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