1. 1115 Behavioral Health Waiver Projects: An overview
Molly Lopez, PhD
Stacey Stevens Manser, PhD
Texas Institute for Excellence in Mental Health
University of Texas at Austin

2. Texas Institute for Excellence in MH
Housed in the School of Social Work at UT Austin
We are all about “Advancing Resilience and Recovery in Systems of Care”
Some projects partnering with LMHAs:
Person-Centered Planning – ATCIC, Bluebonnet, Hill Country
Wraparound Coaching – Tarrant Cty, Pecan Valley, CHCS, ATCIC
Peer Support – CHCS, Tarrant Cty, Andrews Cty, BHC Nueces Cty
Suicide Prevention Zero Suicides in Texas – Denton Cty
Veteran’s Jai Diversion and Trauma Recovery – CHCS, ATCIC, Andrews, Bluebonnet, Emergence Health, Harris Cty, Hill Country, Star Care, Tropical Texas
Trauma Informed Care – Heart of Texas, Bluebonnet
System of Care Expansion – CHCS, Tropical Texas

3. Acknowledgements
This project was supported through a grant by The Meadows Foundation.
Project support was provided by TriWest Consulting.
Texas HHSC provided guidance on database structure and facilitated communication with RHPs (HHSC did not sponsor or request the project).
We want to thank Regional Health Partnerships for reviewing elements of the database for accuracy.

4. The Why… The interest is great:
Most significant funding increase for behavioral health services in Texas in decades
The projects chosen by regions provides insight on the needs of local areas
Provides for local innovation and development of best practices
It will be critical to demonstrate good return on investment.
TIEMH’s goal is to document characteristics of the projects undertaken in the state and to provide a useful database to HHSC and other stakeholders.
A report will be issued summarizing the information in the next few months.

5. The How…
Behavioral health projects were identified initially by HHSC and then additional projects added based on key word searches.
Reviewers with behavioral health knowledge were trained on data definitions and coding and reviewed initial proposals to reach adequate reliability.
All proposals were scored and then received a secondary review for reliability by a lead investigator.
RHPs were provided a subset of data elements to review for accuracy.

6. The What…
Data is primarily focused on the 201 projects that were fully approved by CMS in the initial review.
Data may still change prior to the release of the report (currently being reviewed by RHPs).
Reviews are based solely on information provided in the initial CMS proposals. Providers may be doing more than is reflected in the brief proposal and additional specification may have occurred during the planning year.
Some data elements are more subjective. They are coded when reasonable assumptions could be made.

7. CMS Project Status Initially approved With priority technical issues 8
Initially approved
RHP
Partnership
Full
With priority technical issues
With valuation adjust-ments
Not approved at this time
Total # RHP Projects
% of All Plans 1
Anchor: University of Texas Health Science Center - Tyler 12 8 3 24
6.0% 2
Anchor: University of Texas Medical Branch at Galveston 7 17 28
7.0%
Anchor: Harris County Hospital District 11 13
50*
12.5% 4
Anchor: Nueces County Hospital District 14 6 21
5.3% 5
Anchor: Hildago County (South Texas) 18
4.5%
Anchor: University Health System (San Antonio) 20 35
8.8%
Anchor: Healthcare District (Austin) 22 9 39
9.8%
Anchor: Texas A&M Health Science Center (Round Rock) 16 25
6.3%
Anchor: Dallas County Hospital District 10
Anchor: JPS Health Network (Ft. Worth) 29
7.3%
Anchor: Palo Pinto General Hospital (Mineral Wells)
2.5%
Anchor: Lubbock County Hospital District
5.5%
Anchor: McCulloch County Hospital District (Brady)
2.8%
Anchor: Medical Center Health System (Odessa)
1.5% 15
Anchor: University Medical Center of El Paso
1.8%
Anchor: Coryell Memorial Hospital (Gatesville)
3.5%
Anchor: Texas A&M Health Science Center (College Station)
2.0%
Anchor: Collin County (Collin, Grayson & Rockwall)
4.0% 19
Anchor: Electra Hospital District
Anchor: Webb County Indigent Health Care Services (Laredo)
All
All RHPs
201 86 59 53
400
100.0%
Most projects: Region 3 (Houston), Region 7 (Austin), and Region 6 (San Antonio)
Fewest projects: Region 14 (Odessa), Region 15 (El Paso), Region 20 (Laredo), and Region 17 (College Station)

