1. Andy Keller, PhD | Nelson Jarrin, JD | January 14, 2019
MMHPI Policy Briefing: Opportunities to Advance Texas Behavioral Health Policy
Andy Keller, PhD | Nelson Jarrin, JD | January 14, 2019

2. Meadows Mental Health Policy Institute
Mission Statement
To provide independent, non-partisan, and trusted policy and program guidance that creates systemic changes so all Texans can obtain effective, efficient behavioral health care when and where they need it.
Vision
We envision Texas to be the national leader in treating people with mental health needs.

3. Opportunities to Advance Texas Behavioral Health Policy
Build on our accomplishments.
Intervene early to address the mental health needs of Texas children.
Fight mental illness like we fight cancer.

4. 1. Build on our accomplishments

5. Build on Our Accomplishments
The Texas Legislature has worked systematically to eliminate waitlists, maintain a minimum hospital safety net, redesign our crisis systems, and make investments for targeted populations (e.g., homeless, veterans).
The 85th Texas Legislature increased behavioral health funding by $749.3 million (AF).
The 2018–19 General Appropriations Act appropriates over $7.6 billion (AF) for behavioral health.
We must maintain and build on the work of the Texas Legislature and Texas communities to strengthen and transform our mental health system.

6. 85(R) SB 292
SB 292 (Huffman, Nelson, Schwertner) created the Mental Health Grant Program for Justice-Involved Individuals.
GOAL – to reduce: (1) recidivism rates, arrests, and incarceration for people with mental illness; and (2) the wait time for forensic commitments of people with mental illnesses to a state hospital.
FUNDING – $12.5 million in fiscal year (FY) 2018 and $25 million in FY 2019, plus $5 million per fiscal year for Harris County.
APPLICANTS must be a county-based community collaborative consisting of a county, a local mental health authority serving the county, and each hospital district, if any, located in the county.

7. 85(R) HB 13
HB 13 (Price) created the Community Mental Health Grant Program.
GOAL – to support community mental health programs that provide services and treatment to people experiencing mental illnesses.
FUNDING – $10 million in FY 2018 and $20 million in FY 2019.
APPLICANTS must be a nonprofit or governmental entity (e.g., city, school district, institution of higher education).

8. Progress Thus Far – SB 292 (Urban)
January (Urban Grant Awards): 14 awardees
My Health My Resources of Tarrant County

9. Progress Thus Far – SB 292 (Rural)
August 2018 (Rural Grant Awards): 10 awardees, which cover a total of 31 counties with a population of less than 250,000 people.

10. Progress Thus Far – HB 13 85(R) HB 13 Announcements for FY 2018-19
January 2018: 25 awardees, which include 16 rural service areas.
May 2018: 31 awardees, which include seven rural service areas.
My Health My Resources of Tarrant County
National Alliance on Mental Illness – Tarrant County and multiple additional counties

11. 84(R) SB 55
SB 55 (Nelson) created the Texas Veterans + Family Alliance Grant Program.
GOAL – to support community mental health programs that provide and coordinate mental health services and treatment for Texas veterans and their families.
FUNDING – $20 million in FY 2018 with authority to carry forward unexpended balances to FY 2019.
APPLICANTS must be a community program that demonstrates a commitment to addressing mental health needs of veterans and their families.
Equest – Tarrant County and multiple additional counties
Recovery Resource Council – Tarrant County and multiple additional counties
University of Texas Health Science Center at San Antonio – Tarrant County and multiple additional counties

12. 86(R) Grant Funding Opportunities
Fund 85(R) SB 292 at $60 million for the FY 2020— 21 biennium: $25 million for each fiscal year, plus $5 million per fiscal year for Harris County.
Fund 85(R) HB 13 at $40 million for the FY 2020— 21 biennium: $20 million for each fiscal year.
Fund 84(R) SB 55 at $20 million for the FY 2020— 21 biennium.
For SB 292 and HB 13, see HHSC Exceptional Item 37.

13. State Hospital System
We need to replace aging state hospitals with state-of-the-art medical facilities optimally positioned to serve people well and support transitions out of care back to where they live.
Austin State Hospital (1861)
Big Spring State Hospital (1938)
North Texas State Hospital –
Wichita Falls Campus (1922)
El Paso Psychiatric Center (1996)
Rusk State Hospital (1919)
Kerrville State Hospital (1951)
San Antonio State Hospital (1892)
Vernon Campus (1969)
Terrell State Hospital (1885)
Rio Grande State Center (1962)
Waco Center for Youth (1919)

14. State Hospital Catchment Areas

15. State Hospital System Transformation
The 85th Texas Legislature appropriated $300 million for new state hospital planning and construction. This is Phase I of a three-phased approach to improve the state hospital system in the current and future biennia.

