What’s Our Agenda? Center for School Behavioral Health

In April 2012, Mental Health America of Greater Houston (MHA) launched the Harris County School Behavioral Health Initiative, a community-wide collaboration aimed at ensuring students with behavioral health needs are identified early and able to receive needed services. The initiative convened school district personnel, behavioral health providers, child-serving and education-related agencies, and parents to develop recommendations to improve the prevention, identification, and treatment of behavioral health issues among students. The initiative was born out of a 2003 report on school-based mental health care sites in Abilene, Austin, El Paso, Houston, Lubbock, Tarrant/Denton Counties, and Tyler. According to the report, counselors across the state faced challenges in providing appropriate levels of mental health services to students; teachers lacked both experience in recognizing early signs of mental health issues and an awareness of available community treatment resources; and schools burdened by financial constraints were unable to adequately meet the needs of students with mental health problems who were ineligible for services under federal law.

What began as a stakeholder meeting comprised of 40 organizations has grown into The Center for School Behavioral Health,  thanks in large part to the ongoing commitment and engagement of collaborative members and generous philanthropic support. A major gift from the Houston Endowment enabled the creation of the Center, which serves as a “living laboratory” for incubating innovative, cost-effective and replicable best practices to improve the behavioral health of students by facilitating collective action; providing highly specialized professional development opportunities, technical assistance and community education; and conducting research, advocacy, and policy analysis. The long-term vision of the Center is to transform school behavioral health to support the healthy psychological and cognitive development of children in the Greater Houston region through services and programs promoting behavioral health, as well as the prevention, early identification, and treatment of behavioral health disorders.

School Behavioral Health Initiative: 37 Recommendations

Harris County School Behavioral Health Initiative (SBHI) meetings included personnel from ten school districts, county level educational organizations, behavioral health providers, child-serving agencies and advocacy organizations, and during the course of a year, workgroups prioritized the following activities:

  • Review of state and federal laws that govern the identification and treatment of students with behavioral health issues, including the Individuals with Disabilities Education Act and Section 504 of the Rehabilitation Act, as well as relevant state regulations;
  • Creation of a system “maps” of four school districts to determine their policies related to prevention, identification and treatment of mental health and/or substance use issues;
  • Examination of national evidence-based and promising school behavioral health programs. These included best practices related to prevention, identification, and intervention;
  • Completion of 32 individual interviews with key community members to obtain their views of how school behavioral health processes currently are working and ways in which they can be improved;
  • Execution of site visits to locations that have been recognized statewide or nationally for innovative and best practice-based school mental health initiatives.
  • Collection of data from the 20 Harris County school districts related to special education categorization, racial patterns, and disciplinary placements.

By February 2013, the SBHI developed and shared 37 recommendations based on their activities, including 7 recommendations for the Texas legislature:

  • Restore the $5.4 billion in education funding cuts made during the 82nd Legislature
  • Restore the almost $13 million in funding cuts made to Communities in Schools during the 82nd Legislature.
  • Increase funding for substance use prevention, intervention and treatment for children and adolescents.
  • Increase funding for children’s mental health treatment services.
  • Designate at least 5% of current funding for children’s mental health treatment services to prevention programs, such as mental health literacy, personal safety, and suicide prevention.
  • Appropriate General Revenue funds to increase grants for school-based health clinics.
  • Require, in educator preparation programs, that teachers receive training in the detection of students with behavioral health issues.

Between 2013 and 2016, the School Behavioral Health Initiative worked toward system or district-wide implementation of the 37 recommendations. All seven of the legislative recommendations were fully or partially implemented, and 20 of the 21 school district recommendations were being implemented district-wide by at least one area school or charter school district.  In total, 34 of the 37 recommendations have been realized.

85th Legislative Session Platform: Education

Guided by the 37 recommendations at the core of the Center’s advocacy efforts, MHA prioritized the development and implementation of school behavioral health services in our 85th Legislative Session Platform. Some may ask why it is necessary or, even, appropriate to address mental and behavioral health issues in a classroom environment instead of a home or doctor’s office. The answer to that question is simple, but not easy: One out of every five children has a mental illness or addictive disorder that causes some type of functional impairment. Youth with behavioral health issues may experience challenges such as academic underachievement, criminal justice involvement, and even suicide, and more than one-quarter of the total costs for mental health treatment services among adolescents were incurred in the education and juvenile justice systems. Lastly, children and adolescents spend much of their waking hours at school, making classrooms the ideal setting to recognize and initiate services to address the social, emotional and behavioral needs of our kids. Based on these facts, we support legislation focusing on school-based initiatives to improve prevention, identification and treatment of behavioral health issues among students. Specifically, we are looking at legislation related to behavioral health campus professionals, general reporting and trauma training, and transition services planning.

We spoke with Center for School Behavioral Health Director, Janet Pozmantier, and Professional Development Manager, Betsy Blanks, to get a comprehensive understanding of the legislative needs of the Center.

Janet: The Center came about because our schools were being overwhelmed with the number of children who were experiencing severe emotional difficulties and because of the severity of the difficulties our students were experiencing. We had long-time educators who were at a loss of what to do and how to handle so many children. We had a big win during the legislative session with Senate Bill 460, which mandates that all educators receive training in identifying the signs and symptoms of mental health problems among students and how to assist the child to get the appropriate help.  We are grateful for that legislation being passed. It was very unusual because normally legislation does not pass right out the gate. Usually, it takes at least three sessions to pass.

What we have found four years later is that most of our educators are not aware of the fact that this mental health training is required, and the districts that are implementing the training do not have the time or resources to reach all of their teachers in an effective manner.

There are some wonderful evidence-based trainings out there. A free online training is Kognito At-Risk, a phenomenal interactive avatar based training. Unfortunately, free access to that may end and then I don’t know what’s going to happen. A lot of us offer the Youth Mental Health First Aid training.  These trainings are free to districts through the Harris Center for Mental Health and IDD, our local mental health authority. However, there is a limit to how many the Harris Center can serve in any given year so organizations like Mental Health America of Greater Houston and NAMI are certified trainers. The challenge we have encountered is that our training is eight hours and costs money, limiting the number of school personnel who can take the training. The legislature did provide some money during the 83rd legislative session for these trainings but it is not enough to take care of the majority of teachers in the Greater Houston region because the money is to fund trainings statewide. That is a big problem.

The Center’s priority is getting these trainings out to people. Making sure people know about it. Currently, there are no “teeth” in the training legislation and that is why we have the proposed amendments to SB 460 that we are looking at today. There is no reporting requirement and so the schools are not going to do it. So, we want to make sure we have that reporting component inserted into the language of the updated bill. We also want to have trauma training included because of the things we have learned– especially from our conference this past fall — is there is an overwhelming desire from schools and districts to learn more about trauma and how it shows up in the classroom, and how to handle it. So many of the behavioral health problems we are seeing are not necessarily due to someone having a serious mental illness, but because it is a response to unresolved trauma and grief.

Betsy: Students who experience trauma are two and a half times more likely to be retained and are suspended and expelled more often. A student’s academic achievement can also be harmed because of trauma with reports of lower scores on standardized achievement tests and substantial impacts on IQ, reading achievement and language. Over the last ten years, teachers have really started to realize that this is an issue.  Many of their students are not necessarily suffering from a mental illness but they are impacted by trauma. Teachers are recognizing it but they do not know what to do about it.

Annalee: Betsy, as a former teacher coming into this, what can you say about seeing both sides of this issue?

Betsy:  The first time I attended the Mental Health First Aid course, it was after I started here at the Center, throughout the training, all day long, it just hit me over and over and over again how many kids I failed because I did not have this mental health training; the context. I worked at an inner-city school where kids were coming in with a lot of trauma and my school never talked about mental health, never talked about trauma. Teachers did not receive any information about that side of a child. It was all academic focus, and they did great things academically at my school, but you lose a lot of kids if you are not addressing that side.  It was really hard as someone who cared deeply about being a good teacher and about my students. It was really difficult to later receive this training and get this information and look back and think about the specific children I let down because I was not prepared to handle their traumas. That’s not acceptable. We do such a disservice to our children in schools when our teachers are not prepared to address the whole child. They want to. No one goes into teaching with bad intentions. They want to do the best for their students and it’s not fair to the child to not equip our teachers with those tools. We send them to a lot of professional development and it’s not acceptable that at least a certain portion of that training is not dedicated to mental health training.

Janet: Our public schools are de facto providers of mental health services, and who is on the front lines at schools? The teachers. They don’t have the necessary training so we want to give them the tools to be trauma informed and understand mental health issues in order to understand how to refer out. We don’t want teachers to be therapists. That’s not their role. But who are they going to refer to?  In many of our schools, there is no one there. Even if there is someone there, for example, school counselors are busying working on graduation plans and writing letters of recommendation or doing lunch line duties or testing. So, that is why we are advocating for one licensed behavioral health professional on every school. To help our teachers have more time to teach. If they identify a student who is in need of some type of service, then they can make sure that student gets those services. In other school districts around the country, schools have three, four, five counselors per grade because they realize a child cannot learn if they are experiencing homelessness, poverty, hunger, or trauma of any kind.

Trauma is everywhere, in all strata of society, and that is why we want a licensed behavioral health professional on every campus. I don’t buy the argument that we don’t have the money. We have the rainy-day fund, and you can get very creative with Medicaid reimbursement. We have great models here in Houston. Legacy Community Health has partnered with schools and figured out how to host integrated health care clinics on every campus so we can do this. You cannot live in a city like Houston and use the arguments that we cannot afford it. It’s not okay. Or in a state like Texas.

Behavioral Health Campus Professional

No conversation about improved prevention, identification and treatment of behavioral health issues among students would be complete without addressing the shortage of school counselors in Texas schools. National prevalence estimates indicate that one in five children have a mental illness or addictive disorder, meaning that approximately one million Texas public school students are dealing with these issues on a daily basis.  These illnesses can cause mild to significant impairment in home and school activities and can lead to school failure, disciplinary placements,  juvenile justice involvement, and, in extreme cases, suicide.

Despite the high prevalence of mental health and substance use disorders among children and adolescents, most schools do not have a designated staff person available to provide counseling or other needed services. In addition, school counselors, who historically were responsible for providing some of these services, are increasingly loaded down with administrative duties unrelated to mental or behavioral health counseling. They also are expected to handle increasingly large student caseloads.

Although the counselor shortage can be attributed to a mix of overburdened caseloads, funding cuts, and hiring shortages, the result is a student-to-counselor ratio well above the American School Counselor Association recommendation of 250-to-1. Following the 2011 cuts to public education, the Ray Marshall Center for the Study of Human Resources at the LBJ School of Public Affairs released Texas School Counselor Study: Exploring the Supply, Demand, and Evolving Roles of School Counselors. The study found “[b]eginning in 2012 and through 2014 the student-to-counselor ratio also remained relatively constant … between 460:1 and 470:1.”  These numbers do not take into consideration the counselors’ ability to identify and address the behavioral health needs of students.


Credit: MARSHALL CENTER FOR THE STUDY OF HUMAN RESOURCES /UT AUSTIN


Credit: MARSHALL CENTER FOR THE STUDY OF HUMAN RESOURCES /UT AUSTIN

To address the shortage of counselors and other student support staff, MHA of Greater Houston supports legislation requiring at least one licensed behavioral health professional on each campus, as funding allows. While the long-term goal would be requiring one behavioral health professional per campus, the cost of associated with this type of legislation would be prohibitive in the current legislative climate. We have seen great success in meeting the behavioral health needs of students in public-private partnerships between school districts and community-based organizations like Communities in Schools and believe this is an incredibly positive starting point that would greatly benefit students.

