1. Mental Health System Update Senate Finance Committee Tuesday, May 20, David L. Lakey, MD Commissioner

2. Topic Overview Mental Health Hospital Funding Other Fiscal Issues
Patient Protection and Rights
Community Crisis Funding Rollout

3. Mental Health Hospital Funding
Projected shortfall, FY
$19.8 million
Contributing Factors
Staffing
Medications
Medical costs
Operating costs

4. Mental Health Hospital Funding
Cost Drivers
24/7 psychiatric and medical care
Maintaining capacity at 2477 beds
Increasing competition for clinical staff in local markets
Increased cost for pharmaceuticals
Outside medical costs
Increased cost of food
Other unavoidable costs

5. Mental Health Hospital Funding
DSHS has taken the following steps:
Improved flow of financial information to and from hospital system
Developed baseline for analysis of trends in expenditures after consolidation
Begun work on an exceptional item request to meet salary and health care inflation at hospitals for 2010 and 2011

6. Mental Health Hospital Funding
Inflation in Clinical Salaries
Competition in local markets for professions with limited labor pool
Average salary increase for clinical staff, rose by 6% above legislative pay increases (FY )
64% of hospital employees are clinical staff

7. Mental Health Hospital Funding
Pharmaceutical cost increases
Psychiatric drugs (82% of purchases)
9% increase in cost
All other drugs
25% increase in cost

8. Mental Health Hospital Funding
Outside Medical Services
DSHS responsible for health care of patients
Difficult to predict
Examples of individual patient medical costs in FY 2008:
Cardiovascular $133,000
End stage renal $334,000
Dialysis $177,000
Pneumonia $148,000
Neck cancer $145,000
Cardiovascular $178,000

9. Other Operating Costs
Examples:
Food
Equipment
Furnishings

10. Mental Health Hospital Funding
Factors, FY
Projected
Salaries $4.5
Drugs $7.8
Medical Services $1.1
Other Operating Costs $6.4
Total $19.8
All numbers are in millions

11. Other Fiscal Issues Health Care Associated Infections
Significant contributor to preventable illness
SB 288: Monitoring and reporting by hospitals and ASCs
Advisory panel recommends infection reporting system developed by the Centers for Disease Control and Prevention

12. Patient Protection and Rights in State Hospitals
Hospitals take responsibility for physical and mental health care of patients
Goals are quality care and safe environment
Accreditation Standards
Prevention first
Pre-employment screening
Initial and annual training
Communicate expectations
Reporting and Investigation
Reporting required
Investigations conducted by outside entities
Response to findings

13. Challenges 6th largest hospital system in Texas
Patients admitted because they are mentally ill and at serious risk of harm to self or others
7,400 employees
Around 18,000 admissions per year
Round-the-clock care

14. Accreditation
All DSHS hospitals are accredited by the Joint Commission
To achieve that, they must meet standards in many areas, including:
Patient rights
Patient safety
Risk management
Clinical care

15. Pre-employment Screening
Criminal background checks conducted prior to hiring and annually thereafter
Drug and alcohol screening prior to hiring and again any time there is reasonable suspicion of abuse
All prospective employees checked on:
Client Abuse and Neglect Reporting System (CANRS)
Nurse Aide Registry
Employee Misconduct Registry

16. Employee Training
Direct care employees are trained before working and annually while working
Preventing and reporting abuse and neglect
Prevention and management of aggressive behavior
Rights of people with mental illness/mental retardation
Appropriate use of restraint and seclusion

17. Reporting Staff required to report suspected abuse/neglect
Patients and families are also encouraged to report
Central posting of phone numbers for external investigating entities
Patient access to telephones
Patients may contact law enforcement

18. Investigations Conducted by outside entities
All reports referred to DFPS through 24 hour hotline
Other entities receive complaints and conduct investigations:
Joint Commission
Advocacy, Inc.
Center for Medicare and Medicaid Services
Law enforcement

19. Definitions of Abuse/Neglect
Class I: Serious physical injury
Class II: Non-serious injury
Class III: Verbal or emotional abuse
Class IV: A negligent act that results in harm

20. Allegations of Abuse/Neglect

21. Confirmed Incidents

22. Response to Findings Confirmed Class I Abuse Confirmed Class II Abuse
automatic termination
Confirmed Class II Abuse  
punishment decided by Superintendent including termination, demotion or suspension
Confirmed Class III Abuse & Neglect
punishment decided by Superintendent including termination, demotion, suspension, or reprimand