16. Phase II Transformation Opportunities
Fund Phase II of the state hospital system transformation at an amount to be determined (at least $300 million).
Potential Opportunities
Austin State Hospital construction
San Antonio State Hospital construction
Planning for a potential hospital in the Dallas area
Planning for a potential hospital in the Texas Panhandle
Construction of a 100-bed unit at Rusk State Hospital
See HHSC Exceptional Item 8.

17. 2. INTERVENE EARLY TO ADDRESS THE MENTAL HEALTH NEEDS OF TEXAS CHILDREN

18. Needs Among Texas Children and Youth
Specific subsets are at higher risk:
20,000 children and youth with the most severe needs and the fewest economic and family resources
900 youth with new psychotic disorders each year are at the highest risk (15 times more likely to commit homicide if untreated)

19. The Progression of Mental Health Conditions
Half of all mental health conditions manifest by age 14; interventions work best at this early stage when symptoms are less severe, more treatable, and more readily prevented from escalating to more dangerous conditions that increase risk.
By young adulthood, 75% of lifetime cases have presented.
Early Detection, Intervention
Appropriate Treatment

20. The Ideal Mental Health System for Children
THREE KEY COMPONENTS:
Helping local schools identify needs and link to help:
Early, before situations become harder to treat; and
Fast, when a severe need arises and expertise is essential to maintain safety and functioning;
Helping pediatric primary care providers find and treat mental illness early when it is mild to moderate; and
Making intensive treatment available to children and youth with the most severe needs, quickly, when needs emerge.

21. 1. Helping Local Schools Get Expert Evaluation
All schools need someone to coordinate identification and linkage (“liaisons”). This role can be filled by school counselors with dedicated time to address mental health concerns, school- based clinics, Communities In Schools, and others.
When a severe need arises, schools must be able to get expert evaluation on the scene quickly, and teachers and staff need rapid access to reliable advice and care.
A few Texas schools have mental health experts on site, but that solution is not feasible for most schools and no single expert can answer every question.
Telemedicine offers the infrastructure to fill the gaps in expertise.

22. 86(R) Funding Opportunities
The Texas Education Agency (TEA) Legislative Appropriations Request (LAR) proposes the Safe and Healthy Schools Initiative as their highest priority exceptional item.
$52.5 million in grant funding is requested for FY 2020.
The Initiative is grounded in four primary pillars: 1) Mental Health Supports; 2) Positive School Culture; 3) Facility Safety; and 4) Emergency Response Coordination.
85(R) HB 13 (Community Mental Health Grant Program) supports community mental health programs that provide services and treatment to people experiencing mental illness. School districts may apply.
Mental Health Supports includes access to counseling resources, mental health professional networks, threat assessment protocols, and teacher and administrator training on mental health needs.
Positive School Culture includes character education, positive behavior supports and interventions, trauma-informed education, restorative discipline practices, suicide prevention, resiliency, anti-bullying, and anti-cyber-bullying. This would include programs to encourage student, family, school staff and community engagement on these issues.

23. 86(R) SB 63: Texas Mental Health Care Consortium
Senator Nelson filed SB 63 on November 12, 2018, the first day to pre-file legislation for the 86th Legislative Session.
ESTABLISHES a consortium of state-funded medical schools.
GOAL – to coordinate the expansion and delivery of mental health care services by using the infrastructure and expertise of state-funded medical schools and community providers.
FOCUS – children and youth with behavioral health needs.
86(R) SB 63 proposes the use of telemedicine and telehealth programs to identify and assess behavioral health needs and provide access to mental health care services.

24. 2. Leveraging Pediatric Primary Care Providers
75% of children with mental health issues who receive care are treated in a primary care setting (family doctor, pediatrician).
With the right early support, most would not need a specialist.
In addition to routine care, pediatric primary care is key to early identification, referral, & coordination for higher risks.
Over a decade of research demonstrates that primary care providers can treat behavioral health issues as they would any other health issue – treating mild and moderate cases and detecting the more complex or severe cases for specialists.
Limited time during each visit
Minimal training and a lack of confidence in knowledge of behavioral health disorders
Limited capacity to link cases to needed specialists and behavioral health consultation
Current Barriers

25. Leveraging Primary Care: Child Psychiatry Access Programs (CPAP)
Nearly 30 states have implemented CPAP programs.
The Massachusetts Child Psychiatry Access Program, established in 2004, is the longest-running program.
A statewide system of regional children’s behavioral health consultation and referral hubs located at academic medical centers.
Each hub can expand over a few years to support the primary care needs of 500,000 children and youth.
Once fully operating, the cost is $2 a year per child.

