure Proposal for Fiscal Year 2017 includes: Description of how identified appropriations at each agency will be spent in accordance with and to further the goals of the approved strategic plan

6. Statewide Behavioral Health Coordinating Council Members
The Council, includes the Texas Education Agency as a voluntary member, as well as representation from the following agencies:
The Office of the Governor
Texas Veterans Commission
Health and Human Services Commission
Department of Aging and Disability Services
Department of Family and Protective Services
Department of State Health Services
Texas Civil Commitment Office
The University of Texas Health Science Center at Houston
The University of Texas Health Science Center at Tyler
Department of Criminal Justice
Texas Juvenile Justice Department
Texas Military Department
Health Professions Council has one seat representing the Texas Medical Board, Texas Board of Pharmacy, Texas Board of Dental Examiners, Texas Board of Nursing, Texas Optometry Board, and Texas Board of Veterinary Medical Examiners

7. Statewide Behavioral Health Strategic Plan & Coordinated Expenditure Proposal
Expected Outcomes
Significant improvements in behavioral health coordination across state agencies
Maximize use of existing resources and services
Address behavioral health gaps identified through strategic approach
More efficient and effective state government
Ensure utilization of successful best, promising, and evidence-based behavioral health services and service delivery
Ensure prompt access to quality behavioral health services

8. Statewide Behavioral Health Strategic Plan
Vision: To ensure that Texas has a unified approach to the delivery of behavioral health services that allows all Texans to have access to care at the right time and place.
Mission: To develop a coordinated statewide approach to providing appropriate and cost-effective behavioral health services to Texans.
The system must:
Demonstrate coordination across Texas agencies and organizations to enhance continuity of care.
Support recovery as an ever-evolving process where Texans with behavioral health challenges are empowered to take control of their lives.
Value peers, family, friends, behavioral health professionals, and other stakeholders and their vital roles in a person's journey.
Be trauma-informed and acknowledge the widespread impact of trauma, understand potential paths for recovery, and seek to actively resist re-traumatization.
Utilize best practices in contracting standards and follow state guidelines.
Programs and services must be:
Person-centered with the strengths and the needs of the person determining the types of services and supports provided.
Culturally and linguistically sensitive with agencies, programs, and services that reflect the cultural, racial, ethnic, and linguistic differences of the populations they serve.
Delivered in a flexible manner, where possible, to meet the needs of each child, family, or adult close to their community.
Accessible to all Texans regardless of setting (i.e. prison, jail, school, etc.) through the use of innovative technologies, such as telemedicine, which increase access to treatment and address transportation barriers.
Ensure each child, family, or adult receives care based on the person's unique needs.

9. Behavioral Health Prevalence in Texas by Condition, Fiscal Year 2014
SUD (Adults)
SMI
SED
SPMI
SUD (Youth)
Mental illness is a leading cause of disability in the U.S.
It is estimated that 17.8 percent of the adult U.S. population has a mental health disorder during the course of a year.
In Texas, the 2014 estimated number of adults with serious and persistent mental illness was 515,875.
Approximately 20 percent of U.S. children and adolescents have some type of mental disorder.
Federal regulations also define a sub-population of children and adolescents with more severe functional limitations, known as serious emotional disturbance (SED).
Children and adolescents with SED comprise approximately 7 percent of children ages 9 to 17.
Using SAMHSA's prevalence rate, the estimated number of Texas children and youth ages 17 years and younger with SED is 519, 368.
U.S. Burden of Disease Collaborators.
The state of U.S. health, : burden of diseases, injuries, and risk factors. JAMA, 310(6): , 2013.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (November 19, 2013). The NSDUH Report: Revised Estimates of Mental Illness from the National Survey on Drug Use and Health. Rockville, MD. (
CMHS, SAMHSA, HHS (1999) Estimation Methodology for Adults with Serious Mental Illness (SMI). Federal Register v 64.
National Institute of Mental Health. Any disorder among children. Accessed March
Legend:
SUD – Substance Use Disorder
SMI – Severe Mental Illness
SED – Severe Emotional Disturbance
SPMI – Serious & Persistent Mental Illness