Reporting and Trauma Training

MHA is incredibly proud of our work on Senate Bill (SB) 460, passed by the 83rd Texas Legislature in 2013. SB 460 requires school districts to provide teachers, administrators and staff with training in mental health intervention and suicide prevention to help them identify red flags in a child’s behavior and respond effectively.  House Bill (HB) 2186, passed by the 84th Texas Legislature in 2015, requires suicide prevention training for all new school district and open-enrollment charter school educators annually and for existing school district and open-enrollment charter school educators on a schedule adopted by the Texas Education Agency (TEA) by rule.


Source: Understanding Child Trauma, National Child Traumatic Stress Initiative

Currently, Section 161.325 (Early Mental Health Intervention and Suicide Prevention), Health and Safety Code requires teachers, counselors, principals, and all other appropriate personnel to be trained in how to recognize and appropriately respond to signs of mental health and substance use disorders, as well as suicide. However, the trainings are not required to cover students who have experienced physical and emotional trauma. Additionally, there are not any reporting requirements to ensure that school districts are conducting the trainings.

The goal of MHA’s proposed general reporting and trauma training legislation is two-fold: 1) to provide accountability measures to reinforce the training mandate through reporting to the  Texas Education Agency; 2) to require all school personnel to receive training in how to recognize and appropriately respond to signs of trauma.

As proposed, this legislation would amend SB 460 to require school districts to train educators in how to recognize and appropriately respond to physical and emotional trauma, as well as to report all training information to the Texas Education Agency. This accountability measure does not serve as a new mandate. SB 460 already requires school district employees to receive training. The school district is also required to keep records of all training participation. This amendment would strengthen the already existing requirements in the bill by ensuring the records kept by the district on the required training would then be reported to the TEA and be accessible to parents and community members.

To better understand the need for trauma training and the impact of trauma on students, Annalee Gulley sat down with Julie B. Kaplow, Ph.D., A.B.P.P., Director of the Trauma and Grief Center for Youth at The University of Texas Health Science Center at Houston. The Trauma and Grief Center for Youth opened in December 2014  and treats youth ages seven to 17 who have experienced trauma and loss.

Annalee:  If you were a teacher and were in your classroom, what are some of the signs you might recognize in a child who has experienced some type of trauma?

Julie:  What makes this difficult is that posttraumatic stress symptoms can look a lot like ADHD symptoms. We will often hear from teachers, “This child won’t sit still. They are distracted. They seem like they are in another world. You say one thing that sets them off and you cannot seem to calm them down.” These may be signs of ADHD, but they can also be signs of posttraumatic stress. It is important to help teachers understand how kids may react in the aftermath of trauma and put these behaviors into context. Many traumatized kids may be triggered without knowing why inside the classroom. It is often helpful to inform teachers about potential trauma reminders – people, places, situations, or things that remind kids of the frightening thing that happened to them. Trauma reminders can be as subtle as kids screaming on the playground (if the traumatic event involved the sound of screams) or the teacher giving that child a certain look or scolding them. These kids often get mislabeled or are misunderstood as “behavior problems” when in fact they are simply reacting to their environment and are being reminded of whatever traumatic experience they had.

A trauma training would help to educate teachers about the many ways in which various forms of trauma and adverse life events, such as the death of a loved one, as well as accompanying posttraumatic stress or maladaptive grief can impact learning and how this may manifest in the classroom. When teachers really do understand how trauma impacts children, they are able to have more empathy in the classroom, they are better able to see why certain children may be behaving the way they are and are then able to help them to modify those behaviors in a much more effective way. What we also know is that teachers can use all of the behavioral strategies and positive reinforcement they want with a traumatized child, but if they are not able to identify what it is that is triggering them, that’s not going to help them in the classroom. A trauma training for teachers would help to explicate the ways in which posttraumatic stress and/or grief reactions can manifest in the classroom and what teachers can do to help these youth to de-escalate and stay on track.

Annalee: How would you respond to the argument that this is not a teacher’s job? That we are turning teachers into counselors or behavioral health professionals when we ask them to identify a child who has been traumatized or ask them to de-escalate a situation or determine whether a child has been abused or is suffering PTSD?

Julie: I would say that, first, we are obviously not asking teachers to treat a child’s posttraumatic stress because that would require a higher level of training and intervention. What we are suggesting though is that teachers can play a critical role in identifying those youth who may need to be referred for an evaluation. It is important to remember that, for many traumatized youth, their teachers may be the only adults in their lives who are actually seeing their posttraumatic reactions and/or behaviors. So the school can actually serve as a critical point of entry. In addition, we know that trauma and PTSD can directly impede the child’s ability to learn, and a primary goal of most teachers is to create an environment in which all kids in the classroom are able to learn in the most effective way possible. When youth are struggling with PTSD, this may directly interfere with the primary goal for teachers. By empowering teachers with the knowledge and information needed to identify trauma and PTSD in youth, they will begin to feel like they have more control over their classroom. We see many teachers, particularly in underserved communities, who are faced with a lack of resources and high levels of trauma in the neighborhoods in which they work. Many teachers feel overwhelmed and think “I’ve just got to get through this day” as opposed to ” I am starting to notice a pattern with this child and this might be a sign that they have a history or trauma.” This new knowledge allows teachers to feel more in control of their classroom, less overwhelmed, and better equipped to refer those kids who may need a thorough trauma-informed evaluation and/or intervention.

 Transition Services Plan

To ensure students with prolonged placements in out-of-school facilities, including disciplinary programs and residential treatment facilities to address disciplinary or behavioral health needs, have a continuum of services, MHA of Greater Houston seeks to require the creation of a transition plan for the returning student. Annalee Gulley spoke to Latashia Crenshaw, Director of Educational Support and Advocacy Services at the Harris County Juvenile Probation Department. The Education Support and Advocacy Services is tasked with “advocate[ing] for improved educational services for probation-involved youth in community settings.”

Annalee: When you are able to get them back to the home campus, do you encounter many schools that have the ability or systems in place to integrate that child successfully back into school?

Latashia: Some districts, as with everything, are better than others when it comes to transitioning our youth back into their home school. It also depends on how long the youth has been out of their system and involved in our system. For youth who have not been out of their home school for very long, I can say that they have much easier chances transitioning back into the school from an out-of-school facility. Those who have been out of their school for quite a while, or not attending their home school prior to coming to us, those are the youth who concern us the most. We are trying to focus on making sure we have the correct records, the correct grade level for that student or making sure that the special education services are in place. Transitioning the services we have in place while the youth are in a placement because they may look completely different than what needs to happen when the youth returns to the home school. We have found there are gaps when making sure there is a continuum of support and services between placements.

Annalee: If you were to help facilitate the process of creating a standardized transition plan, what do you think some of the core elements of the plan would need to include?

Latashia: In an ideal world, we would have transition specialists or people designated in the district who would track youth who have been withdrawn from their district and in our facility because once the youth is enrolled in our system for a designated number of days, they are withdrawn from their home district and placed in our school system.

For transition plans, if the youth is in our facility — for say 60 days or longer– if we could have a transition specialist work with us when we know that youth is going to be released, to have the home school become involved with the youth transition plan so that we can ensure that everything is in place when they go back to the home school. This would include setting up Admission, Review, and Dismissal (ARD) meetings, as well as 504 meetings because most of our students have some sort of disability. A  transition plan would definitely include looking at the courses the youth is enrolled in with us versus what they need to be enrolled in when they return to their home school. Again, what types of transition services this youth would need just to really get reintegrated back into their home school system versus the education system we were involved in. To me, a transition plan would include reintegration meetings prior to the youth being released, including staff from probation, the home school and any other services they are going to be involved with in the community. Some sort of meeting that includes all the people who are going to be working with the student and family.

Latashia:  I cannot stress how significant it would be, especially for those youths who have significant mental health concerns and disability, to collaborate on transition meetings while the youth is in placement. This would include having home school personnel come to ARD meetings or hold these meetings in conjunction with our staff so that we can ensure that when this youth leaves placement they are actually successful with transitioning back to their home school and don’t return to us simply because records are not there or they are sitting at home waiting to be in enrolled in a school, which may or may not happen.

What’s Next?

As we build support for this legislation in Austin, we will report on important milestones like bill filings, committee assignments, and committee hearings. Your voices need to be heard by legislators to ensure they understand the importance of these issues for students in Houston and beyond. Stay tuned!

One Month In: A Look at the 85th Legislature

On Tuesday, January 10, the 85th Texas Legislature was officially gaveled into session. As we mark the close of the first month of this biennial 140-day period, our team at Mental Health America of Greater Houston took a quick look back at what has happened thus far inside Austin’s Pink Dome.

Biennial Revenue Estimate
Comptroller Glenn Hegar released the 2018-2019 Biennial Revenue Estimate (BRE) on Monday, January 9, kicking off the 85th Legislative Session with a bleak fiscal report that left lawmakers with roughly $104.9 billion in general revenue funding for the state’s two-year budget. The 2018-2019 BRE is approximately $7 billion less than the 2015 allocation, largely because of low oil prices coupled with the required reallocation of billions of tax revenue dedicated to the State Highway Fund following the passage of Proposition 7* in 2015.

Estimates suggest that it would require $109 billion in general revenue monies to fund state programs at currently established levels. In July, anticipating the budget shortfall to come, Governor Greg Abbott, Lt. Governor Dan Patrick and House Speaker Joe Straus requested all state agencies to scale back their budget requests by 4 percent in an effort to curb government spending. Mental and behavioral health services were deemed priority funding areas, along with funds for public schools, border security, and Child Protective Services, and were excluded from the required 4 percent scale back scenarios. However, the 2.7 percent decrease in overall funding for state provided services established by the Comptroller’s BRE in January leaves less money available for schools, child welfare, and health care, among many others, than originally expected – leading some advocates to call for legislators to dip into the Economic Stabilization Fund, commonly known as the “Rainy Day Fund,” which is currently valued at nearly $12 billion. Legislators have been reticent to draw funds from this emergency fund in the past, which points to difficult – and contentious – decisions to come.

*Proposition 7, passed by taxpayers in November 2015, requires the state to dedicate up to $5 billion in sales tax revenue to the State Highway Fund.

Base Budget Breakdown: SB 1/HB 1
On Tuesday, January 17, State Senator Jane Nelson, Finance Chairman, filed SB 1 – the  Texas General Appropriations Act, which serves as the Senate’s base budget and establishes state funding priorities for the next two years. SB 1 includes $103.6 billion of general state funding with overall spending — including federal and other funds — of $213.4 billion.

Like many of her colleagues, Senator Nelson shared concerns regarding “difficult decisions to make this session,” which makes the inclusion of key funding items for mental and behavioral health significant as they signal the Senate’s commitment to prioritizing these issues this session. Included in the budget is funding for workforce development, with an additional $44.1 million for Graduate Medical Education to ensure residency slots are available for Texas medical school graduates; and $260 million for Child Protective Services. To address current needs, SB 1 committed $1 billion for the state hospital system and facilities and $63 million for community mental health services to eliminate waitlists. Women’s health and veterans’ services programs maintained existing funding levels, including funding for Texas Veterans + Family Alliance, a $20 million grant program to assist veterans with post-traumatic stress and other mental health issues.

Shortly after SB 1 was filed, Texas House Speaker Joe Straus filed HB 1, the House’s initial 2018-2019 budget. HB 1 includes $108.9 billion in general fund allocations, approximately $4 billion more than the Comptroller’s estimated available revenue, and a total budget of $221.3 billion.

The House’s base budget touts a significant investment in public education, child protection, and mental health services, while only increasing the state budget by less than one percent. “We keep overall spending low while making investments in children and our future … This is the first step toward producing a balanced budget that reflects the priorities of the Texas House and does not raise taxes,” said Speaker Joe Straus.