23. Continuous Improvement
Maintaining appropriate staffing levels on each shift
Monitoring trends
New National Patient Safety Goals from the Joint Commission
Enhanced education and training on the appropriate use of restraints and seclusion
STARS project grant
Aims to reduce restraint and seclusion
Suicide prevention workgroup
Abuse/neglect data available on website

24. Crisis Services Funding
DSHS requested and received $82 million from the 80th Legislature for the FY08-09 biennium to redesign the public mental health crisis system
FY FY 2009
$27,317,890 $54,682,110

25. Crisis Redesign Goals
Establish better local systems to serve persons in crisis
Reduce utilization of emergency rooms, state hospital and other inpatient beds
Reduce overtaxing of law enforcement resources
Improve consumers’ access to appropriate services

26. Crisis Services Funding
Overview
$56 million to augment basic and enhanced crisis services
$3.5 million for outpatient competency restoration projects
$21.4 million for psychiatric emergency centers, jail diversion and alternatives to hospitalization
$500,000 for external evaluation
$800,000 for contract management, accreditation fees and training

27. Basic Services
$56 million allocated to Local Mental Health Authorities (LMHAs)
Formula took into account
Proportional distribution based primarily on population
Equity contribution provided to LMHAs with below average per capita funding

28. Basic Services Each contract with LMHAs requires:
a 24 hours a day, 7 days a week hotline
staffed by trained crisis counselors who provide information, screening and intervention, and support to callers
accredited by the American Association of Suicidology (AAS)
Mobile outreach services, which operate in conjunction with crisis hotlines and provide emergency care and crisis follow-up in the community

29. Enhanced Services Above the basic services, LMHAs can use funds for:
Extended Observation Services (up to 48 hours): Emergency and crisis stabilization in a secure inpatient setting with access to urgent medical evaluation and treatment
Crisis Stabilization Units (CSUs):
Short-term residential treatment designed to reduce acute symptoms of mental illness

30. Enhanced Services Crisis Residential/Respite (Child and Adult):
Treatment for individuals with high risk of harm and severe
functional impairment who need direct supervision and care but do
not require hospitalization. 
Transportation:
Assistance with transportation costs incurred by local law
enforcement agencies related to behavioral health crises.
Mental Health Deputies/Crisis Intervention Teams:
Assistance to local law enforcement agencies for providing
specialized training for deputies on the recognition of mental illness
and de-escalation of volatile situations

31. Community Investment Incentive
$25 million for FY08 and FY09 awarded on a competitive basis
$21.4 million for Psychiatric Emergency Service Centers with extended observation or jail diversion/alternatives to state hospitalization
Required at least a 25% match
$3.5 million for Outpatient Competency Restoration Services

32. Outpatient Competency Restoration Pilots
In April 2008, DSHS awarded $3.5 million to 5 sites
Tarrant County MHMR
Center for Healthcare Services (San Antonio)
MHMR Authority of Harris County
Austin-Travis County MHMR
North Texas Behavioral Health Authority (NorthSTAR)
SB 867 made changes to the Code of Criminal Procedure that clarified procedures for outpatient alternatives to inpatient competency restoration for certain defendants
These changes will help gain efficiency of resources and free up bed space in state mental hospitals

33. Psychiatric Emergency Centers or Alternatives to State Hospitals or Jails (14 sites selected)
Austin Travis County MHMR
Betty Hardwick Center
Bluebonnet Trails MHMR
Burke Center
Central Plains
El Paso MHMR
Heart of Texas MHMR
Hill Country MHMR
MHMR of Nueces County
MHMR of Tarrant County
Spindletop MHMR
Tri-County MHMR
Tropical Texas MHMR
West Texas MHMR

34. Impact of Crisis Funding
FY 2007
FY 2008
Crisis Residential 9 12
Crisis Respite 10 17
MH Deputy 6 8
Crisis Stabilization 3 7
Extended Observation Units
Crisis Transportation 5
Rapid Stabilization 21
AAS Accredited Hotlines 1 31
Mobile Crisis Outreach Teams 4 38
Outpatient Competency Restoration Programs

35. External Evaluation Rider 69 requires an External Evaluation
Texas A&M selected and has begun work
Focus on the extent to which:
Stakeholders are satisfied with improvements made to the community mental health crisis system
Texans who are experiencing a mental health crisis are served in appropriate settings in a timely manner
Communities have local alternatives that are less restrictive than state hospitals, emergency rooms and jail for resolving mental health crises
Community mental health crisis services are cost-effective