10. Behavioral Health Funding in Texas for Fiscal Years 2016-17 by Program
The Texas state budget for the fiscal year biennium specifically identifies $3.6 billion in state General Revenue related to behavioral health services in Article IX, Section This funding crosses 18 state agencies (per Article IX, Sec ) and several areas of state government represented on the Council, including health and human services, criminal justice, higher education, general government, and regulatory services.
Notes:
Medicaid expenditures include all claims with a primary diagnosis code that represents a behavioral health condition.
Estimates for Medicaid do not include Delivery System Reform Incentive Payment (DSRIP).
Estimated fiscal years 2016 and 2017 Medicaid expenditures are proportioned from prior year's mental health costs to total costs, and applied to forecasted costs. NorthSTAR costs are included with DSHS in fiscal year 2016 and four months of fiscal year 2017 as appropriated.

11. Criminal & Juvenile Justice
Behavioral Health Population Served by Council Agencies in Fiscal Year 2016
Agency
Youth
Adults
Veterans
Criminal & Juvenile Justice
IDD
Office of the Governor ●
TVC
HHSC
DADS
DFPS
DSHS
TCCO
UTHSC–Houston
UTHSC–Tyler
TDCJ ● 
TJJD
TMD
Health Professions Council*
TEA
* The Health Professions Council represents the Texas Board of Dental Examiners, Texas Board of Pharmacy, Texas State Board of Veterinary Examiners, Texas Optometry Board, Texas Peer Assistance Program for Nurses, and Texas Medical Board.

12. Behavioral Health Investment in Texas
Large investment and stewardship of the Governor and the Legislature to improve Texas’ behavioral health service delivery system have made positive change
Increased treatment alternatives to incarceration
Enhances local community collaboration
Coordinating funding efforts
However, gaps in services still remain
Council member agencies and community stakeholder groups provided valuable insight to identify gaps and challenges related to coordination, access, and service provision
Council members also identified specific populations that are underserved in the current behavioral health system
Identified gaps provide opportunities to strengthen the system as the strategic plan is implemented

13. Strength, Weaknesses, Opportunities, & Threats Survey Feedback
745 individuals responded to a survey of current Strengths, Weaknesses, Opportunities, and Threats related to Texas behavioral health services conducted in February 2016
Geographic Location of Respondents:
69% from large urban areas (population greater than 50,000)
24% from small urban areas (population between 2,500 and 50,000)
7% from rural areas (population less than 2,500)

14. Strength, Weaknesses, Opportunities, & Threats Survey Feedback
Top Three Responses for Each Survey Category
Strength
Weaknesses
Availability of Peer Services
Diverse array of available services; increased services available
Availability of crisis response teams
Limited available services
Shortage of psychiatrists, clinical staff, behavioral health providers and lack of substance use treatment
Low coordination between providers; lack of follow-through, organization, and attention to effective outcomes
Opportunities
Threats
Expand telemedicine/telehealth
Increase stakeholder involvement and front line staff input
Expand existing services
Lack of appropriate and adequate funding; funding cuts
Sustainability of innovative and grant-funded programs
High cost of services; lack of insurance; claims and reimbursement issues
In addition to the top three responses identified in each area, there were also responses collected related to significant areas of interest.
Strengths: Collaboration of service providers, communities, law enforcement, and first responders; dedicated professionals demonstrating genuine concern
Weaknesses: Inability to maintain, develop, and sustain a trained behavioral health workforce; lack of adequate services and access to available services in rural areas
Opportunities: Utilize technology and data to enhance infrastructure and service delivery; assist clients with other needs and services, such as housing
Threats: lack of public awareness, stigma associated with behavioral health conditions
Of particular note are the following responses regarding strengths in the current behavioral health system:
"There is a genuine concern to provide support services to this population, especially to individuals with chemical and/or mental health issues."
"There appear to be several supports for mental health treatment [in my area] and there are supports for substance abuse treatment for adults. The mental health services agency in this town [have] recently implemented wraparound services for children and teens which I feel will be a huge support."
"Psychiatric inpatient care and peer-delivered services are improving. There is also an improvement in supported housing and supported employment services."
"The development of the peer network and providers [is a strength]. Often clients feel they are alone in their struggles and it helps to be connected and know are not [alone]."
"Different agencies have the ability to work together to get the client the help they need in the least restrictive environment."
"Attention is being paid to the continuum of services available, with emphasis on identifying gaps in access to care and sustained engagement in services."