Under the House budget, mental and behavioral health services receive $162 million of additional funding. These funds would eliminate wait lists for mental health services and allow for the implementation of many of the House Select Committee on Mental Health’s recommendations, including efforts to increase the implementation of early identification and jail diversion programs across the state. As in SB 1, HB 1 also earmarks monies for the treatment of post-traumatic stress disorder among veterans.

Nearly $8 billion separates the Senate and House base budgets [difference between the Senate and House base budgets ] and we have until May 29th to see how negotiations between the two chambers unfold.

House Select Committee on Mental Health – Interim Report to the 85th Texas Legislature
In early January, the House released an interim report from the Select Committee on Mental Health. Speaker Joe Straus formed the Select Committee in November 2015 to better understand the existing behavioral health system for adults and children in Texas. Chaired by Representative Four Price, the Select Committee on Mental Health held eight hearings throughout 2015-2016. Representatives Garnet Coleman, Sarah Davis, and Senfronia Thompson served as Houston’s representatives on the committee.

When he announced the formation of the committee, Speaker Straus identified the need for “[a] smarter approach to mental health” and expressed his hope that this approach would result in “improve[d] treatment and care while saving taxpayers money.” The interim report is intended to “give the House valuable guidance,” on how to make positive advancements in behavioral health during this legislative session.

The interim report highlights opportunities to solve existing service gaps and key takeaways include:

  • Prioritizing early intervention and prevention measures – especially among school age children;
  • Expanding innovative public school-based programs;
  • Sustainability of the 1115 Transformation Waiver / DSRIP funded programs;
  • Expanding bed capacity by expanding step-down beds to provide a continuum of care, including expanding jail diversion programs for nonviolent offenders;
  • Continuing to address mental health workforce shortages through educational incentives and by expanding the availability and utilization of technology, such as telemedicine;
  • Integrating healthcare to treat the whole person, physically and mentally, although questions remain among the committee surrounding the implementation.

Committee Assignments: Senate and House Committees Announced
On January 18, Lt. Governor Dan Patrick announced Senate committee assignments for the 85th Legislative Session. The Houston delegation includes Chair and Vice Chair assignments to the Criminal Justice, Education, and State Affairs, Intergovernmental Relations, and Business & Commerce Committees, and is represented on committees relevant to behavioral health work.

houston-senate-delegation

Traditionally, behavioral health bills pass through the Senate Health and Human Services Committee, but to monitor the Center for School Behavioral Health’s bills and issues relevant to Veterans Behavioral Health Initiative, MHA of Greater Houston will also watch the Senate Education Committee and Senate Veteran Affairs & Border Security. Houston Senator Borris Miles is a member of the Health and Human Services Committee. The Education Committee had two members of the Greater Houston delegation: Senator Larry Taylor, Chair, and Senator Paul Bettencourt.

Health and Human Services Committee

Role Senator City
Chair Charles Schwertner Georgetown
Vice Chair Carlos Uresti San Antonio
Member Dawn Buckingham Lakeway
Member Konni Burton Colleyville
Member Lois W. Kolkhorst Brenham
Member Borris L. Miles Houston
Member Charles Perry Lubbock
Member Van Taylor Plano
Member Kirk Watson Austin

Education Committee

Role Senator City
Chair Larry Taylor Friendswood
Vice Chair Eddie Lucio, Jr. Brownsville
Member Paul Bettencourt Houston
Member Donna Campbell New Braunfels
Member Bob Hall Edgewood
Member Don Huffines Dallas
Member Bryan Hughes Mineola
Member Kel Seliger Amarillo
Member Van Taylor Plano
Member Carlos Uresti San Antonio
Member Royce West Dallas

Senate Veteran Affairs & Border Security

Role Senator City
Chair Donna Campbell New Braunfels
Vice Chair Don Huffines Dallas
Member Dawn Buckingham Lakeway
Member Bob Hall Edgewood
Member Eddie Lucio, Jr. Brownsville
Member José Rodríguez El Paso
Member Carlos Uresti San Antonio

On February 9, Speaker Straus shared House assignments to the 38 standing committees, as well as the creation of two new select committees: the Select Committee on State and Federal Power and Responsibility and the Select Committee on Texas Ports, Innovation & Infrastructure.

houston-house-delegation

The Houston delegation includes Chair assignments to Appropriations, County Affairs, General Investigating & Ethics, Government Transparency & Operation Juvenile Justice & Family Issues Local Consent & Calendars, Public Education, Special Purpose Districts, and Urban Affairs. Vice Chairs committee assignments from the Greater Houston area include Corrections, Environmental Regulations, Economic & Small Business Development, International Trade & Intergovernmental Affairs, Judiciary & Civil Jurisprudence, Special Purpose Districts, and Texas Port, Innovation, & Infrastructure.

House Committees of particular interest to MHA of Greater Houston are Public Education, Human Services, Public Health, and Defense & Veterans’ Affairs. Representative Dan Huberty chairs Public Education and members include Representative Alma Allen, Harold Dutton, Jr. and Dwayne Bohac. Public Health membership includes Representatives Garnet Coleman and Tom Oliverson. Houston-area legislators make up half of the membership of the Human Services Committee with Representatives Mark Keough, Rick Miller, Valoree Swanson, and Gene Wu.

Public Education

Role Representative City
Chair Dan Huberty Houston
Vice Chair Diego Bernal San Antonio
Member Alma Allen Houston
Member Joe Deshotel Beaumont
Member Harold Dutton, Jr. Houston
Member Lance Gooden Terrell
Member Dwayne Bohac Houston
Member Ken King Canadian
Member Linda Koop Dallas
Member Morgan Meyer Dallas
Member Gary VanDeaver New Boston

Human Services

Role Representative City
Chair Richard Peña Raymond Laredo
Vice Chair James Frank Wichita Fall
Member Mark Keough The Woodlands
Member Stephanie Klick   Fort Worth
Member  Toni Rose  Dallas
Member Rick Miller Sugar Land
Member Ina Minjarez San Antonio
Member Valoree Swanson Houston
Member Gene Wu Houston


Public Health

Role Representative City
Chair Four Price Amarillo
Vice Chair J.D. Sheffield Gatesville
Member Garnet Coleman Houston
Member R.D. “Bobby” Guerra Mission
Member William “Bill” Zedler Arlington
Member Diana Arévalo San Antonio
Member Nicole Collier Fort Worth
Member Phillip Cortez San Antonio
Member Stephanie Klick Fort Worth
Member Tom Oliverson Cypress

Defense & Veterans’ Affairs

Role Representative City
Chair Roland Gutierrez San An
Vice Chair César José Blanco El Paso
Member Diana Arévalo San Antonio
Member Stan Lambert Abilene
Member Briscoe Cain Deer Park
Member Dan Flynn Canton
Member Terry Wilson Marble Falls

Stay Engaged: Know Your Reps, Advocacy Taskforce, and Social Media 

The procedural nature of the Texas Legislature requires a somewhat paradoxical mix of steadied patience and swift action. In this space, we’ll discuss effective advocacy strategies in the weeks ahead. One simple step to begin to make your voice heard in Austin is to become familiar with the offices of your State Senator and State Representative. Find their district and capitol offices, save their phone numbers, and research the issues they care about the most.

Here within Mental Health America of Greater Houston, the Center for School Behavioral Health and the Women’s Mental Health Initiative joined forces and launched an Advocacy Task Force for the 85th Texas Legislature. The Task Force will be instrumental in advancing legislation around children and women’s mental health in the coming months. We welcome anyone interested in helping our cause to join the Task Force and our Rapid Response Team. For more information, visit our Advocacy Task Force page or email Lauren at lpursley@mhahouston.org.

To keep up with our advocacy work, check back in with Minding Houston every other Thursday starting February 23, like us on Facebook and follow us on Twitter.

Minding Houston XVII: Parity Disparity

With all the issues surrounding mental health, perhaps none has a bigger impact than parity. But parity also happens to be one of the hardest to understand and hardest to implement. In this episode, we will look at the legislative history of parity, current problems with enforcement, and a new ruling that impacts parity across the country. Insurance parity for behavioral health coverage makes providing behavioral health services possible and it is impossible to improve access without it.

This is Minding Houston, I’m Bill Kelly.

When we talk about parity, we need to talk a little political history. The Houston Chronicle’s Jenny Deam wrote about the situation regarding parity and its roots in federal legislation, and she sums it up nicely:

Chronicle

“President George W. Bush signed a law requiring any insurance policy that included mental health treatment to be equal in coverage to medical treatment, in an effort to stop the long-standing practice of charging higher co-pays for mental health care, limiting treatment or denying it outright. It was cheered as a triumph for the nation’s millions with mental illness.

The measure was further strengthened in 2010 with the passage of the Affordable Care Act, which extended federal parity requirements to individual and small-group plans and mandated mental health and substance abuse be covered in any plan sold on the federal marketplace or state exchanges.

But the lofty goal of equality has fallen far short of its promise, providers, patients and policy experts say.”

So with federal legislation passed, what’s the problem? Parity is the law of the land, why isn’t it the standard practice of providers? Well, as Ben Franklin once said, “”Justice will not be served until those who are unaffected are as outraged as those who are,” which I think was his way of stirring up those of us who care about behavioral health coverage. Deam’s article continues:

“In fact, certain managed care groups are well known within the Houston behavioral care community of having a “predictably higher rate of denials” and a “higher hassle factor,” says Dr. George Santos, chief medical officer and executive medical director at Houston Behavioral Hospital. “They hide behind statements like, ‘We are not telling you what to do.’ But I have had many instances where these physicians will make specific treatment recommendations regarding medications and doses. They will certainly say a patient no longer needs inpatient care and will deny approval.”

Take Dr. Richard Noel, medical director at IntraCare North, a Houston psychiatric facility. He spends hours each week on the phone arguing with doctors paid by insurance companies who have never seen his patients. He says he now has to prove that medications for inpatient children and teens are being adjusted every few days – often before the drugs have had a chance to work – or insurers will no longer cover a hospital stay. He says he has had issues with nearly all of the major insurance companies.”

What are the consequences when parity for behavioral health isn’t enforced with providers? Well, I would refer to statements made by Dr. William Streusand, an adolescent child psychiatrist at the Texas A&M Health Science center. He testified in front of the House Select Committee on Mental Health on March 22nd and answered the following question from Rep. Greg Bonnen, also a physician:

Bonnen: “You don’t take private insurance in your practice, why is that?”

Streusand: “I don’t have to.”

Bonnen: “Well, okay, could you elaborate on why you wouldn’t have to?”

Streusand: “Yeah, like I said it is a seller’s market.”

While that is true, what else is true, as followers of Minding Houston well know, is Texas has a scarcity of providers. How bad is the situation and how does it affect parity? From the Chronicle article:

“Texas ranks 47th out of 50 states and the District of Columbia in access to mental health care, and 50th in the number of mental health providers with only one for every 1,757 in the state, according to a study by Mental Health America. By contrast, Massachusetts, which ranks first, has one provider for every 248 people.

“They flat out tell me, ‘We don’t take insurance anymore because we have too much trouble getting paid,’ ” says Carrie Stowell, a single mother whose 16-year-old daughter has been diagnosed with bipolar disorder, attention deficit hyperactivity disorder and anxiety. She lives in Conroe and found 10 doctors in a 40-mile radius who treat adolescents, but only one is taking new patients or is in her plan. The wait for an appointment is six months.

Santos also feels the shortage. “It is extremely difficult to recruit a physician willing to work at an inpatient setting because of insurance,” he says.”

Because of poor parity enforcement, Texas finds itself in a situation where access to care is being limited not only to the number of providers but the number of providers that take insurance. Having a “cash only” payment model for behavioral health is a dangerous trend for Texas and can be one of the most limiting factors in the provision of care. Texas has too many people needing services to be a “seller’s market.” It is time to make some changes.