26. CPAP Opportunity
In response to Hurricane Harvey, local philanthropy funded CPAP prototypes in Harris County and the surrounding region that were developed by Baylor College of Medicine, UTHealth Houston, Texas Children’s Hospital, and Harris Health. Children’s Health in Dallas also has a long-standing project.
Philanthropy alone cannot sustain this initiative.
86(R) SB 63 (Nelson) establishes a network of CPAP hubs across Texas through state-funded medical schools.
Fund the network at $5 million in FY 2020 and $10 million in FY 2021.

27. 3. Making Intensive Treatment Available
About 20,000 children and youth each year need intensive treatment because of severe behavioral dysfunction.
They do not all need the same treatment.
Highest risk of harming others: About 900 Texas youth who first experience an episode of psychosis (FEP) each year.
Psychosis is characterized by hallucinations and delusions.
Those with untreated psychosis are 15 times more likely to commit homicide. Effective treatment decreases the risk.
They also have a dramatically elevated risk of suicide and other mortality: 24 times the risk for their peers.
Today, treatment is delayed for five years post-onset.

28. Treating Psychosis: Coordinated Specialty Care
Coordinated Specialty Care (CSC), a team-based approach, starts assertive and intensive treatment as soon after the initial psychosis as possible.
Texas currently has 12 Coordinated Specialty Care teams located at 10 community centers across the state.
Expected caseload for each team is 30.
Texas should at least expand Coordinated Specialty Care programs for all youth ages (900 new cases a year).
My Health My Resources of Tarrant County is one of these 10.

29. CSC Expansion Opportunity
Last year, the Substance Abuse and Mental Health Services Administration increased the Mental Health Block grant award to the Health and Human Services Commission (HHSC).
HHSC is using $3.7 million of this increase to fund Coordinated Specialty Care expansion in FY 2019.
Teams will be located at 22 community centers in FY 2019.
The HHSC Legislative Appropriations Request (LAR) is seeking $7.9 million in both FY 2020 and FY 2021 (GR) to fund Coordinated Specialty Care expansion (Item 19).
These appropriations are scalable as each new team would cost approximately $400,000 per year.
See HHSC Exceptional Item 19.

30. 3. FIGHT MENTAL ILLNESS LIKE WE FIGHT CANCER

31. Texas Mental Health Research Framework
MMHPI prepared the Texas Mental Health Research Framework upon the request of the chairs of academic departments of psychiatry and behavioral health leaders in state government.
OBJECTIVE – to promote synergistic collaborations in mental health and substance use disorder research across Texas university systems and to advance the research component of the Texas Statewide Behavioral Health Strategic Plan. 
FOCUS AREAS – (1) depression; (2) first episode psychosis; (3) substance use disorder; (4) bipolar disorder and schizophrenia; and (5) community systems research.

32. 86(R) SB 63 Texas Mental Health Care Consortium
86(R) SB 63 (Nelson) also includes a research component.
The Consortium is directed to:
Develop and implement a mental health research plan;
Create an aggregated inventory of mental health and substance use disorder research completed by institutions of higher education in Texas; and
Coordinate mental health and substance use disorder research efforts by state-funded medical schools to ensure those institutions engage in effective and targeted research, which can be used as leverage for additional funding.

33. Additional Opportunities to Advance Texas Behavioral Health Policy
Build on momentum created by the Texas Judicial Council’s Mental Health Committee.
Do more to address Texas’s behavioral health workforce emergency.
Address the tragic impacts of opioids and other substance use on Texans, their families, and their communities.
MMHPI will support Sunset Advisory Commission omnibus legislation – Texas Behavioral Health Executive Council
Senator Nelson filed legislation (SB 63) to enhance collaboration between health-related institutions and community mental health providers to increase psychiatry residency training opportunities.
MMHPI will support the THECB’s base Legislative Appropriations Request (LAR) of $97M to maintain psychiatry residency slots as well as a $60,675,000 exception item to expand residency slots to achieve a 1.1 to 1 ratio (1.1 residency slots to every 1 Texas medical school graduate). See THECB Exceptional Item 10
In May 2017, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded HHSC $27.4 million per year for two years, known as the Texas Targeted Opioid Response (TTOR). TTOR will allow HHSC to expand prevention, early intervention, and treatment efforts for people at high risk for OUD and end April 2019.
In October 2018, SAMHSA awarded HHSC $46.2 million to support a comprehensive response to opioid misuse in Texas, known as the State Opioid Response (SOR). The grant will be funded annually for the next two years. Funds will be used to expand access to treatment and recovery support services and provide increased access to MAT.

34. The truth is: mental illness affects more people than you may think, and we need to talk about it. It’s Okay to say…”  okaytosay.org