15. Statewide Behavioral Health Strategic Plan
Goal 1: Program and Service Coordination
Goal 2: Program and Service Delivery
Goal 3: Prevention and Early Intervention Services
Goal 4: Financial Alignment
Goal 5: Statewide Data Collaboration
Building on the vision, mission, and guiding principles established by the Council, this strategic plan has been developed and is supported by a series of goals, objectives, and strategies to guide innovation, collaboration, and foster opportunities to leverage resources across state agencies. The goals are as follows:
Goal 1: Program and Service Coordination – Promote and support behavioral health program and service coordination to ensure continuity of services and access points across state agencies.
Goal 2: Program and Service Delivery – Ensure optimal service delivery to maximize resources in order to effectively meet the diverse needs of people and communities.
Goal 3: Prevention and Early Intervention Services – Maximize behavioral health prevention and early intervention services across state agencies.
Goal 4: Financial Alignment – Ensure that the financial alignment of behavioral health funding best meets the needs across Texas.
Goal 5: Statewide Data Collaboration – Compare statewide data across state agencies on results and effectiveness.

16. Behavioral Health Strategic Plan Implementation
Two Phases:
Phase I: Immediate implementation of short-term opportunities which are low- or no-cost
Phase 2: Planning and implementation of long-term strategies
Statewide Behavioral Health Advisory Council will seek direction from the Legislature and the Office of the Governor
In Phase I, Council agencies will identify ways they can leverage existing resources that impact psychiatric inpatient hospitalization which means collaborating on training and sharing resources to decrease the inappropriate use of emergency department resources and prevent individuals from requiring an inpatient psychiatric stay.

17. Behavioral Health Gaps in Services
Gap 1: Access to Appropriate Behavioral Health Services
Gap 2: Behavioral Health Needs of Public School Students
Gap 3: Coordination across State Agencies
Gap 4: Veteran and Military Service Members Supports
Gap 5: Continuity of Care for Individuals Exiting County and Local Jails
Gap 6: Access to Timely Treatment Services
Gap 7: Implementation of Evidence-based Practices
Gap 8: Use of Peer Services
Gap 9: Behavioral Health Services for Individuals with Intellectual Disabilities
Gap 10: Consumer Transportation and Access to Treatment
Gap 11: Prevention and Early Intervention Services
Gap 12: Access to Housing
Gap 13: Behavioral Health Workforce Shortage
Gap 14: Services for Special Populations
Gap 15: Shared and Usable Data