So how can this parity enforcement problem be addressed? Based on his experience as a prosecutor and his observations of the mental health needs of so many in the criminal justice system, Congressman Joe Kennedy III has a plan that he believes can help enforce the parity laws on the books. We talked with the Congressman about his Behavioral Health Coverage & Treatment Act last week:

BK & Kennedy

Bill Kelly and Congressman Joe Kennedy III

Kelly: I’m here today with Congressman Kennedy. Congressman, thank you so much for joining us. In December you filed your Behavioral Health Coverage and Transparency Act and, unlike in Texas where we face large problems due to our large uninsured population, this act primarily goes after folks with insurance looking to access services. What particular aspect really raised this on your radar screen?

Kennedy: So, I’ve been diving into issues around mental health now for a while, since I came into office and, actually, really beforehand. Before I ended up running for office, my first campaign, I was a prosecutor. I cannot tell you how many cases came across my desk from the district courts, lower courts, criminal courts in Massachusetts for folks struggling with either mental illness, substance abuse, drug abuse, or alcoholism and my boss at that point, a Republican DA,  said, “Your job is to make sure that person never commits another crime.”

And some folks are bad people and you lock them up for a long time. For others suffering from mental illness or substance abuse, the way you can do that is to treat the underlying condition. It doesn’t matter if you lock them up for three months if they are not able to get treatment for their mental illness or get clean off of a heroin addiction.

So use the tools that you have in your tool kit to help address the underlying concern. As a prosecutor, there are some tools we got; there’s a lot that we don’t and from my perspective trying a bunch of drug cases and working with a lot of drug cases, I became convinced that the way to ensure that those files that were people’s lives on my desk, the way to actually address them much further upstream is to focus on prevention and treatment rather than on prosecution.

The question then becomes how do we make sure there is access to mental health care throughout our society? And as we start peeling back the layers on this, from my perspective on it, there are two main segments. There is the public side of things where folks get their healthcare from the federal government, Medicaid primarily. Medicaid is, of course, the largest payer of mental health care services in the country. Then there is, of course, the private side doing private insurance. We’ve started by looking at the private side marketplace.

What this bill’s focus is to say, look, the combination of mental health parity, which is a simple law that has helped expand coverage, but it’s the combination of mental health parity and the Affordable Care Act that actually said as an essential health benefit in order to participate in these exchanges, you have to actually cover mental health care. So we have the combination of the Mental Health Parity Act, which says we have to treat mental health care like we do physical health care, and then the Affordable Care Act, which says you have to now cover mental health care. That leads to a huge expansion in coverage for states, particularly those who took the Medicaid expansion, which not all states did.

The challenge though is that the marketplaces still are not functioning so we still hear cases all over the country that say “I don’t need to take insurance,” because there are so many people that are in need of care and so few doctors that the doctors are essentially empowered to say “I can cherry pick my clients, I can make sure to get rates that are higher that other insurance companies will reimburse me for and I’ll just be an all-cash doctor.”

The problem with this is that you can’t just create more doctors overnight. So there are systemic issues that are affecting our ability in this country to have patients that are suffering from mental illness to actually access mental health they need. One other step for you: according to one study I saw recently 55% of the counties across our country do not have a single practicing psychiatrist, psychologist or social worker, 55% of the counties across our country!

So when we start talking about trying to get access to care, insurance is an important part to this, but we have to make sure you can actually get a doctor and stay treated. So the bill that we filed is a first step in trying to basically force insurance companies to divulge information around how they are actually covering mental health care. As you know, there are many people that are suffering from mental illness who get their insurance claims denied at a much higher rate than those suffering from typical, physical maladies such as a broken leg or a broken arm. So this bill will hopefully shine a light on some of those practices and force insurance companies to actually make this transition to focus on prevention and treatment, rather than triage at the back end of mental health.

Kelly: And you mention that this bill, it doesn’t put forth any new regulations as much as it focuses on transparency the for given laws that you mentioned with parity and the ACA.

Kennedy: Absolutely. Part of the way we crafted this is to say, look we are not trying to add any additional burden to these insurance companies, but disclose the methodology at which you end up making your decisions and make sure that information is available and digestible to regulators so we can actually start to shine a light on this and ask are things actually going as they should – which case there might be something else that needs to be done – or are they not?

And the idea behind this bill is that if insurance companies can essentially get away with not covering people at the back end when they are in need of mental health care, then there is essentially no reason for them to make the investment they need to actually force the focus of treatment to move up that scale to prevention and treatment rather than just focusing on the back end for folks that end up in a crisis point.

So what we want to do is try to take a step back and say how are we going to address access to mental health care in the system? It needs a full-on continuum of care adjustment. We need the private sector to play a role in that and I think a critical piece to it is by getting insurance companies to not just focus on the back end, the really expensive cases of triage after you’re becoming the victim of mental illness, but to focus on treatment and prevention on the front end. How do we flesh that out? We make sure that you are actually abiding by the terms of the regulation that are already in place.

Kelly: When you talk about the regulations that are already in place, one of the things that make mental health and behavioral health a very bipartisan issue is that people in a very partisan health care landscape, have been really willing to come together. You’ve seen bills move both in the House and the Senate. Do you see your bill possibly being able to hitch onto one of these bills that seem to be making some headway down the track?

Kennedy: Absolutely hope so. This is something that I think Democrats and Republicans agree on, that our mental health system is in crisis. Whether it was folks in Congress that have had similar experiences to me as prosecutors saying this is a real problem, whether you see it in emergency rooms because you have some doctors in Congress, or you are a member in Congress involved in trying to help our access to health care period.

And if you go around even hospitals in Massachusetts it’s one of the things you will hear about in emergency departments is there are a lot of people in their EDs suffering from mental illness. So we hear about this all the time; the question is how do we go about addressing it, again in that full-on continuum of care model? I hope that this legislation will address this, either as a standalone or perhaps as an amendment to one of those other pieces of legislation that we have been working hard on. We have been working with some of our colleagues on it and they have been doing a really good job. There is also a really tricky issue on how to make these reforms across the entire system and some of my colleagues and I are trying to dive into this so hopefully we will get there.

Kelly: Well, thank you, Congressman so much for your time today and for your work on this really important issue that I hope gets the traction that it needs. Like you said, this is a critical first step to ensuring that those with private coverage get the help that they need.

Kennedy. Thank you for your time too, Bill.

As the Congressman mentioned, the largest payer of behavioral health services in the country is Medicaid. And a recent announcement by the Department of Health and Human Services is good news for increasing access.

On March 29th, the Center for Medicare & Medicaid Services (often referred to as CMS) announced the new rule in coordination with President Obama’s visit to the National Rx Drug Abuse and Heroin Summit. From the press release:

CMS

” . . . the Centers for Medicare & Medicaid Services (CMS) today finalized a rule to strengthen access to mental health and substance use services for people with Medicaid or Children’s Health Insurance Program (CHIP) coverage, aligning with protections already required of private health plans. The Mental Health Parity and Addiction Equity Act of 2008 generally requires that health insurance plans treat mental health and substance use disorder benefits on equal footing as medical and surgical benefits.

“The Affordable Care Act provided one of the largest expansions of mental health and substance use disorder coverage in a generation,” HHS Secretary Sylvia M. Burwell said. “Today’s rule eliminates a barrier to coverage for the millions of Americans who for too long faced a system that treated behavioral health as an unequal priority. It represents a critical step in our effort to ensure that everyone has access to the care they need.

“This rule will also increase access to evidence-based treatment to help more people get the help they need for their recovery and is critical in our comprehensive approach to addressing the serious opioid epidemic facing our nation.”

“The need to strengthen access to mental health and substance use disorder services is clear,” said Vikki Wachino, Deputy Administrator of CMS and Director of the Center for Medicaid and CHIP Services. “This final rule will help states strengthen care delivery and support low-income individuals in accessing the services and treatment they need to be healthy.”

The protections set forth in this final rule will benefit the over 23 million people enrolled in Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and CHIP.

A link to the press release and the finalized rule can be found here

Overall, our goal at MHA of Greater Houston has been to make the provision of behavioral healthcare a successful business model. After all, if people want to access services, there needs to be providers available to treat them. Parity can help provide the basic regulatory functions under which providers can be paid in a timely manner for their services. And it is already the law . . .

Parity will continue to be a big issue at the state and national level. We look forward to continuing to work with our elected leaders in Austin and Washington to make sure parity coverage is enforced. Without this level playing field, progress in mental health care access continues to be an uphill battle.

This has been Minding Houston, I’m Bill Kelly.


 

Music for this Episode: “Hotel Rodeo”, “Quisling”, and Bricolage” by Anitek and “Vacate the Premises” by Deadly Combo

Minding Houston XVI: Capacity Questions Answered

 

Whenever the topic of mental health is discussed, one of the most repeated solutions is to increase capacity, usually in the common phrase, “we need more beds.” But do people really have the facts on what the bed capacity issues are for Harris County, and how does that play into what bed capacity issues face the state? Today, we talk to a leader for Harris County’s inpatient mental health hospital to get very specific on capacity issues.

This is Minding Houston, I’m Bill Kelly

Sgt. Joe Friday should have taught public policy. His “just the facts” line is one of my favorites and carries the objective tone of trying to boil down a problem to its core. So it is in that Dragnet spirit that I hope you don’t mind if we focus on a few graphs and numbers to get the story on capacity for state psychiatric beds.

DSHS Graph - Bed Capacity

The Texas Department of State Health Services has often presented the above slide in talking about the number of publicly funded beds available in the Texas State Hospital system. The graph shows two sets of numbers: first, the state hospital psychiatric beds represented with the light blue line, and secondly state funded (or private) psych beds represented by a red line. The black line at the top shows the sum of these two numbers and the overall trend in patient capacity for the state.

What’s apparent from this graph are two things which are important to note when looking at future trends regarding capacity options:

First, the number of state-owned beds has largely flat-lined since 2006, which shows that despite recent investments at the state level, Texas has not increased inpatient capacity for state-owned beds.

Secondly, the number of state-funded, private beds has more than doubled during that same time period, moving close to 20% of the state bed capacity total.

Clearly, the preferred option to increasing state bed capacity has been to buy, rather than build.

However, one number is not included in this data set that is the most important in answering what the real situation is with regards to the capacity of inpatient beds in Texas, and that’s population. Anyone who is living in Texas knows the explosive population growth seen in the past two decades, and in order to get the whole picture, the number of Texans needs to be accounted for in this data.

In a presentation to the Senate Finance Committee on January 15th, Assistant Commissioner Lauren Lacefield Lewis presented the following slide that tracks the total number of state beds to state population, and the numbers are not encouraging:

DSHS - Capacity Rate

From the graph, you can see that Texas is currently at the lowest ratio of beds to population since 1994. So in talking about what the psychiatric bed capacity for Texas is, we are starting from the lowest point based on population.

But aside from just the overall population, there’s another factor putting added pressure on the number of psych beds available for Texans: the criminal justice system. In the same presentation to Senate Finance, Mrs. Lewis showed the following slide that confirms a trend that first reached a tipping point in 2014. That trend is that more people are admitted to the Texas State Hospital system through forensic commitments than civil.

DSHS - Commitments

2014 marked the first year that more people entered the state hospital through the criminal justice system (a forensic commitment) than were voluntarily committed (civil commitment). And the trend has continued in 2015 and 2016.

This is a dangerous situation, as the public safety of Texans is now using up resources designed to make sure Texans have access to mental health beds. And the consequences are already showing up in real world situations right here in Harris County.

Chronicle

According to a March 4th Edition of the Houston Chronicle, the number of beds for forensic commitments were supposed to take up a third of the Texas State Hospital system but have instead become a majority.

