1. Crisis Services Redesign Implementation Overview Texas Department of State Health Services Mental Health & Substance Abuse Division August 2, 2007

2. Crisis Services Funding REQUESTED: DSHS requested $82 million from the 80 th Legislature to make significant progress toward improving the response to behavioral health crises AWARDED: Through the Legislature and Rider 69, $82 million was appropriated over the FY08-09 biennium to redesign the crisis system

3. Crisis Services Funding, cont’d. $27.3 million will be allocated in FY 08 $54.7 million will be allocated in FY 09 Additional funds will be requested to the 81st Legislature It is expected that new funds will be used to improve the current crisis services provided and not replace the current services

4. Allocation of Crisis Services Funding Equity Contribution: Approximately 32% of the funds will be used to improve equity in state funds among LMHAs that have below average per capita funding levels Proportional Allocation: Approximately 36% will be divided proportionally among LMHAs based primarily on local service population.

5. Allocation of Crisis Services Funding, cont’d. Community Investment Incentive: Approximately 30% of the funds will be offered through a competitive process to communities willing to invest significant local resources in the development of Psychiatric Emergency Hub Sites (26%) and Outpatient Competency Restoration Services (4%).

6. Initial Crisis Services: Hotline Every LMHA will be required to provide a continuously available telephone service staffed by trained crisis counselors that provides information, screening and intervention, and support to callers 24 hours per day, 7 days per week. Hotlines must be accredited by the American Association of Suicidology (AAS)

7. Initial Crisis Services: Mobile Outreach Mobile Outreach Services are a combination of crisis services that provide emergency care, urgent care, and crisis follow-up in the child, adolescent, or adult’s community location Current mobile outreach services can be improved with new crisis funds to add team members, to work with law enforcement (MH Deputy/Crisis Intervention Team programs), or provide transportation (as needed)

8. Enhanced Crisis Services Once initial crisis service requirements are satisfied, additional services may be developed or improved upon, to include: Children’s Outpatient Crisis Services: Community-based outpatient services tailored to the needs of children and adolescents, providing immediate screening and assessment and brief, intensive interventions focused on resolving a crisis and preventing admission to a more restrictive level of care Walk-In Services: Office-based outpatient services for adults, children and adolescents providing immediate screening and assessment and brief, intensive interventions focused on resolving a crisis and preventing admission of a more restrictive level of care

9. Enhanced Crisis Services, cont’d. Extended Observation Services (up to 48 hours): Emergency and crisis stabilization services provided to individuals in a secure and protected, clinically staffed (including medical and nursing professionals), psychiatrically supervised treatment environment with immediate access to urgent or emergent medical evaluation and treatment Crisis Stabilization Units (CSUs): Short-term residential treatment (up to a stay of 14 days) designed to reduce acute symptoms of mental illness provided in a secure and protected, clinically staffed, psychiatrically supervised treatment environment that complies with a CSU licensed under Chapter 577 of the Texas Health and Safety Code and Title 25, Part 1, Chapter 411, Subchapter M of the Texas Administrative Code

10. Enhanced Crisis Services, cont’d. Crisis Residential/Respite (Child and Adult): Crisis residential services treat individuals with high risk of harm and severe functional impairment who need direct supervision and care but do not require hospitalization. Length of stay is generally less than one week. Transportation: Funding used to help defray transportation costs incurred by local law enforcement agencies related to behavioral health crises Mental Health Deputies/Crisis Intervention Teams: Funding used to assist local law enforcement agencies in providing specialized training for deputies on the recognition of mental illness and de-escalation of volatile situations

11. Community Investment Incentive Community Investment Incentive Funds will be available through a competitive process to provide:  Psychiatric Emergency Centers (Hub Sites)  Outpatient Competency Restoration Services

12. Psychiatric Emergency Centers (Hub Sites) All LMHAs or communities will be eligible to apply for funds to establish “Hub Sites” Up to 6 sites will be funded and selected in Q3 FY08; operational in Q4 FY08 Elements of Hub Sites will include:  Extended Observation Services (up to 48 hours)  Inpatient services in a Crisis Stabilization Unit (CSU) or hospital for up to 14 days

13. Outpatient Competency Restoration Services Senate Bill 867 allows for development and implementation of an Outpatient Competency Restoration program to enhance the ability of local communities to provide effective treatments and competency restoration programming to appropriate individuals with mental illness identified by the courts as incompetent to stand trial Funds will be allocated for up to 4 sites by Q3 FY 08 All LMHAs will be eligible to compete for services Design and implementation will be based on local and state needs related to providing alternatives to competency restoration and the demand for services to individuals that do not require inpatient settings.