18. 1115 Waiver
The Delivery System Reform Incentive Payment (DSRIP) pool provides incentive payments for 3- and 4-year projects to improve health care access, innovate care delivery, and improve outcomes under the 1115 Waiver.
Supports coordinated care and quality improvement through 20 Regional Healthcare Partnerships
Targets Medicaid recipients and low-income uninsured individuals.
Currently have 1,451 DSRIP projects of which more than one-quarter (461) have a behavioral health focus: peer services, integrated health, telehealth, homeless services, veteran services
342 performed by community mental health centers
119 performed by hospitals and other providers
DSRIP Background Information
1115 Waiver Goals:
Expand Medicaid managed care statewide
Develop and maintain a coordinated care delivery system
Improve health outcomes while containing costs
Protect and leverage federal match dollars to improve the health care infrastructure
Transition to quality-based payment systems across managed care and hospitals
Major Components of 1115 Waiver:
Statewide Medicaid managed care through the STAR, STAR+PLUS, and Children's Medicaid Dental Services programs (including carve in of inpatient hospital, pharmacy, and children's dental services
Uncompensated Care (UC) Pool
Replaces Upper Payment Limit (UPL) program for hospital and physician payments.
Reimburses costs for care provided to individuals who have no third-party coverage for hospital and other services and Medicaid shortfall
The Delivery System Reform Incentive Payment (DSRIP) pool provides incentive payments for 3- and 4-year projects to improve health care access, innovate care delivery, and improve outcomes.
Supports coordinated care and quality improvement through 20 Regional Healthcare Partnerships
Targets Medicaid recipients and low-income uninsured individuals.
Waiver Extension Request
By September 30, 2015, HHSC was required to submit to the federal Centers for Medicare and Medicaid Services (CMS) a request to extend the waiver.
HHSC requested to continue all three components of the waiver (statewide managed care, UC pool and DSRIP pool) for another five years.
Texas has made progress related to all five waiver goals, and has proposed program improvements to make further progress toward those goals to support and strengthen the healthcare delivery system for low-income Texans.
Managed Care Extension Request
HHSC requested to continue all of the existing managed care programs and initiatives that are authorized under the 1115 Transformation Waiver.
HHSC did not request changes to the 1115 waiver related to managed care, but will continue to make managed care program improvements, including directives from the 84th Legislative Session.
Improved monitoring of MCO’s network adequacy
Value based purchasing and aligning Medicaid quality strategies
Improved collaboration between managed care consumer support systems
Extension Request for the DSRIP Pools
To continue the demonstration year (DY) 5 funding level for DSRIP ($3.1 billion annually)
An Uncompensated Care (UC) pool equal to the unmet need in Texas, adjusted to remain within budget neutrality each year (ranging from $5.8 billion - $7.4 billion per DY)
15-Month Waiver Extension Approval
In April 2016, HHSC submitted a request to CMS for a 15-month extension at level funding from demonstration year (DY) 5 of the waiver during which negotiations will continue on a longer-term agreement.
On May 2, 2016, HHSC received approval of this 15-month extension from CMS.
The 15-month extension maintains current funding levels for both UC and DSRIP.
During the extension period, HHSC and CMS will work on a longer term agreement.
Texas DSRIP Extension Principles
Further incentivize transformation and strengthen healthcare systems across the state by building on the Regional Healthcare Partnership (RHP) structure.
Maintain program flexibility to reflect the diversity of Texas’ 254 counties, 20 RHPs, and almost 300 DSRIP providers.
Further integrate with Texas Medicaid managed care quality strategy and value based payment efforts.
Streamline to relieve administrative burdens on providers while focusing on collecting the most important information.
Improve project-level evaluation to identify the best practices to be sustained and replicated.
Focus on Medicaid and low-income uninsured Texans.
DSRIP Projects
The two target populations of the DSRIP program are Medicaid enrollees and low-income uninsured individuals, but DSRIP projects also may serve others such as individuals on Medicare and commercial insurance.
Each DSRIP project has a maximum value that may be earned for achieving specific project metrics each year. DSRIP is funded at the federal matching assistance percentage, which varies each year and is approximately 58%. The non-federal share of DSRIP payments (about 42%) comes from intergovernmental transfers from local and state public entities.
As of July 2016, nearly $7.9 billion has been earned to date.
DSRIP behavioral health projects ending in September 2016 have the potential to earn more than $2.6 billion All Funds based on project achievement be the end of Demonstration Year 5 (FFY 2016).  As of January 2016, these behavioral health projects have earned approximately $1.7 billion in incentive payments to date, with potential to earn almost $1 billion in additional payments by the end of FFY 2016.  Providers have four opportunities to report achievements in FFY 2016 and FFY 2017.
Currently have 1,451 DSRIP projects of which more than one-quarter (461) have a behavioral health focus: peer services, integrated health, telehealth, homeless services, veteran services
115 interventions to prevent unnecessary use of services (i.e., criminal justice system, emergency department, etc.)
77 projects to enhance behavioral health service availability (hours, locations, transportation, mobile clinics, etc.)
53 projects to develop behavioral health crisis stabilization services
53 projects to integrate primary and behavioral health services
20 projects to deliver behavioral health services through telemedicine or telehealth
Of the 461 active behavioral health projects:
342 performed by community mental health centers
119 performed by hospitals and other providers

