1. Resiliency and Disease Management for Community Mental Health
Michael Maples, M.A., LPC, LMFT
Director of Program Services
Mental Health and Substance Abuse
Thank you for coming to this presentation on how we are in the midst of transforming the public mental health system in Texas and our preliminary examination of the Disease Management model.

2. Resiliency and Disease Management in Texas
Part 1
Resiliency and Disease Management in Texas
So let’s begin by setting the stage...

3. Research Practice Stakeholder Input Consensus
And as with all new initiatives in the public mental health sector, the Disease Management model is a product of research, practice, stakeholder input, and the tight-rope-walking exercise known as “consensus.”
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

4. Overall Goal
To promote the uniform provision of services based on clinical evidence and recognized best practices to advance the recovery of adults with serious mental illness and the resilience of children with severe emotional disturbance, as defined by Texas House Bill 2292 and in accordance with the President’s New Freedom Commission on Mental Health.
More specifically, the overall goal of the Disease Management model in Texas is:
to promote the uniform provision of services based on clinical evidence and recognized best practices to advance the recovery of adults with serious mental illness, as defined by Texas House Bill 2292 and in accordance with the President’s New Freedom Commission on Mental Health.
And you know, this process was just so simple, and so much fun!!
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

5. Resiliency and Disease Management (RDM)
Clinical Guidelines
Data Management
Uniform
Assessment
Evidence-Based,
Best Practice
Levels of Care
Fidelity
Outcomes
And the reason it was utter agony, is because the Disease Management model and each of its components was completely new to us in Texas public mental health.
So, even though this model might not be new to you, it was to us.
The Disease Management model in Texas includes a new, stream-lined uniform assessment process that is used to recommend one of five new evidence-based, best-practice levels of care, the fidelity of which is now monitored, followed by a new evaluation of critical outcomes--all under the auspices of a new utilization management system that includes clinical guidelines for the average monthly number of hours per adult consumer among many other parameters, as well as a new data management system that is comprised of a Consumer Analysis Data Warehouse that houses assignment data, encounter data, financial data, and even Medicaid eligibility data.
Now, implementation of this model began first at four public mental health centers in Texas on September 1st, 2003, with the rest of the public mental health centers in Texas having begun to implement the Disease Management model on September 1st, 2004, as mandated by Texas House Bill 2292.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

6. Resiliency and Disease Management (RDM)
Clinical Guidelines
Data Management
Uniform
Assessment
Evidence-Based,
Best Practice
Levels of Care
Fidelity
Outcomes
Uniform
Assessment
Let us now touch upon each of these major components, beginning with the Uniform Assessment.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

7. Part 2
Uniform Assessment

8. Uniform Assessment for RDM
Adult
Texas
Recommended
Assessment
Guidelines
(Adult-TRAG)
Child and Adolescent
Texas
Recommended Assessment
Guidelines
(CA-TRAG)
The uniform assessment for Disease Management is the Adult Texas Recommended Assessment Guidelines, also known as the Adult-TRAG.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

9. TRAG
An instrument for Qualified Mental Health Professionals - Community Services (QMHP-CS) to assess the service needs of adults and children face-to-face, and recommend a level of care for them in the Texas public mental health system.
The Adult-TRAG is an instrument for Qualified Mental Health Professionals - Community Services or QMHP-CS’s to help them assess the service needs of adults face-to-face, and recommend a level of care for them in the Texas public mental health system.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

10. Rationale for the TRAG To reduce inequities in care
Existing instruments have limitations:
Too expensive.
Too complicated.
Not compatible with our population and geography.
Not suitable for adults/children with severe mental illness/emotional disturbance.
Poverty and related services often overlooked.
So, one reason why we needed the Adult-TRAG--part of the rationale for the Adult-TRAG -- was to reduce these apparent inequities in care.
The second reason for why we needed the TRAG was because many of the existing instruments that match adults with an appropriate level of mental health care were limited in their application.
Many of them were too expensive, or too complicated, or they were not compatible with our population and geography, or they were not suitable for adults with serious mental illness, or poverty and the services needed to address it were often overlooked.
So, for both of these reasons--with this rationale in mind--we developed the Adult-TRAG.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