8. Approved RHP Projects by Category and Goal
Number
Percent
Category 1 Projects: Infrastructure
106
52.7%
Category 1 - Goal Number and Description
1.12
Enhance service availability to appropriate levels of BH care 36
17.9%
1.13
Development of BH crisis stabilization services 24
11.9%
1.9
Expand specialty care 15
7.5%
1.11
Implement technology assisted services to support or deliver BH services 11
5.5%
1.7
Introduce, expand, or enhance telemedicine/health 10
5.0%
1.10
Enhance performance improvement and reporting capacity 4
2.0%
1.1
Expand primary care capacity 3
1.5%
1.14
Develop workforce enhancement initiatives to support access to BH providers in underserved areas 2
1.0%
1.3
Implement a chronic disease management registry 1
0.5%
Category 2 Projects: Program Innovation or Redesign 95
47.3%
Category 2 – Goal Number and Description
2.13
Provide an intervention for a targeted BH population to prevent unnecessary services in other settings 43
21.4%
2.15
Integrate primary and BH care services 23
11.4%
2.9
Establish/expand a patient care navigation program 7
3.5%
2.18
Recruit, train, and support consumers of MH services to provide peer support services
2.19
Develop care management function that integrates PH and BH needs of individuals 6
3.0%
2.16
Provide virtual psychiatric and clinical guidance to PCPs delivering BH care
2.2
Expand chronic care management models
2.17
Establish improvements in care transition from the inpatient setting for MH/SA patients
2.3
Redesign primary care
.5%
2.12
Implement/expand care transitions programs
Category 1 represents Infrastructure projects and Category 2 represents Program Innovation or Redesign projects
Fairly evenly distributed across both types of proposals
1.12 Enhance service availability and (expand capacity, include non-priority population consumers, add substance abuse services, create a new clinic)
1.13 Development of BH crisis stabilization (more detail to come) most common
Cat 2
2.13 Provide intervention for BH population to prevent unnecessary services (targeted services to homeless population, crisis follow-up, comprehensive systems for targeted populations, Trauma Informed Care, COPSD, Veterans programs)
2.15 Integrate BH and PH care most common
Chronic disease management registries and care transition programs were not common

9. Age and Population of Focus
Age of Population 
Number
Percent
General Adult Population (18 and older)
184
91.5%
General Child Population (0 to 17) 73
36.3%
Early Childhood (0 to 5) 3
1.5%
Adolescents (12 to 17) 2
1.0%
Transition Age Youth (18 to 25)
Older Adults (65 and older)
Population of Focus
Serious Mental Illness (SMI/Adult)
116
57.7%
General Mental Health (non SMI/SED) 65
32.3%
Severe Emotional Disturbance (SED/Child) 43
21.4%
Substance Use Disorders 42
20.9%
Medical Population 36
18.0%
Intellectual or Developmental Disabilities (other than autism) 23
11.4%
Autism 16
8.0%
Criminal Justice 7
3.5%
Homeless 6
3.0%
Veterans 4
2.0%
High Utilizers of Emergency Care (non-specific population)
.5%
A subset of the adult projects included children in the overall project as well (n=59; 29.4%) or were unclear about whether children were included or excluded (n=36; 17.9%). Fourteen projects (7.0%) focused exclusively on a general child population.

10. Settings for Care Settings for Care Number Percent
Local Mental Health Authority (LMHA)
161
80.1%
Mental Health Clinic (non-LMHA) 6
3.0%
Federally Qualified Health Clinic (FQHC) 7
3.5%
Primary Care Clinic (non-FQHC) 23
11.4%
General Medical Hospital 26
12.9%
General Medical Hospital – Psychiatric Unit 5
2.5%
Psychiatric Hospital 3
1.5%
Substance Abuse Clinic (non-LMHA)
Ambulatory Detoxification Clinic 1
0.5%
Homeless Shelter/Facility 2
1.0%
School
County Health and/or Human Services
County Jail

