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Mental Health SystemUpdate

Senate Finance CommitteeTuesday, May 20, 2008

David L. Lakey, MDCommissioner

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Topic Overview

• Mental Health Hospital Funding

• Other Fiscal Issues

• Patient Protection and Rights

• Community Crisis Funding Rollout

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Mental Health Hospital Funding

• Projected shortfall, FY 2008-9– $19.8 million

• Contributing Factors– Staffing–Medications–Medical costs–Operating costs

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Mental Health Hospital Funding

• Cost Drivers

– 24/7 psychiatric and medical care– Maintaining capacity at 2477 beds– Increasing competition for clinical staff in

local markets– Increased cost for pharmaceuticals– Outside medical costs– Increased cost of food– Other unavoidable costs

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Mental Health Hospital Funding

• DSHS has taken the following steps:

– Improved flow of financial information to and from hospital system

– Developed baseline for analysis of trends in expenditures after consolidation

– Begun work on an exceptional item request to meet salary and health care inflation at hospitals for 2010 and 2011

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Mental Health Hospital Funding

• Inflation in Clinical Salaries

– Competition in local markets for professions with limited labor pool

– Average salary increase for clinical staff, rose by 6% above legislative pay increases (FY 2005-07)

– 64% of hospital employees are clinical staff

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Mental Health Hospital Funding

• Pharmaceutical cost increases

– Psychiatric drugs (82% of purchases)• 9% increase in cost

–All other drugs • 25% increase in cost

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Mental Health Hospital Funding

• Outside Medical Services

– DSHS responsible for health care of patients– Difficult to predict– Examples of individual patient medical costs in FY

2008:

Cardiovascular $133,000End stage renal $334,000Dialysis $177,000Pneumonia $148,000Neck cancer $145,000Cardiovascular $178,000

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Other Operating Costs

• Examples:

– Food

– Equipment

– Furnishings

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Mental Health Hospital Funding

Factors, FY 2008-9

Projected

• Salaries $4.5• Drugs $7.8• Medical Services $1.1• Other Operating Costs $6.4

• Total $19.8

All numbers are in millions

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Other Fiscal Issues

• Health Care Associated Infections

– Significant contributor to preventable illness

– SB 288: Monitoring and reporting by hospitals and ASCs

– Advisory panel recommends infection reporting system developed by the Centers for Disease Control and Prevention

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Patient Protection and Rights in State Hospitals

• Hospitals take responsibility for physical and mental health care of patients

• Goals are quality care and safe environment– Accreditation Standards– Prevention first

• Pre-employment screening• Initial and annual training• Communicate expectations

– Reporting and Investigation• Reporting required • Investigations conducted by outside entities• Response to findings

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Challenges

• 6th largest hospital system in Texas

• Patients admitted because they are mentally ill and at serious risk of harm to self or others

• 7,400 employees

• Around 18,000 admissions per year

• Round-the-clock care

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Accreditation

• All DSHS hospitals are accredited by the Joint Commission

• To achieve that, they must meet standards in many areas, including:– Patient rights– Patient safety– Risk management– Clinical care

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Pre-employment Screening

– Criminal background checks conducted prior to hiring and annually thereafter

– Drug and alcohol screening prior to hiring and again any time there is reasonable suspicion of abuse

– All prospective employees checked on:• Client Abuse and Neglect Reporting System

(CANRS)• Nurse Aide Registry• Employee Misconduct Registry

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Employee Training

• Direct care employees are trained before working and annually while working– Preventing and reporting abuse and neglect– Prevention and management of aggressive

behavior– Rights of people with mental illness/mental

retardation– Appropriate use of restraint and seclusion

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Reporting

• Staff required to report suspected abuse/neglect

• Patients and families are also encouraged to report

• Central posting of phone numbers for external investigating entities

• Patient access to telephones• Patients may contact law enforcement

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Investigations

• Conducted by outside entities– All reports referred to DFPS through 24

hour hotline– Other entities receive complaints and

conduct investigations:• Joint Commission• Advocacy, Inc.• Center for Medicare and Medicaid Services• Law enforcement

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Definitions of Abuse/Neglect

• Class I: Serious physical injury

• Class II: Non-serious injury

• Class III: Verbal or emotional abuse

• Class IV: A negligent act that results in harm

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Allegations of Abuse/Neglect

0

500

1000

1500

2000

2500

FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07

Class I

Class II

Class III

Neglect

Total

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Confirmed Incidents

0

50

100

150

200

250

FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07

Class I

Class II

Class III

Neglect

Total

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Response to Findings

• Confirmed Class I Abuse – automatic termination

• Confirmed Class II Abuse  – punishment decided by Superintendent

including termination, demotion or suspension

• Confirmed Class III Abuse & Neglect– punishment decided by Superintendent

including termination, demotion, suspension, or reprimand

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Continuous Improvement

• Maintaining appropriate staffing levels on each shift

• Monitoring trends

• New National Patient Safety Goals from the Joint Commission

• Enhanced education and training on the appropriate use of restraints and seclusion

