1. Adult Community Mental Health Services
Presented By: Courtney Harvey, Ph.D.
Minority AIDS Initiative Summit
December 2, 2015
Copyright © Harvey, C. (2015)

2. Texas Department of State Health Services
Established in 2003 via House Bill 2292
Merge between the Texas Commission on Alcohol and Drug Abuse and the Texas Department of Mental Health and Mental Retardation
The agency operates as the regulatory agency for the provision of public mental health and substance abuse services.
There are five divisions within DSHS to include the following:
The Division for Mental Health and Substance Abuse Services
Division for Family and Community Health Services
Division for Regulatory Services
Division for Disease Control and Prevention Services
Division for Regional and Local Health Services

3. How we structured as a division.

4. Texas Department of State Health Services
DSHS Budget Strategies
Biennium
Community Mental Health Services: Adult
$551,354,323
Community Mental Health Services: Children
$125,495,554
Community Mental Health: Crisis Services
$168,132,374
NorthSTAR Behavioral Health Waiver
$210,169,317
Substance Abuse Prevention, Intervention, and Treatment
$291,210,871
Mental Health State Hospitals
$809,542,313
Mental Health Community Hospitals
$150,740,973

5. NorthSTAR was developed as an effort by Texas to make its Medicaid Program operate more efficiently through the use of managed care. In the early 1990’s, the state began to adopt managed care as a strategy to achieve desired healthcare goals.
Texas launched a number of Medicaid Waiver Programs under the name of STAR. These plans typically placed primary healthcare and mental health services under the same managed care plan.
NorthSTAR was a Medicaid Waiver Pilot Program launched in 1999 which separated out mental health services from primary care services being provided under one plan. Essentially, with this pilot, mental health and substance abuse services that were provided separately under TCADA and TDMHMR were housed under one plan. These services are operated in a 7-county area in the greater Dallas area.
Our NorthSTAR offices contracts with a Behavioral Healthcare Organization – ValueOptions who is responsible for maintaining an adequate provider network, paying network providers, and managing the care of individuals authorized to receive services in this system.
Copyright © Harvey, C., & Perez, J. (2015)

6. Adult Community Mental Health Services: The Culture
Barriers to Accessing Community and Inpatient Mental Health Services
Inpatient Services
Increase number of individuals on forensic commitments
Forensic: Individuals determined Incompetent to Stand Trial or Acquitted Not Guilty by Reason of Insanity
Mental health workforce shortages – psychiatrists and social workers
No staff to accommodate patient census and level of acuity
Community Services
Substandard clinical assessments that do not reflect medical necessity for the types of services being sought
There is an intellectual acknowledgment that recovery is possible, but, behavior/practice does not reflect this belief
Failure to transition individuals out of services where possible

7. Access and Admission to Community Mental Health Services
Myths
1. The individual must be diagnosed with Major Depressive Disorder, Bipolar Disorder, or, Schizophrenia
Though this is commonly communicated to the public, it is false
Truth: Local Mental Health Authorities can provide mental health services to individuals who do not meet this diagnostic criteria, as long as they have been determined to have a Global Assessment of Functioning of 50 or below
2. Services are provided free of charge
Truth: Fee assessments are conducted with each individual seeking services. If it is determined that payment for services can be made, costs are assessed on a sliding scale
If an individual does not have a third-party payer source, services will still be provided

8. Access and Admission to Community Mental Health Services
Past Philosophy: Mental Illness and Recovery
Prior to September 1, 2013, DSHS utilized a disease focused model as the foundation for the delivery of mental health services
Resiliency and Disease Management (RDM)
A primary aim of RDM was to ensure the provision of interventions that had empirical support and to eliminate or manage symptoms and promote recovery from psychiatric disorders
Other aims of the project included:
establishing who was eligible to receive services
establishing ways to manage the use of services
measuring clinical outcomes or the impact of services and
determining how much these services should cost

9. Access and Admission to Community Mental Health Services
Uniform Assessment
An assessment tool developed by DSHS that includes, but is not limited to, the Adult Texas Recommended Assessment Guidelines (TRAG), the Children and Adolescent Texas Recommended Assessment Guidelines, and the department-approved algorithms (25 TAC, Chapter 412, Subchapter G)
Note: This definition is outdated and must be updated to reflect the current Uniform Assessment

10. Access and Admission to Community Mental Health Services
Under RDM
Texas Recommended Assessment Guidelines (TRAG)
Risk of Harm
Support Needs
Psychiatric-Related Hospitalizations
Functional Impairment
Employment Problems
Housing Instability
Co-Occurring Substance Use
Criminal Justice Involvement
Depressive Symptomatology (MDD Only)
This represents each domain that was captured on the TRAG.