The case of Shannon Miles, who stands accused of the murder of Harris County Sheriff’s Deputy Darren Goforth last August, has had more than its share of strange twists and turns. The case also has highlighted yet another problem with how the state deals with the mentally ill among us.

To review, Goforth was shot 15 times as he walked to his patrol car at a gas station. Sheriff’s deputies within a day arrested Miles, who has a history of mental illness. On Feb. 9, he was found mentally incompetent to stand trial after experts agreed he suffers from schizophrenia, and he was ordered to Vernon State Mental Hospital in North Texas. There he would receive a 120-day mental evaluation to determine whether so-called competency restoration is possible. As of this writing, he’s still in the Harris County Jail – the state’s largest de facto mental health facility, by the way – because some 60 other Harris County inmates are in line to go to Vernon ahead of him.

In 2012, a Travis County judge ruled that defendants requiring a forensic bed at a state mental hospital couldn’t be made to wait in jail for more than three weeks. Forensic beds are the spaces set aside for defendants, like Miles, who need psychiatric treatment to get well enough to stand trial. As Emily DePrang reported in the Texas Observer in 2014, they’ve had to wait in recent years for an average of six months.

Long waits are still the rule, despite the judge’s ruling, because Texas has less than 2,500 beds at its 10 state mental hospitals; less than a third of those are designated for forensic commitments. The cruel irony is that every bed used by someone from a jail is one less bed available for people who have committed no crime.

The wait list for the state hospital is another example of the lack of access for mental health owing to a capacity for treatment. The bottleneck for violent offenders at the Vernon State Hospital is just one example.

Houston Matters

Another example is the overall number of people who are dependent on the public mental health system. Recently, our favorite radio program Houston Matters had me on to talk about the need for crisis clinics while highlighting a new walk-in clinic opened in Meyerland by Memorial Hermann. Houston Public Media has done an extraordinary job when it comes to highlighting mental health, which I think is evident from the questions asked by Houston Public Media’s Craig Cohen. Here’s the part of our interview focusing on the need for services:

Craig Cohen: Bill Kelly, we do tend to think of the need for 24/7 physical health emergency care. Is it something that we tend to forget or not take seriously that there is a need for 24/7 – particularly in the overnight hours – emergency mental health care?

Bill Kelly: Well, I would just point to the overall numbers and then when you look at the gap in coverage and access it really emphasizes the need to invest in them. And according to our State Health and Human Services Commission, we have about half a million Texas adults that suffer from a severe and persistent mental illness. Now severe mental illness results in a serious functional impairment which substantially interferes or limits one or more major life activities. When you add the “persistent” that means that those symptoms have lasted over a year. So if you have half a million adults that breaks down in Harris County to right at 150,000 adults. Now, we know from our Mental Health Needs Council assessment that about 90,000 of that 150,000 have no access to public or private insurance. So the very systems that Memorial Hermann and other partners with the 1115 waiver are trying to build out are badly needed for this group. Like Theresa said, if people do not get the medical services that they need and the mental health care that they need, their safety net all too often is emergency rooms that are already crowded and a system that has a coverage gap or, unfortunately, our criminal justice system.

The capacity question here in Harris County is one that should draw attention. Having such a scarcity of access will place an inordinate demand on existing resources. The relief provided by the expanded footprint of behavioral health from the 1115 Waiver’s DSRIP projects, such as this crisis clinic, should be viewed as vital. We cannot afford to lose these new programs when the waiver expires later in 2016.

Fortunately, we have a resource locally that helps with the inpatient capacity that makes Harris County the envy of other places in Texas. I sat down with Stephen Glazier, Chief Operating Officer of the Harris County Psychiatric Center, or HCPC, to talk about the role his facility plays in helping provide capacity right here in Harris County:

GlazierBill Kelly: I’m here at the Harris County Psychiatric Center (HCPC) with Steve Glazier. Thank you so much for taking the time to meet with us today. I wanted to first go through and describe the mission and capacity here at HCPC and how it really fits into the behavioral health network of providers here in Houston.

Steve Glazier: So HCPC is primarily a short-term acute care psychiatric hospital. We do have a few units that are designed for patients that stay a little bit longer, three or four or five weeks, but the majority of beds are short term acute care which means the patients stay roughly seven to eight days. We are a 276 bed hospital. Currently, we are renovating units; we are going to have our 30th birthday in the fall and 30 years of 8,000 admissions a year. It’s time to do some renovations. So not only are we making the units nicer, we’ve been able to redesign them in a way that also makes them safer, it makes them more therapeutic. So we are keeping one unit closed, we will renovate it and move units in and then we go to renovate the next one so we are operating 250 beds right now. We are the second largest academic psychiatric hospital in the country and we stay functionally full all the time. What I mean by functionally full is if we have an empty bed, it only means that the patient that has been assigned to that bed hasn’t arrived here yet. Every morning we start the day with a list of anywhere from 30 to 45 patients waiting to come in. Most days we are able to find everyone a bed the same day. We get the same number of discharges in a day, but we stay very busy and functionally full all the time. Houston-Harris County has very, very few civil commitments to the state hospitals anymore, so HCPC essentially fills that role for this area as well.HCPCUT

Kelly: And you mentioned being one of the second largest in the nation with regards to academics so to be clear, who funds HCPC?

Glazier: The majority of the beds and the patient days are funded by the state, out of state general revenue. A smaller portion is funded by the county and then also a small portion are funded – we have a few beds that are available for patients with third-party funding, so another small portion is third-party funding. Most of our funding comes from the Harris Center, through our contract with the Harris Center. We do have one contract that is direct with the county with the juvenile probation department so we have one unit that is set aside specifically for adolescents from the juvenile detention center, but the majority of our funding comes from state general revenue.

Kelly: And with that, what’s probably the biggest challenge that you face here at HCPC in order to really carry out your mission?

Glazier: One of the biggest challenges is trying to do our very best with the beds we have to accommodate all the demand for admissions that we have. We take very seriously our role to try to make sure that patients that are in emergency rooms and in hospitals around the medical center, patients that have been court ordered into treatment, patients that are coming in from the neuropsychiatric center that the Harris Center runs, that when we get requests that we are able to get those patients transported here and admitted as quickly as possible. But trying to balance that with trying to manage the patients and treat the patients that are here as thoroughly as possible is a real challenge; it’s a balancing act. We don’t want to push patients out early just to make a bed for someone else who is waiting. On the same token, I don’t want patients to be waiting inordinately long times in an emergency room or a psychiatric center. So trying to manage that queue, that waiting list, can be a real challenge.

Kelly: And on that exact challenge, taking it to the state-wide level, you’re in a position to be able to look at the way the state of Texas delivers a lot of that care. Do you want to talk a little bit about that position, some of the thoughts you bring with your experience at HCPC to that council?

Glazier: One of the difficulties that we have right now, and it’s worse in certain parts of the state, is there are some patients that need longer term care than just short-term acute care, than just a week. And it’s very difficult sometimes to get a civil commitment to a state hospital where a patient can stay longer and get the treatment they need. That is something that we have to figure out because the lack of those types of beds, not only those but also the lack of residential treatment beds for adults which is another low level of care, the lack of supportive housing beds, the lack of a continuum of beds from longer term acute care to shorter-term acute care to residential to supportive housing is what is causing this constant recidivism of some of our patients and is also part of what is causing this huge number of psychiatric patients who are in the Harris County jail. The Harris County jail is commonly said to be the largest psychiatric institute in the state. In fact, the Harris County jail on any given day has more psychiatric patients that it is housing than in all of the state hospitals combined in the state of Texas. Part of the reason for that is that there are some gaps in our treatment system that if we could fill those, if we had better places that had some treatment of care to discharge someone from HCPC into, and also had sufficient case management services to surround them with, we could eliminate a lot of those recidivists and a lot of those patients who end up in jail.

Kelly: Well, thank you for your time. I know all of you are busy doing so many things so thank you so much for taking some time to be with us.

HCPC

The Harris County Psychiatric Center has helped thousands of Harris County residents, and yet we know thousands more needs services. Capacity, especially for inpatient mental health services, is a challenge for all of Texans.

There are many issues to be brought up during the interim, and we look forward to hearing more from Chairman Four Price’s Select Committee on Mental Health. We hope this look at capacity has shown how statewide policy must address the ability for those seeking inpatient care to find it, and the consequences of a lack of investment in access.

This is Minding Houston, I’m Bill Kelly.


 

Music: “Clear Your Head” by Cory Gray and back beats by Frank Nora

Minding Houston XV: Workforce Shortage? We have an app for that!

Welcome to the first Episode of Minding Houston for 2016. While it has been a while since we last spoke, we’ve been holding off as this episode isn’t just about policy discussions, it’s about results. And we need your help to get the word out about a program critical to the future workforce of Texas.

This is Minding Houston, I’m Bill Kelly

Astute listeners to this blog know that we have talked a lot about the mental health workforce being a big obstacle to access. In fact, we devoted a whole episode to it last February (See: Minding Houston IV), and almost a year to the day later, we are happy to announce the state of Texas is taking applications.

Senate Bill 239 by Senator Charles Schwertner creates the Mental Health Loan Repayment Assistance Program and is funded with almost $3 million. Details of the plan are shared below. The most encouraging aspect of the legislation (now law) is the recognition that it isn’t not just a lack of medical physicians, but the full spectrum of mental health providers are sorely needed to treat Texans.

LR slide
While in Austin talking about the lead up to the February 8th application launch, I was able to sit down with one of the leading voices for health care in Texas, Stacy Wilson of the Texas Hospital Association, to talk about the importance of this program:

 

StacyWilson and THA

Bill Kelly: Here with Stacy Wilson of the Texas Hospital Association. Thank you so much for joining me today.
Stacy Wilson: It’s a pleasure.
Kelly: We are talking about SB 239 and the specific loan repayment mental health professions bill. Who should really be looking at taking advantage of these monies.

Wilson: There are five groups of mental health professionals that are targeted under the bill: psychiatrists, psychologists, APRNs who have specialized training in mental health, licensed professional counselors, licensed clinical social workers.

Kelly: And I know we are big fans of the inclusion of social workers, especially in Houston, on it. When we talk about the monies that are available – and I know there is some restriction on exactly how many of each group can be included on that – what do people need to watch out for if they are interested in pursuing a degree in one of these fields?

Wilson: Well the great thing is that now we have included this beyond just physicians as you mentioned, but there are requirements around serving the CHIP and/or Medicaid populations and/or working in a state prison. So there are some certification requirements that you have to do, there is an application you have to fill out and at the end of each year in order to be eligible, you have to certify that you actually served that population and that you’ve met the other requirements.

Kelly: And we are going to be posting a link to information from the college coordinating board on our website, but what are some of the deadlines for people who would be applying for this for some of their graduate education?

Wilson: So what we’ve heard from the higher education coordinating board is that the applications will be available around February [8] and that they will probably be due around April 30. So there is a specific website that links to this as you have mentioned and those dates are a little flexible but obviously beginning February [8] you should start looking for them.

Kelly: And as we talk to different advocacy groups around our area, how important is this to get the message out about our workforce for behavioral health?

Wilson: It’s imperative. We can ask for all the services we want to ask and more impatient beds and outpatient services but unless you have that dedicated workforce, it doesn’t mean anything. So it is the backbone of everything else that we do

Kelly: Staci, thank you so much for joining us.

Wilson: Thank you so much

So, now here’s our deliverable. You will find a link to the Texas Higher Education Coordinating Board’s application for this program here. Now, we need you, the loyal listeners and mental health care advocates, to help get the message out by forwarding this information on to a number of audiences that need to hear it.