11. Types of New Staffing Staffing Number Percent
Licensed mental health practitioner (Psych, LPC, LMSW, LCSW) 56
36.4%
Administrative staff 32
20.8%
Psychiatrist(s) 31
20.1%
Nurse(s)
Qualified mental health practitioner 23
14.9%
Peer specialist 19
12.3%
Physician(s) (non-psychiatrist) 17
9.1%
Licensed chemical dependency counselor
1.5%
Advanced Nurse Practitioner 15
3.0%
Community health worker or promotoro/a 7
4.5%
Certified Behavior Analyst 6
3.9%
Health Information Technology staff 5
3.2%
Telepresenters
154 of the 201 projects indicated new staff
A variety of other staff that could not be classified or rare

12. Evidence-based/Promising Practices
Identified Evidence-Based or Best Practice = 72
Assertive Community Tx - 11
Cognitive Behavioral Therapy - 8
Cognitive Processing Therapy - 8
Whole Health and Resilience – 7
Applied Behavioral Analysis - 7
Supported Employment – 6
Recovery Supports - 6
Seeking Safety - 5
SBIRT - 4
Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) – 4
Motivational Interviewing – 3
Integrated Dual Diagnosis Tx - 3
Wellness Recovery and Action Planning - 2
All the following were identified in 1 proposal:
Cognitive Adaptive Therapy
Electroconvulsive Therapy
Individualized Self Health Action Planning for Empowerment
Cognitive Enhancement Therapy
Wraparound Planning
Functional Family Therapy
Aggression Replacement Therapy
George Real Choice Systems Change Model
Brazelton Touchpoints
Most proposals did not specify EBPs or discussed selecting evidence based models or interventions in the first year. The most common EBPs mentioned were those currently familiar in the system, such as ACT, CBT, Supported housing, CPT.

13. Technology Projects Technology Development or Use = 62 Technology Type
BH Focus
Medical Focus
Telemedicine or telehealth system 36 5
Electronic Health Record System (new or enhanced) 11
Data Portals or Data Sharing 6 3
Data tracking or data dashboard system
CET Computer Based Intervention 1
Tele-consultation
Development of technology was a common component to proposals, with telehealth system and enhanced EHRs most common

14. Crisis Services Enhanced Crisis Services = 54 Crisis Service Type
General BH
Specialty Population
Crisis Stabilization Unit 8 6
Crisis Telehealth 9 2
Mobile Crisis Outreach Team
Crisis Respite
Peer Provided Crisis Services 1
Tele-consultation
Crisis Triage or Psychiatric Emergency Services Unit 5
Psychiatric Consultation in ER 3
In-Home Crisis Supervision
Other

15. Integrated Care Project Focus Number Percent MH Only 122 60.7%
Comorbid BH and PH 65
32.3%
Comorbid MH and SA 31
15.5%
SA Only 30
14.9%
Unspecified BH 26
12.9%
Comorbid IDD and BH 22
11.0%
IDD Only 6
3.0%
Comorbid IDD and PH 5
2.5%
Projects can utilize multiple quadrants
BH & PH Quadrant
Number
Percent
Q1 (Low BH/Low PH) 14
21.5%
Q2 (Hi BH/Low PH) 39
60.0%
Q3 (Low BH/Hi PH) 10
15.4%
Q4 (Hi BH/Low PH) 9
13.8%
MH & SA Quadrant
Number
Percent
Q1 (Low MH/Low SA) 7
22.6%
Q2 (Hi MH/Low SA) 11
35.5%
Q3 (Low MH/Hi SA) 5
16.1%
Q4 (Hi MH/Low SA)
Note: Some projects serving more than one quadrant.

16. Non-LMHA BH Projects 40 projects did not involve the LMHA
These primarily involved a general hospital (45%) and/or a primary care clinic (35%)
Common projects
Add behavioral health staff to clinic
Integrated BH and PH
Telemedicine
Crisis services
Intensive outpatient or partial hospitalization
Patient navigation
Training program expansion (nursing and psychiatry)

17. Indices of Impact
Average # Served is 1171

18. Reflections and Discussion
Opportunities for Collaboration
Opportunities for Evaluation
Opportunities for Communication
What do you hope that stakeholders learn about the behavioral health projects?
Do you have any concerns about this or other efforts to learn about the work?
How can state partners support the success of this work?