1. 1 Mental Health System Update Senate Finance Committee Tuesday, May 20, 2008 David L. Lakey, MD Commissioner

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

3. 3 Mental Health Hospital Funding Projected shortfall, FY 2008-9 –$19.8 million Contributing Factors –Staffing –Medications –Medical costs –Operating costs

4. 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. 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. 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 2005-07) –64% of hospital employees are clinical staff

7. 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. 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. 9 Other Operating Costs Examples: –Food –Equipment –Furnishings

10. 10 Mental Health Hospital Funding Factors, FY 2008-9 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. 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. 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. 13 Challenges 6 th 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. 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. 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. 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. 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. 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. 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. 20 Allegations of Abuse/Neglect

21. 21 Confirmed Incidents

22. 22 Response to Findings Confirmed Class I 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. 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 –http://www.dshs.state.tx.us/mhreports/PIMHpub.shtm

24. 24 Crisis Services Funding DSHS requested and received $82 million from the 80 th Legislature for the FY08-09 biennium to redesign the public mental health crisis system FY 2008FY 2009 $27,317,890$54,682,110

25. 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. 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. 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. 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. 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. 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. 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. 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. 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. 34 Impact of Crisis Funding FY 2007FY 2008 Crisis Residential912 Crisis Respite1017 MH Deputy68 Crisis Stabilization37 Extended Observation Units38 Crisis Transportation510 Rapid Stabilization1721 AAS Accredited Hotlines131 Mobile Crisis Outreach Teams438 Outpatient Competency Restoration Programs17

35. 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