1. Harris County Behavioral Health Policy Efforts David S. Buck, MD, MPH Karen Love, MHA February 2007 Harris County Behavioral Health Policy Efforts David S. Buck, MD, MPH Karen Love, MHA February 2007

2. The Need Harris County jail processed 93,921 unduplicated inmates in the year ending November 2006 24% of inmates have a diagnosable mental illness – about half of whom have a serious, disabling mental illness 2.5% of inmates (~2500) are homeless and half of them also have a mental illness Harris County jail processed 93,921 unduplicated inmates in the year ending November 2006 24% of inmates have a diagnosable mental illness – about half of whom have a serious, disabling mental illness 2.5% of inmates (~2500) are homeless and half of them also have a mental illness

3. The Need Inmates are often released without advance notice to case managers, making discharge planning problematic Inmates are often released in the middle of the night with no medication Inmates are often released without advance notice to case managers, making discharge planning problematic Inmates are often released in the middle of the night with no medication

4. The Need Upon release, MHMRA patients may be referred to the Eligibility Center for assessment and continuation of care, but often do not follow through due to various circumstances including: Lack of transportation Lack of ID (TDL, Birth Certificate, SS etc.) Lack of proof of income and/or insurance Upon release, MHMRA patients may be referred to the Eligibility Center for assessment and continuation of care, but often do not follow through due to various circumstances including: Lack of transportation Lack of ID (TDL, Birth Certificate, SS etc.) Lack of proof of income and/or insurance

5. The Need An inmate with mental illness and/or disability is more likely to be subsequently arrested and charged with another offense, face a more serious charge, stay twice as long in jail and incur more jail time for an equivalent offense (Nguyen, 2005).

6. Silos of Care County Jail MHMRA Harris County Hospital District Social Service Agences CPS Community Clinics Private BH Providers County Jail MHMRA Harris County Hospital District Social Service Agences CPS Community Clinics Private BH Providers

7. Other Factors Harris County growing rapidly – resources not keeping pace 30% uninsured The behavioral health care system strained changes in reimbursement requirements private insurance priorities reduction in psychiatric beds & services… Harris County growing rapidly – resources not keeping pace 30% uninsured The behavioral health care system strained changes in reimbursement requirements private insurance priorities reduction in psychiatric beds & services…

8. Community Consensus Patients with high priority needs face increasing difficulty in accessing services Government, social services, public safety, physical and BH providers and advocates agree – access and service delivery system must be addressed Change is a priority for the community Patients with high priority needs face increasing difficulty in accessing services Government, social services, public safety, physical and BH providers and advocates agree – access and service delivery system must be addressed Change is a priority for the community

9. Identifying Principles for Improving the Harris County Behavioral Health System

10. Phase I: Health Indicators Model for interventions to improve population health Can serve as a basis for developing community goals Adopted by the Council in November 2005 Model for interventions to improve population health Can serve as a basis for developing community goals Adopted by the Council in November 2005

11. Phase I: Health Indicators www.hcphsc.hctx.net/ReferenceMaterial.asp

12. Phase I: Health Indicators (cont’d)

14. BH Performance Indicators Overview: Interviews To identify principles, expectations, standards of care, and outcomes Literature review Investigate literature referenced in interviews Create Harris County Behavioral Healthcare Report Card Create mechanism for reporting modeled from healthcare indicator project Overview: Interviews To identify principles, expectations, standards of care, and outcomes Literature review Investigate literature referenced in interviews Create Harris County Behavioral Healthcare Report Card Create mechanism for reporting modeled from healthcare indicator project

15. Phase II: Provider Interviews What are the principles, expectations, standards of care, and outcomes important to evaluating and defining an accountable behavioral healthcare system? Summary of themes that emerged from these interviews: What are the principles, expectations, standards of care, and outcomes important to evaluating and defining an accountable behavioral healthcare system? Summary of themes that emerged from these interviews: Harris County Interviews Access Social acceptability of mental illnesses Use of community psychiatry literature that identifies principles and ways to measure outcomes Prevention / Screening Need for evaluation Assess quality of care Several outcomes measures Parity for mental and physical treatment

16. Methodologies in the Literature Literature search conducted in community & adolescent psychiatry to look for systems of care that have evaluation tools on behavioral health MHSIP (Mental Health Statistics Improvement Program): Specifically designed to assess consumer concerns with treatment, not merely global satisfaction with mental health services. Report card with domains, concerns, indicators, and measures Indicators included: 1) objective measures of provider's commitment to mental healthcare 2) consumer assessment of the convenience, appropriateness, and outcomes of the services the system supports Literature search conducted in community & adolescent psychiatry to look for systems of care that have evaluation tools on behavioral health MHSIP (Mental Health Statistics Improvement Program): Specifically designed to assess consumer concerns with treatment, not merely global satisfaction with mental health services. Report card with domains, concerns, indicators, and measures Indicators included: 1) objective measures of provider's commitment to mental healthcare 2) consumer assessment of the convenience, appropriateness, and outcomes of the services the system supports

17. Phase II: BIG THANKS Jack Callahan, JD Sarah Flick, MD Thomas Gavagan, MD Mary Lou Heater, RN, NP Sylvia Muzquiz, MD Fred Ramirez Pauline Rosenau, PhD John Sargent, MD Kim Szeto Stephen Williams Jack Callahan, JD Sarah Flick, MD Thomas Gavagan, MD Mary Lou Heater, RN, NP Sylvia Muzquiz, MD Fred Ramirez Pauline Rosenau, PhD John Sargent, MD Kim Szeto Stephen Williams John Burruss, MD Avrim Fishkind, MD Sylvia Fitzgerald Andrew Harper, MD Lois Moore, PhD Tuan Nguyen, PhD Sonja Randle, MD Joe Rubio, PhD Steve Schnee, PhD Mel Taylor, MSW

18. Draft Principles

19. Selected Implications of Report Card: Explore options for aligning resources more effectively Common eligibility Common set of utilization management tools consumer and family involvement in treatment planning and treatment decisions effective strategies for reducing admissions and long term use of incarceration and institutionalization and their offsetting costs Explore options for aligning resources more effectively Common eligibility Common set of utilization management tools consumer and family involvement in treatment planning and treatment decisions effective strategies for reducing admissions and long term use of incarceration and institutionalization and their offsetting costs

20. Phase III: Structuring for Success Technical Assistance Collaborative engaged: On-site environmental scan/system review Develop strategic option analyses Develop legislative proposal for transformation? Initial Report Due March 1 st Technical Assistance Collaborative engaged: On-site environmental scan/system review Develop strategic option analyses Develop legislative proposal for transformation? Initial Report Due March 1 st

21. David Buckdbuck@bcm.tmc.edu Karen Lovekaren_love@hctx.net David Buckdbuck@bcm.tmc.edu Karen Lovekaren_love@hctx.net Contact Information