11. Adult-TRAG Dimensions for Assessment
1. Risk of Harm
2. Support Needs
3. Psychiatric-Related Hospitalizations
4. Functional Impairment
5. Employment Problems
6. Housing Instability
7. Co-Occurring Substance Use
8. Criminal Justice Involvement
9. Response to Medication Treatment (MDD Only)
The Adult-TRAG defines the dimensions clinicians consider when recommending the most appropriate level of care for adults with serious mental illness who are in the public mental health system, including:
1. Risk of Harm;
2. Support Needs;
3. Psychiatric-Related Hospitalizations;
4. Functional Impairment;
5. Employment Problems;
6. Housing Instability;
7. Co-Occurring Substance Use;
8. Criminal Justice Involvement; and
9. Response to Medication Treatment for adults with Major Depressive Disorder only.
And for most of these dimensions, the adult consumer is rated on a scale from1 to 5, where higher ratings mean a greater severity.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

12. CA-TRAG Dimensions for Assessment
1. Ohio Youth Problem Severity Scale (OYPSS)
2. Ohio Youth Functioning Scale (OYFS)
3. Risk of Self-Harm
4. Severe Disruptive or Aggressive Behavior
5. Family Resources
6. History of Psychiatric Treatment
7. Co-Occurring Substance Use
8. Juvenile Justice Involvement
9. School Behavior
10. Psychoactive Medication Treatment
The Adult-TRAG defines the dimensions clinicians consider when recommending the most appropriate level of care for adults with serious mental illness who are in the public mental health system, including:
1. Risk of Harm;
2. Support Needs;
3. Psychiatric-Related Hospitalizations;
4. Functional Impairment;
5. Employment Problems;
6. Housing Instability;
7. Co-Occurring Substance Use;
8. Criminal Justice Involvement; and
9. Response to Medication Treatment for adults with Major Depressive Disorder only.
And for most of these dimensions, the adult consumer is rated on a scale from1 to 5, where higher ratings mean a greater severity.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

13. Resiliency and Disease Management (RDM)
Clinical Guidelines
Data Management
Uniform
Assessment
Evidence-Based,
Best Practice
Levels of Care
Fidelity
Outcomes
As part of the Disease Management Model in Texas, there are five adult evidence-based, best-practice levels of care.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

14. Evidence-Based, Best-Practice Levels of Care
Part 3
Evidence-Based, Best-Practice Levels of Care
So, let’s look at these now...

15. Adult Levels of Care
Service Package 1. Pharmacological Management, Patient and Family Education, and Routine Case Management
Service Package 2. Pharmacological Management, Patient and Family Education, Routine Case Management, and Counseling
Service Package 3. Psychosocial Rehabilitation
Service Package 4. Assertive Community Treatment
SERVICE INTENSITY
The five levels of care available as part of Texas’ Disease Management model include:
Crisis Services
Service Package 1: Pharmacological Management, Medication Training and Supports, Routine Case Management, and Skills Training and Development
Service Package 2: Pharmacological Management, Medication Training and Supports, Routine Case Management, Skills Training and Development, and Rehabilitative Counseling and Psychotherapy
Service Package 3: Pharmacological Management, Medication Training and Supports, Psychosocial Rehabilitation, Supported Employment, and Medical Services
Service Package 4: ACT/ACT Alternative
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

16. Child and Adolescent Levels of Care
Service Package 1.1 Brief Outpatient – Externalizing Disorders
Service Package 1.2 Brief Outpatient – Internalizing Disorders
Service Package 2.1 Intensive Outpatient – Externalizing Disorders – Multi-Systemic Therapy
Service Package 2.2 Intensive Outpatient – Externalizing Disorders
Service Package 2.3 Intensive Outpatient – Internalizing Disorders
Service Package 2.4 Intensive Outpatient – Schizophrenia, Bipolar
Disorder, Major Depressive Disorder with
Psychosis, or Other Psychotic Disorders
Service Package After-Care
The five levels of care available as part of Texas’ Disease Management model include:
Crisis Services
Service Package 1: Pharmacological Management, Medication Training and Supports, Routine Case Management, and Skills Training and Development
Service Package 2: Pharmacological Management, Medication Training and Supports, Routine Case Management, Skills Training and Development, and Rehabilitative Counseling and Psychotherapy
Service Package 3: Pharmacological Management, Medication Training and Supports, Psychosocial Rehabilitation, Supported Employment, and Medical Services
Service Package 4: ACT/ACT Alternative
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