19. Notable Behavioral Health 1115 Waiver Projects
Bluebonnet Trails Community Center: Peer-led Transitional Housing project targets “super utilizers” and provides peer services, housing, other psychosocial supports
MHMR of Tarrant County: Systemic, Therapeutic, Assessment, Respite and Treatment (SMART) model provides behavioral health crisis prevention and intervention services for individuals with IDD and/or Autism Spectrum Disorder with co-occurring behavioral and medical problems
Austin-Travis County Integral Care: evidence-based health promotion programming for adults with severe mental illness in chronic disease management
Notable 1115 Waiver Projects:
Bluebonnet Trails Community Center: Peer-led Transitional Housing project targets “super utilizers”
Provides peer services, housing, other psychosocial supports
The goal of the program was to demonstrate participants' progress toward recovery.
Bluebonnet Trails Community Center found that 9 of the 43 individuals they served had frequent inpatient psychiatric stays. By participating in the project, all 9 had no inpatient stays while in the project, and no inpatient stays after leaving the project. This effort amounted to $12,450 savings from October 2015 through present. A potential for $24,900 in savings if the same trend carries forward through the remainder of the year.
Tarrant County MHMR: Systemic, Therapeutic, Assessment, Respite and Treatment (SMART) model
Provides BH crisis prevention and intervention services for individuals with intellectual and developmental disabilities and/or Autism Spectrum Disorder with co-occurring behavioral and medical problems
Austin-Travis County Integral Care (ATCIC): evidence-based health promotion programming for adults with severe mental illness in chronic disease management
Health Navigator,
HEAL (Healthy Eating Active Living),
InShape (Individual Self Health Action Empowerment Plan, and
Tobacco Cessation.

20. Texas Veterans + Family Alliance
S.B. 55 (84R) requires HHSC to establish a grant program to support community mental health programs providing services and treatment to veterans and their families.
Total Grant Program Funding is $21 million
Mission: Improve the quality of life of Texas veterans and their families by supporting local Texas communities to expand the availability of, increase access to, and enhance the delivery of mental health treatment and services.
Expected Outcomes:
Local communities will increase access to mental health care that is safe, appropriate and timely, of high quality, and respectful of military culture for Texas veterans and their families.
Barriers to accessing care, including community stigma, will be reduced.
Community partnerships will be supported as they develop projects and integrate services to strengthen their collaborative planning capacity.

21. Pilot Program: Texas Veterans + Family Alliance
Phase I: $1 Million Pilot Program: HHSC identified $1 million to support a pilot program to be matched with $1.1 million by grantees
Emergence Health Network – El Paso
Texas Panhandle Centers – 30 northern-most counties in the Texas Panhandle
Tropical Texas Behavioral Health – Cameron County
University of Texas at Dallas – Center for BrainHealth
United Way of Denton County
Expected to serve approximately 1,500 veterans and family members through August 31, 2017

22. Full Program: Texas Veterans + Family Alliance
Phase II: $20 Million Full Program: Article II, HHSC Rider 68 appropriated $20 million for full program to be matched dollar-for-dollar by grantees which will be implemented in two phases: A and B
Phase II-A
14 applicants selected in October 2016
Anticipated start period November 1, 2016
Phase II-B
Request for Award issued soon
Anticipated start period March 1, 2017
Visit for more information
Phase II-A apparent grantees include:
Catholic Charities of Fort Worth
Easter Seals of Greater Houston
The Ecumenical Center
Equest
Family Endeavors
Headstrong Project
Heart of Texas Regional MHMR
Heroes Night Out
Metrocare Services
StarCare Specialty Health
Texoma Community Center
Tropical Texas Behavioral Health
Veterans Coalition of North Central Texas
West Texas Counseling and Guidance

23. Associate Commissioner for Behavioral Health & IDD Services
Questions?
Sonja Gaines,
Associate Commissioner for Behavioral Health & IDD Services