People we are targeting including undergraduate students looking to pursue a degree in one of the above-mentioned fields, current students already pursuing a graduate degree, college faculty or administrators, or anyone else who cares about access to mental health services.

Forward this message or cut and paste the URL for this blog to help us share this information. Our goal is to have as many people as possible help us spread the word about this new program. Texas deserves a workforce to help treat people suffering from a mental illness, and by getting the word out, you are doing your part to help make that happen.

Just as one of the newest mental health programs is rolling out, the Legislative focus is starting to heat up. On January 26th, the Senate Finance Committee, the budget crafting body for the upper chamber in the Texas Legislature, met to discuss two primary budget issues.

First, and what took up all of the media attention, was “Discussion on the Impact of Oil Prices and Production on State Revenue and the Budget” with Texas Comptroller Glenn Hegar testifying. Clearly, this was an important conversation to have, but for this session, it really boiled down to two numbers:

From the Texas Tribune:

Texas-Tribune

Texas Comptroller Glenn Hegar on Tuesday faced some skepticism as he sought to soothe lawmakers’ fears about what plummeting oil prices mean for the state’s bottom line.
“Is the sky falling?” asked Sen. Royce West, D-Dallas, at a hearing of the Senate Committee on Finance, which helps write the state budget.

“No, sir,” Hegar replied, adding that while there are “clouds on the horizon,” he’d rather be in Texas than in any other state.

“I just don’t want to live in a state of denial,” West responded.

{…}

Though Hegar has noted that oil’s plunge means Texas will send hundreds of millions fewer dollars toward road construction and maintenance than originally expected, the drilling slowdown should not leave lawmakers with a revenue shortfall, he said.

In fact, much of the certified revenue estimate Hegar released in October has stayed accurate — even though it was based on significantly higher oil prices — because producers are pumping more oil than anyone expected, Hegar said.

“The budget you passed – it works, and it will continue to work,” Hegar said, noting that lawmakers also left a significant cushion of unallocated funds.

That wiggle room totals about $4 billion, said Ursula Parks, director of the Legislative Budget Board.

There’s the number: a current $4 billion surplus of unspent funds available for the 2016-2017 session. Hegar’s assessment that despite the fall in oil prices that “the sky is not falling” is a very insightful remark. Especially in view of the second number.
According to testimony given by Comptroller Hegar on January 26th, the state has $9.6 billion in the Economic Stabilization Fund, commonly referred to as the state’s “Rainy Day Fund.” Given that the two-year total, or biennium budget, for the state was set at $209.4 billion, having almost $10 billion in the bank is a good position to be in, but should Texas not be spending some of that on needed programs?
The Pew Charitable Trusts released a report on January 19th describing how state’s save money in rainy day accounts and takes a special notice of Texas. Here’s what Pew writes about how Texas has decided to move on this issue:
Pew Trust log

Given the state’s other pressing budgetary priorities— particularly the need for improved water and transportation infrastructure and a desire to reduce the state’s total amount of outstanding debt—Texas lawmakers have been divided over whether the current level of reserves is sufficient or excessive.
At the heart of this debate lies a basic disagreement over the intended purpose of the Economic Stabilization Fund. “It’s become a surprisingly emotional issue in the political debate,” said Dale Craymer, president of the nonprofit Texas Taxpayers and Research Association and a former legislative aide who helped House leaders draft the 1987 constitutional amendment that created the fund. “The last two sessions, the rainy day fund has taken on this sacred nature that was never really intended. It was intended as a management tool.”
As revenue and spending pressures shift along with the booms and busts of the economy, states stand to benefit from the additional flexibility provided by robust rainy day funds to smooth over unexpected bumps in the road. Despite having billions of dollars in its rainy day fund, Texas struggles to answer the question of how much is enough because the state lacks a clear consensus on why the fund exists in the first place. Absent a clear purpose for saving, other states also find it extremely difficult to set a meaningful savings target, which can confound their efforts to manage the budgetary ups and downs of economic activity.

View Report: Pew Charitable Trusts – Why States Save

 

jane nelson

Senator Jane Nelson

While the Legislature deals with those numbers, one thing is clear: there is no need to cut services, especially for newly expanded behavioral health access. The Comptroller was clear in his assessment, and we hope lawmakers continue their investments in better access and quality of services, no matter what the cost of a barrel of oil.

The second part of the meeting, after all the media attention on oil prices left, was on behavioral health funding. Chair Jane Nelson was distressed about inaccurate news reports about how much Texas was spending on behavioral health.
As followers of Minding Houston, you should know all of our numbers come from the Legislative Budget Board, the same body that testified before Senate Finance. A link to their presentation is below, and as someone who has worked for a member of the House Appropriations Committee, these are the numbers I use when looking at state expenditures.

To give a recap of the presentation, the most informative slide is pictured below in what was the main point of the budget conversation: Texas spends about $3.6 billion in a biennium on behavioral health services across 18 agencies in 5 separate articles of the state budget. And as Chair Nelson repeatedly (and very rightly) points out, that total does not include Medicaid expenditures. See the slide below for a good breakdown:

BH Slide

With everyone on the same page with regards to the numbers (again, minus Medicaid), the Finance Committee expressed concern regarding the ability to coordinate spending and break down silos among various state agencies.
This is where Sonja Gaines steps in. As the Associate Commissioner for the Office of Mental Health Coordination for the Health & Human Services Commission, not only does she have a long job title, but a long list of programs to oversee and make work together.

SonjaGaines
A good example of how programs are being integrated came from Sean Hanna, Director of the Military Veteran Peer Network. He testified that after meeting with Gaines, this agency had begun to better coordinate with existing state resources of the Texas State Guard. This has greatly expanded the network of mental health peers working with our state’s armed services by maximizing existing resources.

The presentation notes that the statewide coordinating council should be developing a coordinated expenditure proposal for fiscal year 2017, and that as state budget writers, Chair Nelson will make sure any exceptional items match up within those plans.
The Health and Human Services Commission will submit that proposal to the Legislative Budget Board on June 1st of 2016.

Lastly, I wanted to mention that the new House Select Committee on Mental Health will be holding their first hearing on February 18th. We are looking forward to seeing what direction Chairman Four Price of Amarillo takes in the initial hearing.

 

photo series

Chairman Price, Rep. Thompson, Rep. Davis, Rep. Coleman

As a quick reminder, our Harris County members on this committee include Representatives Senfronia Thompson, Garnet Coleman, and Sarah Davis.

As the Legislature starts to dig into policy and resources, be sure to stay tuned to Minding Houston for the latest information on how mental health policy discussions translate to better access and services in Houston.

This has been Minding Houston, I’m Bill Kelly.

 


 

Music in this episode: “Viper” by Ray Rude, “True Hearts” by Nick Jaina, and “Fly Drexler” by Lazlo Supreme

Minding Houston XIV: Select Committee & Mayor Parker Interview

This November, one of the biggest moves for mental health policies happened in Austin. It wasn’t an election and there weren’t a lot of politicians present. But the leader of the Texas House, Speaker Joe Straus, has made sure that mental health will get more than its fair share of attention during the next legislative session.

And with the final month of her administration coming to an end, Mayor Parker talks about the shift in city policy when it comes to substance use and why funding the Mental Health Division in HPD is a must for city leaders.

It is all about leadership and focus. For December 2015, this is Minding Houston. I’m Bill Kelly.

The State of Texas has challenges regarding how much and frankly how little is invested in public mental health systems. The November 10th edition of the Houston Chronicle explains:

MASTHEAD-Houston-Chronicle

Texas spends less per capita on mental health care than all but a couple states in the nation. Seventy percent of the counties here do not have a single practicing psychiatrist. Forty percent of children experiencing emotional, developmental or behavioral problems do not get any help. And the state’s biggest provider of treatment is the Harris County Jail.

Fair to say, there is work to be done. And while many leaders have found it convenient to not to focus on this issue, Speaker of the Texas House Joe Straus has decided to take a look at the public mental health system head on. The Chronicle continues:

Now, lawmakers are making their most deliberate effort in two decades to address the problems. House Speaker Joe Straus on Monday formed a special committee to “take a wide-ranging look at the state’s behavioral health system for children and adults.”
The House Select Committee on Mental Health, the first such panel since 1995, will study mental health care, as well as substance abuse treatment, recommend ways to improve early identification and treatment, and increase collaboration and measurement of outcomes. It will pay particular attention to services in rural parts of the state and for veterans and the homeless.

“We owe it to taxpayers to make sure the system is as effective and efficient as possible,” Straus, R-San Antonio, said in a statement announcing the committee. Republican Four Price of Amarillo will chair the committee, with Democrat Joe Moody of El Paso as the vice chair.
Republican Sarah Davis and Democrats Garnet Coleman and Senfronia Thompson of Houston will be among the 13 members. The announcement came as welcome news to mental health advocates and providers, many of whom expressed optimism while also noting the long way the state has to go.

{…}

The membership of the new panel also sparked optimism for advocates, such as Bill Kelly of the Houston chapter of Mental Health America, who noted that key budget-writers such as Price and Davis were included alongside policy experts such as Coleman and Thompson.
“That’s the A team,” Kelly said.
Coleman said that he expected the committee to make a difference, including by finding innovative ways to improve care without huge costs. “Mental health crosses into so many areas of public policy, whether it’s criminal justice, juvenile justice, education or health care in general and this is the best way to look at it, by bringing together people who are familiar with the different areas,” he said. “This is a great thing.”

{..}

According to the advocacy group Mental Health America, just 36 percent of Texas adults with mental illness receive help – 44th in the nation. For kids, the estimate of 40 percent is from Kaiser.
As a result of all that, the state’s criminal justice system has become the biggest provider of psychiatric treatment. Around 76,000 people with mental illness were arrested in Texas for minor crimes last year, according to the Texas Department of State Health Services.

One of the most encouraging statements from Speaker Straus in forming this committee was his wide-ranging view of how mental health affects different areas of government. With members from Corrections, County Affairs, Public Health, Criminal Justice, and perhaps most appropriately from Appropriations, Speaker Straus has ensured a comprehensive look at policy. In a supportive editorial, the Chronicle said of the committee, “it will take an IMAX-style approach, at least, to encompass the range of deficiencies in mental health treatment.”

While I would always question that Bill Kelly guy, the local members from Harris County delegation appointed the Select Committee are serious players that can be a strong voice for local concerns.

 

davis

Representatives Davis, Coleman, and Thompson

For example, Rep. Garnet Coleman is the chair of the County Affairs Committee and has been a leader in helping change the process and procedures for law enforcement on jail intake forms. He is widely regarded as the state’s expert on mental health policy in Texas.

Rep. Sarah Davis was one of the 5 House members on the Budget Conference Committee last session while also serving on the House Appropriations Subcommittee on Health & Human Services. She is one of the most knowledgeable members in either the House or Senate when it comes to mental health funding in Texas.

Rep. Senfronia Thompson is one of the most effective Texas House members . . . well in history. According to Capitol Inside’s Mike Hailey, “Thompson has shepherded more legislation successfully than any other state representative here in the past half-century if she isn’t the all-time leader in the respect.” For those that know, Mrs. T will fight for the “little dogs” and get things done.

For these committee members, MHA of Greater Houston will be looking to provide information and policy positions that can best represent the strengths of our region and also identify the shortcomings. Making sure our lawmakers have the best information available is exactly what the legislative advocacy of MHA of Greater Houston is all about.
As some of my fellow Houstonians listening to this can testify to, we’ve recently had an election in Houston. With a new Mayor, we wanted to sit down with Mayor Annise Parker to look back at the accomplishments of her administration and how she sees behavioral health policy at the municipal level.