17. Resiliency and Disease Management (RDM)
Clinical Guidelines
Data Management
Uniform
Assessment
Fidelity
Outcomes
Evidence-Based,
Best Practice
Levels of Care
Also a major part of the Disease Management Model in Texas is fidelity - to measure the fidelity of mental health providers to the clinical and structural requirements for each evidence-based, best-practice, Disease Management level of care.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

18. Part 4
Fidelity
And so, let’s examine what we mean by fidelity in more detail now...

19. Use Communicating expectations about RDM level of care components.
Initial training of providers in RDM service models.
Self-monitoring and assessment of service model implementation.
Technical assistance in service model implementation.
External review and accountability.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

20. Example Item for Adult Service Package 3
Definition: Effective skills training methods are utilized, including a) instructions; b) modeling;
c) role play or rehearse; d) positive feedback and shaping; and e) repetition of role plays or rehearsal.
Rationale: To measure the degree to which effective skill training methods are utilized.
Information Sources: Progress notes
Item Scoring: 5-point rating based on the presence of the element:
1. No evidence of any skills training methods described in a - e.
2. Skill training methods as described in a - e are used in 25% - 49% of the progress notes.
3. Skill training methods as described in a - e are used in 50% - 74% of the progress notes.
4. Skill training methods as described in a - e are used in 75% - 94% of the progress notes.
5. Skill training methods as described in a - e are used in 95% or more of the progress notes.
Source: DSHS Fidelity Toolkit for Resiliency and Disease Management,
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

21. Example Item for Child and Adolescent Service Packages 1.2 and 2.3
Definition: As part of Cognitive Behavior Therapy (CBT), children and adolescents are taught self-monitoring — skills to recognize and record specific experiences that affect anxiety and depression. Children and adolescents are taught to self-monitor in some or all of the following critical areas: physical sensations that occur when anxiety and depression are present; thoughts that precipitate anxiety and depression; emotions experienced; events that precipitate anxiety and depression; and actions that may follow the feelings of anxiety and depression.
Rationale: Self-monitoring is an intervention that assists children and adolescents to become self-aware of factors that contribute to anxiety and depression, and to become self-aware of the impact of their new skills on their symptoms of anxiety and depression. Self-monitoring provides the “data” upon which interventions are based. Progress can be measured over time and children and adolescents can become aware of the strengths and skills gained to manage anxiety and depression.
Information Sources: Child record (progress notes), child interviews, supervision notes, observation, and audio or videotapes.
Item Scoring: This item is scored “yes” if sources demonstrate that the youth was: a) instructed in how to self-monitor their experiences of anxiety and/or depression and associated elements; and b) practiced this skill either in one or more therapy sessions or as a “homework” assignment.
Source: DSHS Fidelity Toolkit for Resiliency and Disease Management,
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

22. Resiliency and Disease Management (RDM)
Clinical Guidelines
Data Management
Uniform
Assessment
Outcomes
Evidence-Based,
Best Practice
Levels of Care
Fidelity
Which brings us to outcomes--another major component of the Disease Management model in Texas.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

23. In God we trust; everyone else must supply outcome data.
U.S. Health Care (Ross, 1997)
After all:
“In God we trust;
everyone else must supply outcome data.”

24. Part 5
Outcomes
So let’s have a look at some system outcomes now for the first, four Disease Management implementation sites -- four public mental health centers in Texas.
Because remember that the Disease Management model is based on the principle that adults do recover from mental illness when they are given appropriate treatment and supports.
And so, the real test of success for the Disease Management model is whether adults are recovering.
And I would like to thank the members of the Disease Management Evaluation Team, including Mark Mason and Judy Temple…in fact, Judy is in the audience today!