• STARS project grant– Aims to reduce restraint and seclusion

• Suicide prevention workgroup

• Abuse/neglect data available on website– http://www.dshs.state.tx.us/mhreports/PIMHpub.shtm

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Crisis Services Funding

DSHS requested and received $82 million from the 80th Legislature for the FY08-09 biennium to redesign the public mental health crisis system

FY 2008 FY 2009

$27,317,890 $54,682,110

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Crisis Redesign Goals

• Establish better local systems to serve persons in crisis

• Reduce utilization of emergency rooms, state hospital and other inpatient beds

• Reduce overtaxing of law enforcement resources

• Improve consumers’ access to appropriate services

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Crisis Services Funding

• Overview– $56 million to augment basic and enhanced

crisis services – $3.5 million for outpatient competency

restoration projects– $21.4 million for psychiatric emergency

centers, jail diversion and alternatives to hospitalization

– $500,000 for external evaluation– $800,000 for contract management,

accreditation fees and training

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Basic Services

• $56 million allocated to Local Mental Health Authorities (LMHAs) • Formula took into account– Proportional distribution based

primarily on population– Equity contribution provided to

LMHAs with below average per capita funding

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Basic Services

• Each contract with LMHAs requires:

– a 24 hours a day, 7 days a week hotline• staffed by trained crisis counselors who provide

information, screening and intervention, and support to callers • accredited by the American Association of

Suicidology (AAS)

– Mobile outreach services, which operate in conjunction with crisis hotlines and provide emergency care and crisis follow-up in the community

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Enhanced Services

• Above the basic services, LMHAs can use funds for:

Extended Observation Services (up to 48 hours): Emergency and crisis stabilization in a secure inpatient setting with access to urgent medical evaluation and treatment

Crisis Stabilization Units (CSUs): Short-term residential treatment designed to reduce acute symptoms of mental illness

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Enhanced Services

Crisis Residential/Respite (Child and Adult): Treatment for individuals with high risk of harm and severefunctional impairment who need direct supervision and care but donot require hospitalization. 

Transportation:Assistance with transportation costs incurred by local lawenforcement agencies related to behavioral health crises.

Mental Health Deputies/Crisis Intervention Teams:Assistance to local law enforcement agencies for providing specialized training for deputies on the recognition of mental illnessand de-escalation of volatile situations

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Community Investment Incentive

$25 million for FY08 and FY09 awarded on a competitive basis

• $21.4 million for Psychiatric Emergency Service Centers with extended observation or jail diversion/alternatives to state hospitalization– Required at least a 25% match

• $3.5 million for Outpatient Competency Restoration Services

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Outpatient Competency Restoration Pilots

• In April 2008, DSHS awarded $3.5 million to 5 sites– Tarrant County MHMR– Center for Healthcare Services (San Antonio)– MHMR Authority of Harris County– Austin-Travis County MHMR– North Texas Behavioral Health Authority (NorthSTAR)

• SB 867 made changes to the Code of Criminal Procedure that clarified procedures for outpatient alternatives to inpatient competency restoration for certain defendants

• These changes will help gain efficiency of resources and free up bed space in state mental hospitals

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Psychiatric Emergency Centers or Alternatives to State Hospitals or Jails

(14 sites selected)

Austin Travis County MHMRBetty Hardwick CenterBluebonnet Trails MHMRBurke CenterCentral PlainsEl Paso MHMRHeart of Texas MHMR

Hill Country MHMRMHMR of Nueces CountyMHMR of Tarrant CountySpindletop MHMRTri-County MHMRTropical Texas MHMRWest Texas MHMR

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Impact of Crisis FundingFY 2007 FY 2008

Crisis Residential 9 12

Crisis Respite 10 17

MH Deputy 6 8

Crisis Stabilization 3 7

Extended Observation Units 3 8

Crisis Transportation 5 10

Rapid Stabilization 17 21

AAS Accredited Hotlines 1 31

Mobile Crisis Outreach Teams 4 38

Outpatient Competency Restoration Programs 1 7

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External Evaluation

• Rider 69 requires an External Evaluation• Texas A&M selected and has begun work• Focus on the extent to which:– Stakeholders are satisfied with improvements made

to the community mental health crisis system– Texans who are experiencing a mental health crisis

are served in appropriate settings in a timely manner – Communities have local alternatives that are less

restrictive than state hospitals, emergency rooms and jail for resolving mental health crises

– Community mental health crisis services are cost-effective