The-Influentials-Mayor-Annise-Parker-January-2014_071823

Mayor Annise Parker

Bill Kelly: We are here at City Hall with Mayor Parker. Mayor, thank you so much for sitting with us today for Minding Houston. We greatly appreciate it.
Mayor Annise Parker: Glad to do it. You know I don’t have many days left so it’s nice to look back over the accomplishments.

Kelly: Well, first question, when you supported the creation of The Sobering Center, were you actively looking at changing the city’s response to substance use and addiction from a criminal justice setting to more of a health care treatment one?

Parker: I would love to say that was the foremost reason I was doing it. It was really a much more practical need and the way it turned out we were able to address several important issues at one time. The city of Houston is the last big city in Texas that has its own jail. That’s a county function. Cities have gotten out of the jail business and we have been under a consent decree for at least two decades, trying to shut it down or rebuild it. The real solution is to merge with Harris County and one of the reasons that we had been unable to do it is just the capacity of Harris County. We did some analysis and on a given year we would arrest 17,000 to 19,000 people for public intoxication of some kind. And if we could take those out of the inmate stream it would significantly reduce the census and make that arrangement with Harris County easier. At the same time as we began to analyze, a wealth of benefits came out. It was an opportunity for intervention, clearly. It was an opportunity to get a police officer who picks somebody up out of the street faster. Fifteen minute turn around at the Center for Sobriety rather than a couple of hours booking somebody into jail. It means that someone doesn’t have a criminal record and there is a whole host of problems that come when you criminalize the behavior and hang that arrest record on somebody. And then finally, it costs significantly less to put someone in the Center for Sobriety than it is to put somebody in jail. So it was a win-win-win-win and it has absolutely proved that. Going forward now that we have a few years of history with the Center for Sobriety, the challenge has been that it has to be routine for law enforcement. You have to train them to really look at who they are picking up and make an informed decision and it has to become habit. We have broadened it; it started with police officers and broadened it to the larger law enforcement community here in Houston and they just have to get it to be a routine. But the next thing we have to do is – we don’t do a forced intervention. The premise is you come, you stay four hours minimum or until you sober up and are able to leave on your own, and you don’t have to talk to a counselor although the counselor is there. You don’t have to do anything but just get yourself under control and you can walk out the door. Well, then we discovered the frequent flyers that cycle through over and over and over again. And so this is a neutral space where all of the various agencies deal with addiction and substance abuse so all those turf wars don’t have to break out. We have a number of partners there, so now we are gradually adding in the appropriate level of intervention where someone is clearly a danger to themselves. If you are coming through more than once a month – even that is a lot, but at more than once a month we have to do something. So that’s the next phase and I am very, very excited about that.

Kelly: Picking up on some of your comments, the mental health division of the HPD is one of the national models and it is the only mental health division in the state of Texas for any major police department. What made you, in some lean budgetary times, make the investment in this public safety team?
Parker: Well again, it’s a very practical decision because we recognize that a lot of the interventions from the mental health team are in our homeless community and it dovetailed with the initiative that began four years ago to move the needle on homelessness. People aren’t chronically homeless because they like living outside. People are chronically homeless because they have substance abuse or mental health issues or both. So in the mental health unit they interact with an individual who may be in their own home and in crisis, but on a daily basis they also interact with the folks on the street who are chronically homeless and, in fact, they were among those who came to me and said ‘You know, we really need to do something to these folks other than put them in jail.’ Or send them over to the emergency rooms, which is the most expensive care you can provide. Sometimes doing the right thing, the most humane thing is also the most cost effective. It’s just a matter of analyzing why you are really doing something and how you are doing something and seeing if there is a better way.

Kelly: At a recent celebration at The Sobering Center you were able to say some remarks and really see this project to completion or to the status that it has become today. It was a particular person that you mentioned and pointed out who had dealt with addiction and substance abuse and was really an inspiration to you. What would you really look back and say, in view of the accomplishments of creating The Sobering Center and the expanded mental health division in HPD as it relates to him?

Parker: Well first I would say that many of us in America have people in our families that have dealt with addiction and substance abuse, as have I, but what is important is being able to acknowledge those who have dealt with their demons successfully and can be a resource to others and an inspiration to others. My very, very close friend of 30 years is a local judge. He has publically acknowledged that more than 25 years ago he had a substance abuse problem. He himself was arrested and he did what he needed to do. He faced his problems, he still goes to AA, he counsels others who have addictions. We have to get past the stigma of talking about substance abuse problems and addiction and the fact that he is a former elected official – I know he hopes to return to the bench in the future – but that he had made it a part of what he offers that it made him a better judge because it gave him compassion and understanding. He created our homeless court because he had that heart for what some of these folks who were in homelessness were going through. You can’t address addiction with punitive measures. It solves one piece of the problem, but it doesn’t solve the problem and it doesn’t heal the person. You have to have a combination of carrots and sticks and support and compassion and the worst thing you can do is to make it something to be ashamed of.

Kelly: Last question for you, Mayor Parker, in view of this week’s election what advice would you give incoming Mayor Sylvester Turner about the city’s role in mental health and substance abuse addiction issues?

Parker: The city has to be a full partner in this because it affects the greater society. It affects us directly through law enforcement, emergency services, through our health care system but it also affects us as a society and rather than treating it as ‘well, all we as a city only have to focus on – we arrest them, we take them here or there.’ We have to be a partner and I trust that the new mayor understands that and will continue to do that because he will have the opportunity to see how well our homeless team in the city of Houston and the mental health unit of HPD and the folks at The Sobering Center and our many, many nonprofit community partner based organizations that are engaged in this space all work seamlessly together to make sure that we give a safe dignified place to sober up if that’s what’s needed or assistance to those who need help and we keep everybody healthy together.

Kelly: Mayor Parker thank you not only for your time but for your service and particularly what you have done for behavioral health here in Houston.

We offer our sincere congratulations to Mayor-Elect Sylvester Turner. Turner’s concerns about mental health are clear not only from his voting record in Austin but also the fact that his campaign website had a “mental health” platform on his Issues page. A link for that page is below, as well as this picture of his campaign’s door hangers that specifically mentions mental health investments.

Our hope is that the incoming City Council members have the same focus that Mayor-Elect Turner has in continued support for our city’s behavioral health programs.
From all of us at Mental Health America of Greater Houston, we wish you very happy holidays and hopes for an exciting and prosperous new year!

This is Minding Houston, I’m Bill Kelly.

Minding Houston XIII: Minding Houston XIII: Post Session Drama! Medicaid Rate Cuts & Jail Suicide Hearings

So after a Legislative Session that boosted mental health funding and saw the passage of important new laws and programs, how do two issues continue to make the front pages? Turns out that advocacy for mental health services isn’t confined to any legislative calendar. In this episode, we will look at the issues around recent Medicaid rate reduction for children’s therapy and new hearings focusing on jail suicide prevention that continue to generate headlines.

This is Minding Houston. I’m Bill Kelly.

MedicaidNow you may be asking: What is this all about? And why wasn’t this handled during the Legislative Session?

Well, turns out that the budget really isn’t as set as you would think it would be. Several riders direct various state agencies to do certain things, and Rider Number 50 for the Health and Human Services budget is one of them. Emily DePrang of the Quorum Report gives the specifics about how this rider looks at cuts to the Texas Medicaid Acute Care Therapy Program. She writes:

As written, they’ll slash by 25 to 90 percent what Texas pays for medically necessary physical, occupational and speech therapy through the Texas Medicaid Acute Care Therapy Program, which serves about 440,000 poor people with severe disabilities each year, most of them children. Advocates say at least 7,500 therapists will lose their jobs and 60,000 children will lose access to medical care because of the cuts. HHSC can’t refute these claims because it conducted no research in potential impact before announcing the new rates on July 8th.

Why would our Health & Human Services Commission decide to cut the reimbursement to acute care therapies for children with disabilities without doing the proper research on insuring access to services were maintained?

Texas-Tribune

That’s what our elected officials in both parties wanted to know. In an excellent piece by Texas Monthly’s Erica Grieder, the leadership of the Texas Legislature is pushing back hard against the HHSC decision. She reports:

As of August 20th, half a dozen Republicans had sent letters of concern to HHSC Commissioner Chris Traylor, asking him to hold off on implementing those changes until the probable effects could be assessed. Joe Straus, the Speaker of the House, said the same in a Facebook post on September 10: “I expect the Commission to keep us in compliance with federal law as it works through a new proposal. I also believe it is the agency’s responsibility to inform the Legislature if the proposed reductions would harm access to care and network adequacy.” And last week, Robert Garrett, of the Dallas Morning News, reported that Representative John Otto and Senator Jane Nelson–the chairs of House Appropriations and Senate Finance committees respectively—have sent their own letters to Traylor, insisting that the cuts be implemented only if access to care is preserved, and if the state remains on the right side of federal law.

Now, let’s take a step back and remember where we are coming from with this budget. Grieder writes:

On April 1, the House passed its biennial budget bill, which came in at $209.8 billion, and included $62.9 billion for Medicaid. On April 14, the Senate passed its version of the budget, which was bigger, at $211.4 billion overall, but included $800 million less for Medicaid. On May 29th, after House and Senate budget conferees hashed out their differences, both chambers passed the final budget, which authorized $209.4 billion in spending for the 2016-17 fiscal biennium. Of that, $61.2 billion was appropriated for Medicaid–less than either chamber had sought in their respective budgets.

Budget Graphic

So that’s the situation, a budget with lower funding for Medicaid than either the House or Senate passed. As you can imagine, Representatives on both sides of the aisle warned this would be bad. Grieder continues:

On April 22, for example representatives Sylvester Turner, a Democrat, and Bryan Hughes, a Republican, spoke at a rally at the Capitol, where they warned that the Senate’s proposed budget would necessitate severe cuts to Medicaid therapy services. When the conference committee budget came back to the House floor for final passage, John Zerwas and Dan Huberty, both Republicans, flagged concerns about the cuts now in question.

Texas Monthly points out that both the House & Senate chief budget writers are on record as opposing this drastic cut, it concludes with this:

This is a pretty sloppy way to run a major state, clearly. Still, we shouldn’t make poor disabled children pay the price for political exigency. HHSC should hold off on implementing the cuts as planned.

So we’ve heard from the Legislative leaders, but we haven’t heard much from the Governor’s Office. And with that silence came increased attention. After all, HHSC is an executive agency, so it would be natural for the Governor’s office to communicate with HHSC on implementation of the rider.

I’ll leave it to Harvey Kronberg, perhaps the most respected journalist covering the Texas Capitol, to talk about his search for information and the challenges he experienced:

Kronberg

Capitol Tonight: Harvey Kronberg with the Quorum Report goes on the agenda with us tonight and you know this Medicaid cut story of course is still with us. The governor publically made a comment on Friday during that emotional hearing that took place here in Austin. What did he have to say?
Harvey Kronberg: He simply said that they were working out legislative intent which was due to the Medicaid funding cuts. Of course the second half of legislative intent was to do no harm and the cuts that they are proposing do extraordinary harm.
CT: And in the mean time I know you posted your thoughts about a request for information from the governor’s office regarding all of this. What were you after and what was the response?
Kronberg: Well, the governor’s office has been amazingly nonresponsive on this really fairly significant issue, one that has gotten the legislature reengaged by being essentially appalled by the fact that they are going to do 90% cuts to providers for severely disabled children. So we have not been able to get a comment out of the governor’s office so we simply did an open records request to seek the communication between the governor’s office and the Department of Health and Human Services to see if they were trying to solve the problem or were they part of the problem. They did an extraordinary thing, something that I have never seen in almost three decades of doing this: they invoked the entire Public Information Act and said they were not going to respond and turned it over to the Attorney General’s Office. Now, anybody that reads the Public Information Act will see that includes things about exemptions for sexual offenders, for automobile accidents. Typically when someone uses the Public Information Act not to respond they cite what the clauses are that they used.
CT: And you point out about what was said during the campaign.
Kronberg: It’s still on his website unless he’s taken it down that he’s going to be the ‘Transparency Governor’ and this is anything but transparent. And it’s not unreasonable to conclude that if they are trying to hide their emails that they are actually not trying to solve the problem. The legislative budget board has a lot of discretion in being able to move funds around and enact legislative intent. It’s perfectly capable of resolving this problem if it has got gubernatorial support and legislative support. At least the House seems to be resolved and certainly the Senate finance chair seems to have come around so I’m not sure why the governor is being so mysterious and guarded in terms of his office’s communication with Health and Human Services.