25. NUMBER OF ADULTS SERVED at DSHS-Funded Community Mental Health Centers
STATEWIDE IMPLEMENTATION OF RDM
As you can seen, the number of adult served at DSHS-Funded Community Mental Health Centers has remained relatively constant from FY2003 to FY2006 — pre-implementation through post-implementation of Resiliency and Disease Management — with 110,491 adults being served in FY2003 and 109,227 being served in FY2006.
Source: FY2003 = CARE Report HC028488, TDMHMR MH Priority Population Counts by Month for through , prepared on 09/20/03, total is unduplicated; FY2004 = CARE Report HC028488, TDMHMR MH Priority Population Counts by Month for through , prepared on 09/18/04, total is unduplicated; FY2005 = DSHS Mental Retardation and Behavioral Health Outpatient Warehouse, Business Objects Corporate Report, LBB RDM Served for FY2005, 08/01/06, used for LBB reporting for number of adults receiving community mental health services per year (i.e., number who received a full RDM service package); FY2006 = DSHS Mental Retardation and Behavioral Health Outpatient Warehouse, Business Objects Corporate Report, LBB RDM Served for FY2006, 09/17/06, used for LBB reporting for number of adults receiving community mental health services per year (i.e., number who received a full RDM service package).
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

26. OUTCOMES among Adults Assigned to a Full RDM Service Package at DSHS-Funded Community Mental Health Centers in FY2005 and FY2006
Source: FY2005 = DSHS Mental Retardation and Behavioral Health Outpatient Warehouse, Business Objects Corporate Report, PM Adult Outcomes Report for FY2005, 11/30/05 (Co-Occurring Substance Use, 08/01/06), Business Objects Corporate Report, PM Crisis Avoidance Report for FY2005, 12/01/05, Business Objects Corporate Report, PM Time Between Assessment and First Service Encounter Report for FY2005, 12/01/05; FY2006 = DSHS Mental Retardation and Behavioral Health Outpatient Warehouse, Business Objects Corporate Report, PM Adult Outcomes Report for FY2006, 09/17/06, Business Objects Corporate Report, PM Crisis Avoidance Report for FY2006, 09/17/06, Business Objects Corporate Report, PM Time Between Assessment and First Service Encounter Report for FY2006, 09/17/06.
FY2005 Ns = Functioning, Housing, Employment = 74,943; Criminal Justice Involvement = 10,753; Co-Occurring Substance Use = 16,172; Avoided Crisis = 105,131; Received First Service within 14 Days of Assessment = 78,782.
FY2006 Ns = Functioning, Housing, Employment = 84,616; Criminal Justice Involvement = 12,447; Co-Occurring Substance Use = 17,201; Avoided Crisis = 109,227; Received First Service within 14 Days of Assessment = 62,597.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

27. STATEWIDE IMPLEMENTATION OF RDM
NUMBER OF CHILDREN SERVED at DSHS-Funded Community Mental Health Centers
STATEWIDE IMPLEMENTATION OF RDM
As you can seen, the number of children served at DSHS-Funded Community Mental Health Centers has remained relatively constant from FY2003 to FY2006 — pre-implementation through post-implementation of Resiliency and Disease Management — with 25,622 children being served in FY2003 and 27,665 being served in FY2006.
Source: FY2003 = CARE Report HC028488, TDMHMR MH Priority Population Counts by Month for through , prepared on 09/20/03, total is unduplicated; FY2004 = CARE Report HC028488, TDMHMR MH Priority Population Counts by Month for through , prepared on 09/18/04, total is unduplicated; FY2005 = DSHS Mental Retardation and Behavioral Health Outpatient Warehouse, Business Objects Corporate Report, LBB RDM Served for FY2005, 08/01/06, used for LBB reporting for number of children receiving community mental health services per year (i.e., number who received a full RDM service package); FY2006 = DSHS Mental Retardation and Behavioral Health Outpatient Warehouse, Business Objects Corporate Report, LBB RDM Served for FY2006, 09/17/06, used for LBB reporting for number of children receiving community mental health services per year (i.e., number who received a full RDM service package).
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