14. Competency Restoration Services, cont’d. Outpatient competency restoration allows some individuals determined Incompetent to Stand Trial receive evidence-based and necessary services from community providers. Proposed goals are:  Providing alternatives to inpatient competency restoration services for persons who do not need inpatient care  Decreased costs of housing forensic patients/inmates in state hospital system and jails  An effective, evidence-based program providing stabilization of symptoms for individuals and less recidivism into inpatient levels of care or jail system

15. Crisis Service Local Planning The Crisis Service Plan will require a detailed description of the current crisis response systems in addition to details of how any additional funding will enhance the current systems. Community stakeholders are a vital part of the local planning process and will be key in successful implementation of crisis services.

16. Community Stakeholders Involved  Client representatives  Client family member representatives  Child and adult advocates  Mental health service providers  Emergency healthcare providers  local public healthcare providers (i.e., Federally Qualified Health Centers, local health departments, etc)  Law enforcement representatives from each jurisdiction in the local service area  Probation and parole department representatives  Judicial representatives from each county in the local service area  Outreach, Screening, Assessment and Referral (OSAR) provider(s) serving the counties in the local service area  Substance abuse service providers  Others deemed appropriate by the LMHA. (e.g. concerned citizens, representatives from the private sector)

17. Crisis Services Implementation: Timeline  Release of Performance Contract Amendment to LMHAs:  September 2007  Return of Crisis Service Plan to DSHS from LMHAs:  October 2007  New local crisis redesign services begin:  December 2007

18. Measuring Accountability Rider 69 outlines the options of reporting requirements from DSHS to the Legislative Budget Board (LBB) and the Governor on the implementation of crisis services DSHS will add Performance Measures to the Performance Contract Amendment on Crisis Services for all LMHAs

19. Proposed LBB Measures No.LBB MeasureDefinition 1Number of New Psychiatric Emergency 23/48 Hour Observation Sites The number of new psychiatric emergency 23/48 hour observation sites at Community Mental Health Centers paid from DSHS funding sources. 2Number of Persons Receiving 23/48 Hour Observation, Mobile Outreach, and/or Children’s Crisis Outpatient Services The number of persons receiving 23/48 hour observation, mobile outreach, and/or children’s crisis outpatient services at Community Mental Health Centers. This is a duplicated number, since persons may receive one or more of these services. 3aPercent of Persons Receiving Crisis Services Who Relapse The percent of persons receiving front door or community crisis services at Community Mental Health Centers who experience another crisis within 30 days. This includes hourly services. 3bPercent of Persons Receiving Crisis Services that Result in a Psychiatric Hospitalization The percent of persons receiving front door or community crisis services at Community Mental Health Centers that result in a psychiatric hospitalization at a State or Community Mental Health Hospital within 30 days.

20. Proposed LBB Measures, cont’d No.LBB MeasureDefinition 4Number of Community Mental Health Center Staff with AAS Hotline Training The number of Community Mental Health Center staff trained to support certification of the hotline per American Association of Suicidology (AAS). 5Percent of Stakeholders Satisfied with Crisis Services The percent of stakeholders, including law enforcement and hospital staff, who agree that Community Mental Health Center staff are competent to resolve crises or that there is good coordination between law enforcement and Community Mental Health Centers. 6Percent of Persons Receiving Crisis Services Who Have a Criminal Justice Contact The percent of persons receiving community crisis services who had a complete assessment 90 or more days after their crisis service which showed an arrest within the past 90 days.

21. Proposed Performance Contract Measures No.Contract Performance MeasureDefinition 1Percent of Persons Receiving Crisis Services Who Relapse The percent of persons receiving front door or community crisis services at Community Mental Health Centers who experience another crisis within 30 days. This includes hourly services. 2Percent of Persons Receiving Crisis Services that Result in a Psychiatric Hospitalization The percent of persons receiving front door or community crisis services at Community Mental Health Centers that result in a psychiatric hospitalization at a State or Community Mental Health Hospital within 30 days. 3Percent of Crisis Client Episodes Linked with DSHS-Funded Mental Health Community and/or Substance Abuse Treatment Services. The percent of front-door mental health crisis episodes that are followed by a community level of care authorization at the LMHA, and/or OSAR or DSHS- funded Substance Abuse Treatment service encounter, no later than 14 days after the first day of their front-door mental health crisis episode.

22. Proposed Performance Contract Measures, cont’d. No.Contract Performance MeasureDefinition 4Percent of Persons Receiving Crisis Services Who Have a Criminal Justice Contact The percent of persons receiving community crisis services who had a complete assessment 90 or more days after their crisis service which showed an arrest within the past 90 days. 5Percent of Clients with an Initial Crisis Screening who have a Subsequent Crisis Service The percent of Clients with a level of care of 0 who have a crisis service within 30 days of the initial crisis screening. Excluding clients who are admitted to a community or State hospital after the initial crisis screening and clients who are determined to be non- crisis. 6Percent of Hospitalizations without a Crisis Assessment The percent of clients who have a community or State hospitalization and who do not have a crisis assessment within 5 days prior to their hospitalization