So, with disagreement between the Legislature and the Governor’s Office, it took the third branch of government to break the tie. And in this case, the Court’s stepped in to provide relief for Texas families. Edgar Walters with the Texas Tribune reports:

Deep cuts to a therapy program for poor and disabled children will not take effect Oct. 1, a state district judge ruled Tuesday afternoon — the second such delay in recent weeks.

“Procedurally I’m not making a determination that these acts are valid or invalid,” said State District Judge Tim Sulak in his announcement that he would grant a temporary injunction to prevent the state from slashing payments to therapists. But he said he made his ruling in part because he’d been convinced the cuts could jeopardize the health of children receiving the therapy services.

The health commission says it’s just following the Legislature’s orders by implementing the cuts, and that opponents’ claims providers will stop treating disabled children are exaggerated. In closing arguments, Eugene Clayborn, a lawyer representing the state, said there was “no evidence” of critics’ arguments that “the sky’s going to fall in” because of the cuts.
“There will still be access to care,” he said.

The lawyers suing the state focused much of their argument on trying to disprove that point. Owners of home health agencies in North and Central Texas testified that their businesses would be forced to close, including in markets where they are the main provider of therapy care.

And they presented evidence from inside the health commission that shed light on the agency’s discussions around access to care.

One director at the health commission testified that state employees had been told never to say that they were certain the cuts would not jeopardize access to care.

And an internal memo from the health commission presented by Dan Richards, a lawyer suing the state, warned that payment cuts to therapists “could have serious negative implications for the maintenance of an adequate therapy provider base.”

So for now, it seems that the Texas Medicaid Acute Care Therapy Program will not see the dramatic rate cut, at least until the state appeals this decisions. Stay tuned to Minding Houston as this public policy drama continues to play out.

Next, we move to another issue making headlines: jail suicides. After the legislative session ended, two committees have taken up this issue in interim hearings: The House County Affairs Committee, chaired by our friend and Houston, and the Senate Committee on Criminal Justice chaired by Houston’s own Senator John Whitmire.

COLEMAN

Representative Garnet Coleman

During Rep. Coleman’s hearing, a number of officials testified about the huge challenge that County Jails face in Texas. Brandon Wood with the Texas Commission on Jail Standards testified first, and the hearing was reported on by our friends with the Houston Chronicle. They report:

The announced ramp-up of anti-suicide measures came as Brandon Wood, executive director of the Texas Commission on Jail Standards, which monitors jail conditions, told the House committee that half of the record 29 people who have committed suicide in Texas county jails this year told jailers they were suicidal when they arrived at the lockups.

The increased number of jail suicides this year – compared to 22 in 2014, 25 in 2013, and 23 in 2012 – has become the focus of several ongoing investigations and legislative inquiries, spurred, in part, by the July 13 death of community activist Sandra Bland in the Waller County Jail.

Despite general support from sheriffs to stop suicides, some counties already have expressed concerns about the additional costs the changes could bring in areas of Texas where jail budgets are small and taxpayers cannot pay for expensive new programs. In years past, several plans by state officials to impose tougher rules on county and local jails have been scuttled by opposition from local officials who oppose unfunded state mandates on their jail operations and who wield considerable clout with local legislators.

Wood said the new intake screening form is designed to help jailers better identify potentially suicidal inmates.

“We need to make this as user friendly as possible,” he said. “I’m willing to try just about anything to prevent these suicides, if we can.”

Previous screening forms asked jailers whether they suspected an inmate was suffering from mental illness. The new form removes that subjective element, officials said; if inmates give certain answers, jailers are required to notify their supervisors and contact local mental health authorities.

The form also uses a grading system to serve as an additional guide to jailers on when to contact mental health professionals even if an inmate’s answers would not immediately initiate a referral.

A draft of the new form can be found below. Mr. Wood promised to continue to work with the committee on how they could immediately change both the form and procedures during the interim.

LINK: Screening Form for Suicide and Medical and Mental Impairments

But changing the form isn’t going to be enough for the Senate Criminal Justice Committee. Before his hearing on September 22nd, I was able to sit down with the Dean to find out his ideas on preventing jail suicides:

Bill Kelly: I’m with the Dean of the Texas Senate, Senator John Whitmire, chair of the Senate Criminal Justice Committee. Senator, thank you so much for taking time to meet with us today. So Senator, we were at Representative Coleman’s hearing and you heard a lot about jail intake forms. And a lot of this has been made about moving away from subjective questions on there to more of a standard operating procedure. What do you think about the changes to intake forms and are there any other immediate fixes we can do to address jail suicides?

Sen. John Whitmire: Well, I think reviewing the forms is proper and in fact today in our hearing we will hear about the new forms and they are going to be much more comprehensive at intake.

But I’m quickly pointing out that you can redo all the forms you want, but if the person doing the screening is not trained, if the person doing the screening does not have the right compassion and attitude, doesn’t work for the right person, you can have all the new forms you want and we will still have a difficult situation. Because I think it gets down to attitude, you want to treat people in intake like you would like to be treated or one of your family members and that’s just not the case today particularly as they review any concerns for mental health or emotionally disturbed individuals. You can see it, you can question it, fill out the forms, but if you do not respond properly we will still have a person in danger.

Kelly: And Senator you have been a longtime critic of the budget cuts, particularly in 2003, to mental health services and other state services and now we have seen some of the biggest advocates for mental health services be our law enforcement community. Has their advocacy changed some of the minds of your peers when it comes to funding mental health services?

Whitmire: It’s impacting the legislature and, to some degree, local governments who often times have to pay for the jail. The problem is that it’s too slow. Obviously you know me well, I’m an impatient person. We have identified a problem and we haven’t attacked it to the degree that it needs to be. Law enforcement is recognizing and talking about it more because its impacting their criminal justice system. It’s using up valuable resources for largely non-violent low-level offenders who are mental health patients so it’s beginning to interfere with law enforcement’s main mission of going after dangerous criminals. It’s kind of a culmination of “let’s be tough on crime but we can’t do that if we’ve got these nonviolent folks.” I’m encouraged that we are having a grown up discussion, but we’ve got a hell of a long way to go.

Kelly: Senator, last question. I know the push to address a lot of this jail suicide issue has been very bipartisan. When it comes down to really making a difference a lot of times it’s going to take funding. Do you feel confident whether its increased money for training for jailers, whether its increased inspection money for the Texas Commission on Jail Standards do you have faith that your Republican colleagues will stand with you for allocating funding?

Whitmire: There’s been indication in recent sessions. Joan Huffman and a Senator from Houston helped fund a pilot diversion program for mental health for individuals in Harris county jail. That was a good start but still we’ve got to do a lot more. My colleagues are very fiscal conservative and what I’ve got to convince them is that you either pay now or you pay later. You either pay upfront with treatment and counseling and medication and diversion programs and alternatives to incarceration or you are going to pay later not only in dollars but you could be a victim and certainly we will have compromised the life of the individual who needed the treatment. We got a lot of work to do.

I hate to put a cost factor on doing the right thing, but I do work in an environment – the Capitol – where it’s not uncommon to leave money unspent so they can say that they are fiscal conservatives. I made a commitment to the mental health community ten years ago when I recognized that they didn’t really have a lobby. They didn’t have someone in your position as we do today. We have got to get people, as I have committed. I won’t give a speech about anything dealing with criminal justice without mentioning mental health because they don’t have a paid lobby; they have an organization such as yourself, but they don’t have the lineup that big business and big labor has. The only lobby that they are going to have are the legislators that care and the people of Texas and so our work is cut out for us.

Kelly: Absolutely. Senator, thank you so much and best of luck in the hearing today.

The Senator got a lot of confirmation during the hearing on his analysis of the impact mental healthcare has on the criminal justice system. One of the best presentations was provided by Lauren Lacefield Lewis, Assistant Commissioner for Mental Health & Substance Abuse Services for the Department of State Health Services. Some quick numbers to consider:

  • As of August 1st, 2015, approximately 66,625 individuals were in Texas county jails
  • An estimated 30% of inmates have one of more serious mental illnesses
  • This equates to nearly 20,000 people in Texas county jails with serious mental illnesses

Now, with those numbers in mind, check out this slide for the cost the criminal justice system bears in housing and treating individuals suffering from a mental illness.

From these numbers, it is clear that the provision of mental healthcare on the front end is ¼ the cost of prisons and jails per day, with a yearly savings of $15,000 per individual. For the 20,000 people in Texas County jails with a serious mental illness, if we were able to divert just half into treatment, it would save the state $150 million a year.

We hope the Senator will let his colleagues know, even in Texas, that’s a LOT of money.

Texas-TribuneThe Texas Tribune’s Johnathan Silver reports from the hearing about the popularity these savings could have with both lives and money:

Diversion, the overwhelmingly preferred treatment for low-level offenders with mental health problems would work best with coordination among mental health authorities, law enforcement, jails and courts, lawmakers said.

If an inmate has a mental health problem, all those entities should work together to move them into treatment as soon as possible, Whitmire said, adding that it shouldn’t be an issue in rural areas where officials likely know each other well and can use that as a benefit to help with seeking treatment.

{…}

Ultimately, Whitmire said, the state has a responsibility to address this issue because if it denies someone their freedom, there are constitutional responsibilities involved in caring for people in custody.

“A lot of it gets down to attitude and cultural awareness,” Whitmire said. “You have to recognize mental health and emotional problems.”

Sen. Charles Perry, R–Lubbock, injected caution throughout the hearing, warning that the state risks having a knee-jerk reaction to high-profile cases such as Bland’s and not seeing that protocol is not the enemy. He asked Wood what ultimately led to Bland’s death.

“People not following through, first and foremost,” Wood said.

CHRONICLEWell, to follow through on the local end, this report from the Houston Chronicle’s Mike Ward notes the testimony of someone we know quite well from the City of Houston:

Houston Police Chief Charles McClelland detailed how his agency has implemented a program to do just that in the city jail, which, as a municipal lockup, is not regulated by the state.

Whitmire and other lawmakers have suggested that municipal jails should be regulated by the state, like Texas’ 242 county jails.

McClelland said the Houston jail that handles about 75,000 low-level offenders annually has had only two suicides in recent years, including this year, and has beefed up mental health screenings, supervision and interventions.

Chief McClelland testified about the fabulous work done by the Mental Health Division of the Houston Police Department. From the Homeless Outreach Team to the Chronic Consumer Stabilization Initiative, McClelland was very proud of the work done but emphasized the training that new HPD cadets receive as part of the academy.

MCCLELLAND

Houston Police Chief Charles McClelland

As we’ve mentioned, Houston is recognized by the Department of Justice for having one of six national training sites for Crisis Intervention Training (or CIT) in the country. As Senator Whitmire has said, your programs are only as good as the people implementing them. In Houston, we are lucky to have some of the best.

Now, neither of these two issues will be solved any time soon. But they will need people to advocate for them: for their importance on the agenda and in the budget. That’s exactly what we hope to do in the lead up to the 85th Legislative Session in 2017.

For now, this is Minding Houston.
I’m Bill Kelly.