11. Access and Admission to Community Mental Health Services
Texas Recommended Assessment Guidelines (TRAG)
Ratings: Most dimensions were rated on a scale of 1-5
Example:
Risk of Harm

12. Access and Admission to Community Mental Health Services
Risk of Harm con.

13. Access and Admission to Community Mental Health Services
Risk of Harm con.

14. Access and Admission to Community Mental Health Services
Radical Change in Philosophy: Treatment of Mental Illness
September 1, 2013
DSHS implements Texas Resilience and Recovery (TRR) to replace Resiliency and Disease Management
TRR
TRR is representative of SAMSHA’s initiative.

15. Access and Admission to Community Mental Health Services
New Uniform Assessment
The Adult Needs and Strengths Assessment (ANSA)
Developed by John Lyons who is a Senior Policy Fellow with the University of Chicago
It is a tool that is used internationally, though, the instrument is modified by state, or, country to fit the needs of each system
All persons who administer the ANSA must become certified through the Praed Foundation
The Praed Foundation is public charitable foundation committed to improving the wellbeing of all through the use of personalized, timely, and effective interventions
For Texas, reliability of scores on the instrument averages .78
Focus on needs as well as strengths
TRR - Adult Needs and Strengths Assessment (ANSA)

16. Adult Mental Health Services
Full Level of Care (LOC): Utilization Management
Delineation between a Level of Care vs. a Full Level of Care
Level of Care:
Ranges from 0 – 5 (i.e., LOC-0, LOC-1M, LOC-1S, LOC-2, LOC-3, LOC-4, and LOC- 5)
LOC-0: Crisis Services – Authorization period of 7-days
LOC-5: Transitional Services – Authorization period of 90-days
Full Level of Care
Ranges from 1 – 4 (i.e., LOC-1M, LOC-1S, LOC-2, LOC-3, LOC-4)

17. Adult Mental Health Services
LOC-1M
LOC-1S
Full Level of Care (LOC): 1M
Authorization period: 365 days
Pharmacological management
Routine case-management services
Psychiatric diagnostic interview examination
Authorization period: 180 days
Pharmacological management
Routine case-management services
Skills training and development
Supported employment
Supported housing
Cognitive-Processing Therapy
Peer Supports

18. Adult Mental Health Services
LOC-2
LOC-3
Authorization period: 180 days
Pharmacological management
Routine case-management
Cognitive-Behavioral Therapy
Medication training and supports
Skills training and development
Supported employment
Supported housing
Peer supports
Cognitive-Processing Therapy
Authorization period: 180 days
Pharmacological management
Psychosocial rehabilitative services
Supported housing
Medication training and supports
Supported employment
Cognitive Processing Therapy
Residential treatment
Day programs for acute needs

19. Adult Mental Health Services
LOC-4
Assertive Community Treatment
Authorization period: 180 days
Pharmacological management
Psychosocial rehabilitative services
Supported housing
Medication training and support services
Supported employment
Cognitive Processing Therapy
Cognitive Behavioral Therapy
Residential treatment

20. Adult Mental Health Services: Evidenced-Based Practices
Illness Management and Recovery (IMR)
IMR is designed to help people with serious mental illness work with professionals to reduce their susceptibility to the illness and cope with their symptoms. IMR helps people discover, or rediscover, their strengths and abilities for pursuing personal goals, and developing a sense of identity. This allows them to grow beyond their mental illness. IMR is a treatment that is delivered through the use of the Substance Abuse and Mental Health Services Administration Toolkit.
Assertive Community Treatment (ACT)
Individuals who receive ACT services have serious mental illnesses that get in the way of living a quality life. Most of these individuals have had multiple hospitalizations. Treatment involves a multidisciplinary treatment team to include psychiatrists, nurses, and case- managers. Caseloads are small as defined by no more than 10 people. Treatment is targeted to include medication management, housing, substance abuse treatment, and employment.

21. Adult Mental Health Services: Evidenced-Based Practices
Permanent Supportive Housing
Permanent Supported Housing: Activities to assist individuals in choosing, getting, and keeping regular housing in the community. Services consist of assistance in finding and moving into habitable, regular, integrated (i.e., no more than 50% of the units may be occupied by individuals with serious mental illness), and affordable housing. Supported housing includes:
Housing Assistance - Funds for rental assistance. To receive rental assistance, the person must apply for Section 8/public housing or have a plan to increase his or her income so he or she can afford housing without assistance. Housing assistance without services and supports cannot be counted as supported housing.
Services and Supports - Assistance finding, moving into, and maintaining regular integrated housing that is habitable. This includes treatment to facilitate recovery.