28. OUTCOMES among Children and Adolescents Assigned to a Full RDM Service Package at DSHS-Funded Community Mental Health Centers in FY2005 and FY2006
Source: FY2005 = DSHS Mental Retardation and Behavioral Health Outpatient Warehouse, Business Objects Corporate Report, PM Child Outcomes Report for FY2005, 11/30/05 (Co-Occurring Substance Use, 08/01/06), Business Objects Corporate Report, PM Crisis Avoidance Report for FY2005, 12/01/05, Business Objects Corporate Report, PM Time Between Assessment and First Service Encounter Report for FY2005, 12/01/05; FY2006 = DSHS Mental Retardation and Behavioral Health Outpatient Warehouse, Business Objects Corporate Report, PM Adult Outcomes Report for FY2006, 09/17/06, Business Objects Corporate Report, PM Crisis Avoidance Report for FY2006, 09/17/06, Business Objects Corporate Report, PM Time Between Assessment and First Service Encounter Report for FY2006, 09/17/06.
First Service Encounter Report for FY2006, 09/17/06.
FY2005 Ns: Functioning, Problem Severity = 14,767; School Behavior = 8,421; Co-Occurring Substance Use = 1,708; Avoided Crisis = 26,213; Received First Service within 14 Days of Assessment = 17,400.
FY2006 Ns: Functioning, Problem Severity = 16,905; School Behavior = 8,306; Co-Occurring Substance Use = 1,754; Avoided Crisis = 27,665; Received First Service within 14 Days of Assessment = 17,765.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

29. Part 6
Challenges
So let’s have a look at some system outcomes now for the first, four Disease Management implementation sites -- four public mental health centers in Texas.
Because remember that the Disease Management model is based on the principle that adults do recover from mental illness when they are given appropriate treatment and supports.
And so, the real test of success for the Disease Management model is whether adults are recovering.
And I would like to thank the members of the Disease Management Evaluation Team, including Mark Mason and Judy Temple…in fact, Judy is in the audience today!

30. ADHERENCE TO CLINICAL GUIDELINES Recommended vs
ADHERENCE TO CLINICAL GUIDELINES Recommended vs. Actual Average Monthly Service Hours per Adult in FY2005 and FY2006
One major challenge has to do with adherence to the Resiliency and Disease Management clinical guidelines and the recommended average monthly service hours per adult and per child.
As you can see, although much progress was made from FY2005 to FY2006, the actual average monthly service hours per adult for each Service Package at DSHS-funded Community Mental Health Centers are still considerably lower than what are recommended by the Resiliency and Disease Management clinical guidelines.
Source: DSHS Mental Retardation and Behavioral Health Outpatient Warehouse, Business Objects Corporate Report, UM Avg Client Hours by Svc Pkg, 09/18/06.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

31. ADHERENCE TO CLINICAL GUIDELINES Recommended vs
ADHERENCE TO CLINICAL GUIDELINES Recommended vs. Actual Average Monthly Service Hours per Child in FY2005 and FY2006
The same is true for children.
As you can see, although much progress was made from FY2005 to FY2006, the actual average monthly service hours per child at DSHS-funded Community Mental Health Centers in FY2006 are still substantially lower than what are recommended by the Resiliency and Disease Management clinical guidelines, especially for children assigned to Service Package 2.1, 2.2, and 2.3.
And so, the challenge is for the Centers to better adhere to these recommended clinical guidelines for adults and for children, in terms of average monthly service hours per client.
Source: DSHS Mental Retardation and Behavioral Health Outpatient Warehouse, Business Objects Corporate Report, UM Avg Client Hours by Svc Pkg, 09/18/06.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

32. Part 7
Structure
So let’s have a look at some system outcomes now for the first, four Disease Management implementation sites -- four public mental health centers in Texas.
Because remember that the Disease Management model is based on the principle that adults do recover from mental illness when they are given appropriate treatment and supports.
And so, the real test of success for the Disease Management model is whether adults are recovering.
And I would like to thank the members of the Disease Management Evaluation Team, including Mark Mason and Judy Temple…in fact, Judy is in the audience today!

33. Structure Local Authority conducts initial assessment.
Local Authority authorizes care including overrides.
Provider delivers service.
Provider conducts follow-up assessments, requests authorizations.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006

34. Key Components Evidence-based and consensus-based.
Person centered – focus on outcomes.
Continuity-of-care across levels.
Information available on performance and outcomes.
Utilization Management – right service, right amount.
Flexibility.
RDM for Community Mental Health  Negotiated Rulemaking for Provider of Last Resort Meeting  October 11, 2006