22. Adult Mental Health Services: Evidenced-Based Practices
Supported Employment
Intensive services designed to assist the person in keeping a job and providing assistance in choosing, getting, and keeping employment in regular community jobs. Includes activities such as:  
assisting the individual in finding a job;
helping the person fill out job applications;
advocating with potential employers;
assisting with learning job-specific skills; and
employer negotiations.

23. Adult Mental Health Services: Evidenced-Based Practices
Cognitive-Behavioral Therapy
Individual, family, and group therapy used to lessen a person’s symptoms of mental illness. It is also used to increase the individual’s ability to perform activities of daily living. CBT is the preferred treatment for adult counseling. This service includes recovery/treatment planning to improve recovery and resiliency.
Cognitive Processing Therapy
Individual therapy that aims to reduce or eliminate a person’s symptoms of post-traumatic stress disorder (PTSD). CPT is the favored treatment for adults with PTSD, including military veterans. This service includes recovery/treatment planning to improve recovery and resiliency.

24. Legislative Mandates 84th Legislative Session
House Bill 1, Rider 73: Forensic Peer Re-entry Pilot Program
The Department of State Health Services (DSHS) through a Memorandum of Understanding shall allocate up to $1,000,000 in General Revenue for the biennium from strategy B.2.1, Mental Health Services for Adults, to implement a mental health peer support re-entry program. DSHS in partnership with Local Mental Health Authorities and county sheriffs shall establish a pilot program that uses certified peer support specialists to ensure inmates with a mental illness successfully transition from the county jail into clinically appropriate community- based care.

25. Legislative Mandates House Bill 1, Rider 80: Community Facility Review
Out of funds appropriated above, the Department of State Health Services (DSHS) shall conduct a comprehensive review of contract funding requirements and standards governing community-based crisis and treatment facilities for persons with mental health and substance abuse disorders. As part of the review, DSHS behavioral health program staff and regulatory staff, in collaboration with the Health and Human Services Commission and stakeholders, shall identify best practices for and unnecessary barriers to the effective delivery of mental health and substance abuse services by community-based crisis and treatment facilities.

26. Legislative Mandates
House Bill 1, Rider 82: Performance Measures and Contract Review Process
Out of funds appropriated above, the Department of State Health Services (DSHS), in collaboration with the Health and Human Services Commission (HHSC), shall conduct a review to identify improvements to performance measurement, contract processing, and payment mechanisms for behavioral health services contracts with DSHS. In conducting the review, DSHS shall solicit stakeholder input and may use funds appropriated above to seek the assistance of a third party with expertise in health purchasing. DSHS shall complete the review and report findings no later than December 1, 2016 to the Legislative Budget Board, the Office of the Governor, and the permanent standing committees in the House of Representatives and the Senate with jurisdiction over health and human services.

27. Legislative Mandates
Adult Mental Health Services, Crisis Strategy: Roughly 31 Million Awarded
DSHS released a Needs and Capacity Assessment in May 2015
Local Mental Health Authorities and NorthSTAR providers were eligible to apply
17 contractors were awarded funding to implement, or, enhance a variety of crisis projects
Examples:
Veterans Resource Center
Extended Observation Unit
Mental Health Docket
Mental Health Deputy Program
Crisis Peer Respite Center
Crisis Stabilization Unit

28. Legislative Mandates
Community Hospital Strategy: Roughly 50 Million Awarded
DSHS released a Needs and Capacity Assessment in June 2015
Local Mental Health Authorities eligible to apply
13 contractors were awarded funding to purchase additional bed capacity in the community (i.e., 94 beds were purchased)

29. Legislative Mandates Senate Bill 1507
Relating to the statewide coordination and oversight of forensic mental health services overseen by the Department of State Health Services, including the appointment of a forensic director.
DSHS must hire a Forensic Director
DSHS must establish a forensic workgroup to develop a plan for addressing forensic mental health services
The department shall ensure that each local mental health authority and local behavioral health authority operates a toll-free telephone hotline that enables a person to call a single hotline number to obtain information from the authority about mental health services, substance abuse services, or both

30. Questions & Answers

31. Contact Information
Courtney Heard Harvey, Ph.D. DSHS-MHSA Phone: