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Valley Baptist Legacy Foundation Rio Grande Valley Behavioral Health Systems Assessment

Table of Contents Purpose..................................................................................................................................1

Approach...............................................................................................................................1

MentalHealthNeedsandCapacityintheRioGrandeValley..................................................3

Highlights–PopulationBasedSummaryofMentalHealthNeeds........................................4

Highlights–CapacityofMentalHealthServicesbyPopulation.............................................4

Highlights–LargestServiceGaps...........................................................................................5

FindingNC-1:MentalHealthNeeds(N)andCapacity(C)intheRioGrandeValley..................6

FindingNC-2:CorePublicOutpatientSystemCapacityforAdultswithSevereNeeds............13

FindingNC-3:OtherAdultServicesPublicOutpatientandCrisisSystemCapacity..................26

FindingNC-4:CorePublicOutpatientSystemCapacityforChildrenandYouthwithSevereNeeds.......................................................................................................................................27

FindingNC-5:OtherChildandYouthServicesPublicOutpatientandCrisisSystemCapacity.31

FindingNC-6:InpatientandCrisisSystemCapacity.................................................................33

FindingNC-7:PublicFundsAvailableforBehavioralHealthServices......................................38

FindingNC-8:FundingforVeterans’Services..........................................................................40

MajorSystemLevelFindingsandRecommendations.............................................................41

SystemLevelFindings(SF)........................................................................................................43

County-LevelPlanningNeeds...............................................................................................43

CrisisDeliverySystem...........................................................................................................46

AdultDeliverySystem..........................................................................................................47

Co-OccurringMentalHealthandSubstanceUseDisorderDeliverySystem........................51

Children,YouthandFamiliesDeliverySystem.....................................................................53

Prevention............................................................................................................................55

IntegratedCare....................................................................................................................55

IntegratedBehavioralHealth(IBH)Findings........................................................................57

CriminalJusticeDeliverySystem..........................................................................................58

Veterans’ServicesDeliverySystem......................................................................................59

HousingNeeds......................................................................................................................59

WorkforceNeeds.................................................................................................................60

TransportationNeeds...........................................................................................................61

UseofTelemedicine.............................................................................................................61

StateLevelFindingsRelatedtoLMHAs(STF)...........................................................................61

MajorSystemLevelRecommendations(SR)............................................................................62

County-LevelPlanning..........................................................................................................62

CrisisDeliverySystem...........................................................................................................67

AdultMentalHealthandCriminalJusticeDeliverySystems................................................70

Co-OccurringMentalHealthandSubstanceUseDisorderDeliverySystem........................71

Child,YouthandFamiliesDeliverySystem...........................................................................71

Prevention............................................................................................................................72

IntegratedBehavioralHealthCareDeliverySystem............................................................73

Veterans’ServicesDeliverySystem......................................................................................76

Housing.................................................................................................................................77

Transportation......................................................................................................................78

Workforce............................................................................................................................78

UseofTelemedicine.............................................................................................................79

MajorStateLevelRecommendations(STLR)...........................................................................79

MajorBehavioralHealthProviderFindingsandRecommendations.......................................80

TropicalTexasBehavioralHealth(TTBH).................................................................................80

Overview..............................................................................................................................80

HighlightedAgencyStrengths..............................................................................................81

TTBHFindings.......................................................................................................................83

TTBHRecommendations......................................................................................................96

BorderRegionBehavioralHealthCenter.................................................................................98

Overview..............................................................................................................................98

AdultMentalHealthServices...............................................................................................98

Children’sMentalHealthServices........................................................................................99

HighlightedAgencyStrengths(contributionstoRGVsystemsofcare)...............................99

BRBHCFindings....................................................................................................................99

BRBHCRecommendations.................................................................................................101

BehavioralHealthSolutionsofSouthTexas...........................................................................104

HighlightedAgencyStrengths(contributionstoRGVsystemsofcare).............................105

BHSSTFindings...................................................................................................................106

Recommendations.............................................................................................................106

Doctor’sHospitalatRenaissanceHealthSystem(DHRHS)....................................................107

DHRHSFindings..................................................................................................................109

DHRHSRecommendations.................................................................................................110

RioGrandeStateCenter(RGSC).............................................................................................110

HighlightedAgencyStrengths............................................................................................112

RGSCFindings.....................................................................................................................113

RGSCRecommendations....................................................................................................114

StrategicBehavioralHealth–PalmsBehavioralHealth(PBH)...............................................115

PBHFindings.......................................................................................................................116

PBHRecommendations......................................................................................................117

TexasValleyCoastalBendHealthCareSystem(VA-TVCBHCS)..............................................118

VA-TVCBHCSFindings.........................................................................................................120

VA-TVCBHCSRecommendations........................................................................................121

ValleyBaptistMedicalCenter................................................................................................122

VBMCFindings...................................................................................................................124

VBMCandSystemRecommendations...............................................................................125

TheWoodGroupCrisisRespiteProgram...............................................................................125

OtherOrganizationsFindingsandRecommendations..........................................................127

CatholicCharitiesoftheRioGrandeValley............................................................................127

CounselingProgram...........................................................................................................128

CCRGVFindingsandRecommendations............................................................................128

JohnAustinPeñaMemorialCenter........................................................................................129

Services...............................................................................................................................129

JAPCFindings......................................................................................................................131

JAPCRecommendations.....................................................................................................132

TheUniversityofTexasRioGrandeValleySchoolofMedicineDepartmentofPsychiatryandNeurology...............................................................................................................................133

UTRGV-SOMFindings.........................................................................................................134

UTRGV-SOMRecommendations........................................................................................135

TheUniversityofTexasRioGrandeValley-DoctorsHospitalatRenaissanceFamilyMedicineClinic.......................................................................................................................................136

UTRGV-DHRFMCFindings..................................................................................................137

UTRGV-DHRFMCRecommendations.................................................................................138

TheUniversityofTexasSchoolofPublicHealth–BrownsvilleRegionalCampus.................139

UTSPH-BRCFindings...........................................................................................................141

UTSPH-BRCRecommendations..........................................................................................141

OtherOrganizationFindings..................................................................................................142

OtherOrganizationRecommendations..................................................................................142

PhysicalandBehavioralHealthIntegrationintheRGV........................................................143

CoreIntegratedBehavioralHealthCapacity..........................................................................144

PrevailingIBHProgramModels..............................................................................................146

AnalysisofIBHCoreComponentsAcrossOrganizations.......................................................147

IBHFindings............................................................................................................................151

IBHRecommendations...........................................................................................................151

AdultCriminalJusticeSystemFindingsandRecommendations...........................................153

AdultCriminalJustice(ACJ)Findings......................................................................................153

AdultCriminalJustice(ACJ)Recommendations.....................................................................154

AppendixA:ListofParticipantsintheSystemAssessment..................................................156

SiteVisitParticipants..........................................................................................................156

AdditionalIn-PersonandPhoneInterviewParticipants....................................................161

AppendixB:GlossaryofAcronyms......................................................................................163

Valley Baptist Legacy Foundation Rio Grande Valley Behavioral Health Systems Assessment 1

Purpose TheValleyBaptistLegacyFoundation(LegacyFoundation)engagedtheMeadowsMentalHealthPolicyInstitute(MMHPI)toconductareviewofmentalhealthsystemsintheRioGrandeValley(RGV).1TheprimarypurposeoftheassessmentwastounderstandthecurrentcapacityoftheRGVtomeetitspopulation’smentalhealthneeds(rangingfrommildtosevere),developpracticalrecommendationsthatwouldallowlocalstakeholderstobuildoncurrentstrengths,andsupportadvancementofthecounties’mentalhealthservicesdeliverysystems.Becauseofthehighlevelsofcomorbiditybetweenmentalhealth(MH)andsubstanceusedisorders(SUD),wealsoreviewedthecapacityofsubstanceusedisordertreatment,particularlyintegratedtreatmentapproachesforco-occurringconditions.2Welookedatthestatusofbehavioralhealthandprimarycareintegrationtoassessprogressinthisimportantareabecausethisapproachoffersopportunitiestopromotehealthandwell-beingforpeopleofallagesandalsoextendsaccesstobehavioralhealthcareforpopulationsthatotherwisemaynothaveaccess.Wereviewedtheneedsofspecialpopulations,includingveterans,youth,andfamilies,aswellasindividualswithbehavioralhealthconditionswhoareinvolvedinthejusticesystem.AglossaryofacronymsusedthroughoutthisreportisincludedinAppendixB.Intotal,theassessmentcoveredmultipleareasofbehavioralhealthsystemneeds,capacity,andfunctioning,withthegoalsofidentifyingopportunitiesforimprovementandprovidingrecommendationsthatwouldbepracticaltoimplement.Approach TheMMHPIteamincludedexpertsinbehavioralhealthservices,behavioralhealthintegrationwithprimarycare,criminaljustice,veterans’services,andmentalhealthandsubstanceusedisordertreatmentdeliverysystemsforadultsandchildren,youth,andtheirfamilies.Thereviewprocessbeganin2016withmeetingswithkeyleadersfromtheLegacyFoundationandbehavioralhealthservicedeliverysystemsinordertoengagestakeholdersinthereviewfromthebeginning.MMHPIthensentselectedbehavioralhealthprovidersaninformationrequestforprogramdescriptions,benchmarkdataandreports,andfinancialinformation.Wealsobegantocollectdatafromothersources(e.g.,HealthandHumanServicesCommission,TexasDepartmentofCriminalJustice,nationalbenchmarkstates)toassistuswithacomparisonoftheRioGrandeValleyservicetrendstootherpartsofTexasandotherstates,aswellasa

1Specifically,ourreviewcoveredtheLegacyFoundation’sfundingarea,whichincludesCameron,Hidalgo,Willacy,andStarrCounties.2Forthepurposesofthisreport,weusethetermbehavioralhealthtodescribementalhealthorsubstanceuseconditions.

comparisonofTropicalTexasBehavioralHealthandtheBorderRegionalBehavioralHealthCenter–thetwolocalmentalhealthauthorities(LMHAs)thatcovertheRGVareasinvolvedinthisassessment–toothercomparableLMHAsinTexas.Combiningthesedatawithcounty-specificprevalenceestimatesofmentalhealthneedsacrosstheregion,wewereabletoconductacomprehensiveanalysisofthecurrentcapacityandutilizationofbehavioralhealthservicescomparedtotheprevalenceofmentalhealthconditions.Thisdata-drivenapproachwassupplementedbyon-the-groundinterviewsandsitevisitstoyieldapopulation-levelviewofstrengthsandneedsacrossthecountiesintheregion.Wecarriedoutsupplementalanalysesoftheintegratedbehavioralhealthcare(IBH)3capacityandneedsintheRGV,interviewingleadersfromsixprovideragencies,includingthreefederallyqualifiedhealthcenters(FQHCs),aprimarycareclinic,astate-operatedhealthclinic,andTropicalTexasBehavioralHealth,inadditiontootherstakeholderswithperspectivesonIBH.AgencyinterviewsincludedasurveyoncoreaspectsofIBHprograms.AlistofallpeopleandprogramsthatwereengagedinthisassessmentisincludedinAppendixA.Thisreportfocusesonneedsandcapacityatfourlevels:

• Inthefirstsectionofthereport,MentalHealthNeedsandCapacity,wehighlightsystem-levelfindingsonneedsandoverallservicecapacity.Inthissection,wecalculatetheprevalenceofmentalillnessbycountyandfortheRGVasawhole,includingpeoplewithmildtomoderateconditionsaswellasthosewithmoresevereconditions.Wethencompareddataontheprevalenceofbehavioralhealthconditionswithdataoncurrentserviceutilizationtohelpusunderstandtheoverallcapacityofservicescomparedtotheneedsforthoseservices.Weorganizedthesefindingsbypopulationsandagegroups.

• ThenwefocusontheMajorSystem-LevelFindingstoprovideanunderstandingofthestrengthsandgapsofthebehavioralhealthdeliverysystemsacrosstheRGV.Thesefindingsfocusonbroadersystemcapacityandneedsrelatedtotheplanningandorganizationofservicedeliverysystems,andthestrengthsandgapsofservicesforspecificpopulations:crisissystems;adultservicesystems;child,youth,andfamilydeliverysystems;integratedcaredeliverysystems;andservicesystemsforspecialpopulations,includingindividualswithco-occurringpsychiatricandsubstanceuseconditions,individualsinvolvedwiththecriminaljusticesystem,andveterans.Wealsodescribesomeofthechallengesandopportunitiesrelatedtohousing,transportation,theworkforce,andtheuseoftelemedicine.

3Weareusingintegratedbehavioralhealthtoreferbroadlytointegratedprimarycareandbehavioralhealthservices,regardlessofthesettinginwhichtheyareprovided.

• TheMajorSystemRecommendationssectionofthisreportfocusesonstrategiesandconsiderationsfortheLegacyFoundation,counties,providers,andotherstoaddressthemajorsystemfindings.Thissectionofferspracticalstrategiesthatstakeholderscouldimplementasnextsteps.ItalsoincludesState-LevelRecommendationstoaddresssystemissuesthatwillneedtobeaddressedatthestatelevel.Thislistofrecommendationsandachievablenextstepsprovidestheunderpinningforastrategicimplementationplanthatismeasurable,prioritizestasks,supportsaccountability,andproposesadefinedprocesstoorganizetheworkforthewholecommunity.

• Thefinalsectionsofthereportaddressfindingsandrecommendationsforspecificproviders,includingMajorBehavioralHealthProvidersandOtherOrganizationsthatofferbehavioralhealthorrelatedsupports.Therecommendationsfocusonstrategiesthatproviderscanusetoimprovethedeliverysystemsforadults;children,youth,andfamilies;integratedcare;personswithco-occurringpsychiatricandsubstanceuseconditions;veterans;andindividualsinvolvedwiththecriminaljusticesystem.Theserecommendationswerereviewedandvettedwiththeproviderspriortopublication.Onlyrecommendationsapprovedforpublicreleasebytheprovideragencieswereincluded.Insomecases,providersweremadeawareofadditionalfindingsandrecommendationsnotincludedinthisreport.Thefindingsandrecommendationsweredesignedtoofferarangeofprovider-specificinputthatcanbeactedupontohelpindividualprovidersengageinandcontributetotheproposedsystem-wideimprovements.AtthetimethefinalreportwassubmittedtotheLegacyFoundationinAugust2017,twoprovidershadnotprovidedfeedbackontheirsummaries,andtherefore,thatmaterialwasnotincludedinthepublicreleasereport.

TheMMHPIteamishonoredtohavehadtheopportunitytoworkwiththeValleyBaptistLegacyFoundationandthemanyagenciesthatparticipatedintheassessment.Weappreciatetheparticipationofthenumerouscountyofficials,providers,andotherstakeholdersintheRioGrandeValleynotedinAppendixA.Mental Health Needs and Capacity in the Rio Grande Valley

Thissectionofthereportdescribesbehavioralhealthneedsandcapacity.ThefindingsonneedsisbasedondatacollectedbyMMHPIontheprevalenceofmentalhealthconditionsintheRioGrandeValley(RGV)incomparisontoinformationonservicecapacityandutilization.Keyfindingsarehighlightedpriortothedetaileddiscussionofthefindings.

Highlights–PopulationBasedSummaryofMentalHealthNeeds

Ofthe1.2millionRGVresidents,oneinfourhavesomelevelofmentalhealthneeds.

• Thereare45,000adultsand25,000childrenwhohavethemostsevereneeds.

• Ofthese,approximately35,000adultsand20,000childrenliveinpoverty.4

• Annually,approximately700adultswithhighlycomplexneedsbecometrappedincyclesof“super-utilization,”withabout500inneedofintensivebehavioralhealthtreatmentandabout400inneedofforensically-focusedintensivebehavioralhealthtreatment(withasmallamountofoverlapbetweenthetwogroups).

• About2,000childrenandyouthneedtime-limited,intensivehomeandcommunity-basedsupportstoreturnfromoravoidout-of-homeplacements.

• Thereareabout200newcaseseachyearofpsychosis(includingschizophrenia)amongolderadolescentsandyoungadultswhoneedearlytreatmenttoavoidtheriskofdevelopinghighlycomplexneeds.

• Over45,000individuals(adultsandchildrenovertheageof12years)intheRGVhaveanalcoholorsubstanceusedependencedisorder.Ofthese,over40,000areadultsandover4,000areyouth.Basedonnationalprevalenceinformation,weestimatethat50%oftheadultshaveaco-occurringmentalhealthcondition.

Highlights–CapacityofMentalHealthServicesbyPopulation

• Thereisnocomprehensiveandcompleterepositoryofdatacollectedforallbehavioralhealthservices,butthedatathatarecollectedindicatethatthecapacityofservicesissignificantlybelowwhatisneeded.

• About76%ofadultsintheRGVwhohaveaseriousmentalillnessandliveinpovertyreceivedsomeoutpatientlevelsofservices.Itisnotclearfromthedatawhethertheseindividualsreceivedtheappropriatelevelofcare.

• About50%(inthecatchmentareaservingStarrCounty)and26%(inthecatchmentareaservingCameron,Hidalgo,andWillacycounties)ofchildrenandyouthwithseriousemotionaldisturbancesandlivinginpovertyreceiveongoingtreatment.However,veryfewreceiveintensiveservices:only1%ofchildrenreceivingongoingcarefromTTBHandBRBHCareprovidedintensiveservices.

• ForSUDs,specificdataarenotavailabletocontrastneedswithservicecapacity,butresultsfrominterviewssuggesttheneediswellabovecurrentcapacity.

4“inPoverty”definedasatorunder200%oftheFederalPovertyLevel

Highlights–LargestServiceGaps

• Accordingtoouroverallanalysisofneedsandutilization,aswellasthefindingsfromoursitevisitsandinterviews,thelargestservicegapscenteroncrisisservicesandongoingintensivetreatmentsthatwouldprovidealternativestoinpatientcareforadultsandout-of-homeplacementsforchildrenandyouth.

• Whiletherearemanystrengthsintheservicesofferedbymanyoftheproviders,therearesignificantresourcelimitationsforbehavioralhealthservicesforallpopulations,evenmoresoformedicallyindigentindividualsandfamilies.Theselimitationsincludethefollowing:

- Acrosstheboard,servicesforallpopulationshavenotkeptpacewithpopulationgrowthintheRGV.

- Whiletherearesomeexcellentcrisisservicesinspecificcommunities,thereisnosystem-widecrisisinterventionprogram.

- Crisisdiversionservicesaredramaticallyunderdevelopedforyouthandadults.

- AswiththerestofTexasandmostcountiesinthenation,alackofresourcesforassertivecasemanagementforadultscontributestoacycleof“super-utilization.”

- Thereisaveryunderdevelopedcontinuumofservicesbetweeninpatientservicesandcommunity-basedoutpatientservices.

- Theco-occurringmentalhealthandSUDdeliverysystemisunderdeveloped.

- Therearesomeeffectiveintensiveservicesforchildrenandyouth,buttheseareunderdevelopedandaccesstocrisisservicesandinpatientcareisachallenge.

- AdditionalsignificantservicegapsincludealackofaffordablehousingintheRGVandalackofresidentialtreatmentforalcoholandsubstanceusedisorders.

- Thecriminaljusticedeliverysystemforindividualswithbehavioralhealthneedsisdeveloping,buthassignificantgapsinservicesthatleadtoincarcerationratherthantreatment.

- Accesstoservicesforveteransisincreasingbutthestigmaofmentalillnesscontinuestobeasignificantbarriertoseekingtreatment.

Specificfindingsonneedsandcapacityaremorefullydescribedinthefollowingsections.

Finding NC-1: Mental Health Needs (N) and Capacity (C) in the Rio Grande Valley

TheRioGrandeValleycomprisesfourruralcounties–Cameron,Hidalgo,Star,andWillacy–locatedinthesouthernmostpartofTexasalongtheMexicanborder.Thesecountiescover4,316squaremilesandhave47incorporatedcitiesandtownswithpopulationsrangingfrom307individualsinGranjenoto138,082inMcAllen,5alongwithnumerousunincorporatedcommunities.6Thetotalpopulationofthisregionisabout1.2millionpeopleagessixorolder,withover90%residinginCameronandHidalgocounties.ComparedtootherTexascounties,thepovertyrateinthisregionisrelativelyhigh,withnearlytwothirdsofresidentslivinginpoverty.PopulationEstimatesforRioGrandeValley(RGV)AreaCounties7

County Total2015PopulationAge6+

Texas 25,050,000

CameronCounty 380,000

HidalgoCounty 750,000

StarrCounty 55,000

WillacyCounty 20,000

RGVAreaTotal 1,200,000

ThisreportisintendedtoaddresstheneedsoftheentirepopulationoftheRGVbecausebehavioralhealthneedsaffectthewholepopulation,notjustthosewhoareindigentorservedinthepublicsector.Becausetheprevalenceofmentalhealthneedsofchildrenages0–5yearsarepoorlyunderstood,wehaveexcludedchildreninthatagerangefromallpopulationandprevalenceestimates.Overallintheregion:

• Ina12-monthperiod,oneinthreeadolescentsandoneinfiveadultshavementalhealthneeds,anduptooneinfouradultsandtwoinfiveadolescentshavementalhealthand/orsubstanceusedisorders,basedonthelatestepidemiologicalresearch.8

5Populationisfor2015,andcoverschildrenandyouthages6-17,andadultsages18+.AllpopulationandprevalenceestimatesareroundedtoreflectuncertaintyintheunderlyingAmericanCommunitySurveydataandestimationprocess.6RioGrandeValleyLinkingEconomicandAcademicDevelopment(LEAD).(2015).Targetingthefuture:2015labormarketinformationreport–ananalysisoftheemerginglabormarketintheRioGrandeValley.Retrievedfromhttp://techpreprgv.com/pdf/2015.RGV.LEAD.LMI-Report.pdf7Forthepurposesofthisreport,“RioGrandeValley(RGV)AreaCounties”referstothecountieswithintheValleyBaptistLegacyFoundation’sfundingarea:Cameron,Hidalgo,Starr,andWillacycounties.8Kessler,R.C.etal.(2005).Prevalence,severity,andcomorbidityof12-monthDSM-IVdisordersinthenationalcomorbiditysurveyreplication.ArchivesofGeneralPsychiatry,62,617-709.Kessler,R.C.etal.(2012).Prevalence,

But,individualneedsvaryinintensityfromverymildtoextremelyacuteandchronic.Ananalogytothisisdiagnosingcancerinprimarycare:manypeoplehavemolesandbenignmasses,butamuchsmallernumberactuallydeveloplife-threateningcancer.

• Aboutthreeoutofeveryfour(75%)friendsandfamiliesofTexasvotersareaffectedbymentalhealthissues,basedonstatewidesurveysconductedbyMMHPI.9Thesesamevotersurveysfindthatthesameproportionhavefamilyorlovedonesaffectedbymentalhealthasthosewhohavefamilyorlovedonesaffectedbycancer.

• Wecanalsobreakdownthispopulationofpeoplewithsevereneedsintwofurtherways:severityandprimarydiagnosis.Webelievethatonebarriertobettertreatmentofmentalillnessisthetendencytogrouparangeofdiverseneedsintoasingle,largegroupof“peoplewithmajormentalillness”or“adultswithseriousmentalillness.”Thisisnotdoneforotherseveremedicalconditions.Forexample,themostrecentTexasCancerPlan10doesnotevennotethetotalnumberofpeopleinTexaswithcancer(whichisjustover500,00011),nordoesitbreakoutthenumberofseverecases(e.g.,“StageFour”cases).Instead,theplanfocusesonspecificcancerconditions(e.g.,breastcancer,prostatecancer)andthenumberofnewcasesthatemergeeachyear(otherwiseknownasincidence).

TECHNICALNOTE:Thetablesonthefollowingpageslistsomeofthemostcommonmentalillnessesandbreakoutprevalenceratesbyseverityforadultsandchildrenandyouth.Thepopulationinformationisfrom2015andcoverschildrenandyouthages6-17,andadultsages18andolder.

• Allpopulation,prevalence,andneedestimatesareroundedtoreflectuncertaintyintheunderlyingAmericanCommunitySurveydataandestimationprocess.

• Allpercentagesofpeopleservedarecalculatedwithunroundedestimatesofneed(basedonnumberofindividualsservedasreportedbythestate)inordertoavoidmisrepresentation.

Forexample,ifourestimateofthenumberofpeopleinneedis92,thisnumberisroundedto100inthecorrespondingtabletoindicatethatthisisanestimatebasedonasample.Ifsixpeoplewereserved,thepercentageinneedservedwouldbecalculatedas6/92=6.5%,which

persistenceandsociodemographiccorrelatesofDSM-IVdisordersintheNationalComorbiditySurveyReplication-AdolescentSupplement.ArchivesofGeneralPsychiatry,69,372-380.9MeadowsMentalHealthPolicyInstitute(2014).TexasMentalHealthSurvey.10CancerPreventionandResearchInstituteofTexas.(2012).TexasCancerPlan,2012.Retrievedfrom:http://www.cprit.state.tx.us/images/uploads/tcp2012_web_v2a.pdf11TexasDepartmentofStateHealthServices(DSHS)(nowHHSC).(2015).CalculatedcancerprevalenceofcancerinTexas,1/1/2012.Retrievedat:https://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8590004026

wewouldreportinthesametable.Wewouldnotcalculatethepercentservedbyusingtheroundedversionofthenumberinneed(e.g.6/100=6%).Whilethenumbersassociatedwithallbehavioralhealthneeds(approximately340,000)mayseemhigh,uptotwothirdsofpediatricneedsandover80%ofadultneeds(mildtomoderateconditions)canbeaddressedbybestpracticeintegratedbehavioralhealthservices,allowingcommunitiesandhealthsystemstofocustheirspecialtyresourcesonmoreseveresubsetsofneed.Forexample,byidentifyingandaddressingtheneedsofpeoplewiththehighestutilizationofexpensiveand/orrestrictivecare(lessthan1%oftheoverallneedincludesthe700adultswiththehighestcomplexityandserviceuse,andjustoveranadditional1%includesthe2,000childrenandyouthwiththemostsevereneedsatriskofout-of-homeandout-of-schoolplacement),theuseofresourcescanthenshiftinwaysthathavethepotentialtoexpandtheirreach. Twelve-MonthPrevalenceofMentalHealthDisordersinRGVAreaCountiesin2015MentalHealthCondition–Adults PrevalenceTotalAdultPopulation 900,000

PopulationinPoverty12 500,000

AllBehavioralHealthNeeds(Mild,Moderate,andSevere)13 220,000MildConditions 90,000ModerateConditions 80,000

SeriousMentalIllness(SMI)14 45,000ComplexNeeds15/SuperUtilization 700SubsetwithHighForensicNeeds 400

SMIinPoverty16 35,00012“Inpoverty”referstothenumberofindividualsbelow200%ofthefederalpovertylevelforthespecifiedregion.13NationalestimatesofprevalenceandseveritybreakoutsaredrawnfromKessler,R.C.,etal.(2005).Prevalence,severity,andcomorbidityoftwelve-monthDSM-IVdisordersintheNationalComorbiditySurveyReplication(NCS_R).ArchivesofGenPsychiatry,62(6),617-627.Thedataarefromastudywithadults.14EstimatesofSMIandSEDaretakenfromthefollowingsource:Holzer,C.,Nguyen,H.,&Holzer,J.(2015).Texascounty-levelestimatesoftheprevalenceofseverementalhealthneedin2015.Dallas,TX:MeadowsMentalHealthPolicyInstitute.Byincorporatingspecificcounty-leveldemographics.Holzer’sestimateofSMIismoreprecisethanKessler’s.15Theseadultsareatthehighestriskforrepeateduseofemergencyrooms,hospitals,andjails.Cuddebackandcolleagues(2006and2008)haveestimatedthat7.7%ofadultswithSMIneedAssertiveCommunityTreatmentorForensicAssertiveCommunityTreatment,orboth.[Cuddeback,G.S.,Morrissey,J.P.,&Meyer,P.S.(2006).Howmanyassertivecommunitytreatmentteamsdoweneed?PsychiatricServices,57,1803-1806.Cuddeback,G.S.,Morrissey,J.P.,&Cusack,K.J.(2008).Howmanyforensicassertivecommunitytreatmentteamsdoweneed?PsychiatricServices,59,205-208.].16EstimatesofSMIandSEDaretakenfromthefollowingsource:Holzer,C.,Nguyen,H.,&Holzer,J.(2015).Texascounty-levelestimatesoftheprevalenceofseverementalhealthneedin2015.Dallas,TX:MeadowsMentalHealthPolicyInstitute.Byincorporatingspecificcounty-leveldemographicsforSmithCounty,Holzer’sestimateofSMIis

MentalHealthCondition–Adults PrevalenceSpecificDiagnoses17Schizophrenia18 5,000

FirstEpisodePsychoses(FEP)Incidence–NewCasesperYearAges18–3419 200

MajorDepression 65,000BipolarIDisorder 5,000Post-TraumaticStressDisorder 30,000AlcoholDependenceDisorder 30,000DrugDependenceDisorder 15,000NumberofDeathsbySuicide(includingChildren) 90

MentalHealthCondition–ChildrenandYouth AgeRange Prevalence

TotalPopulation–ChildrenandYouth 6–17 300,000

PopulationinPoverty20 6–17 210,000

AllBehavioralHealthNeeds(Mild,Moderate,andSevere)21 6–17 120,000MildConditions 6–17 65,000ModerateConditions 6–17 25,000

SeriousEmotionalDisturbance(SED)22 6–17 25,000

moreprecisethanKessler’s.“Inpoverty”referstothenumberofindividualsbelow200%ofthefederalpovertylevelforthespecifiedregion.17NationalestimatesofprevalenceandseveritybreakoutsunlessotherwisecitedaredrawnfromKessler,R.C.,etal.(2005).Prevalence,severity,andcomorbidityoftwelve-monthDSM-IVdisordersintheNationalComorbiditySurveyReplication(NCS_R).ArchivesofGenPsychiatry,62(6),617-627.Thedataarefromastudywithadults.18McGrath,J.,etal.(2008).Schizophrenia:Aconciseoverviewofincidence,prevalence,andmortality.EpidemiologicalReviews,30,67-76,p.70.Literatureontheprevalenceofschizophreniainadolescentsisverysparse,perhapsnon-existent.Basedonthefactthatestimatesoftheincidence(newcases)ofschizophreniaincludeadolescents,wehaveroughlyestimated0.2%oftheadolescentpopulationhasschizophreniaovera12-monthperiod.19Kirkbride,J.B.,etal.(2013).Apopulation-levelpredictiontoolfortheincidenceoffirst-episodepsychosis:Translationalepidemiologybasedoncross-sectionaldata.BMJOpen,3,1-12.20“Inpoverty”referstothenumberofindividualsbelow200%ofthefederalpovertylevelforthespecifiedregion.21NationalestimatesofprevalenceandseveritybreakoutsunlessotherwisecitedaredrawnfromKessler,R.C.,etal.(2012).Severityof12-MonthDSM-IVDisordersintheNationalComorbiditySurveyReplicationAdolescentSupplement).ArchivesofGenPsychiatry,62(6),617-627.Thedataarefromastudywithyouth.Kesslerprovidesmildandmoderateestimatesforyouthages13-17yearsoldandthisratehasbeenappliedtoallchildrenandyouthages6-17.However,childrenaged12andunderlikelyhavelowerprevalenceofmentalhealthdisorders.22EstimatesofSMIandSEDaretakenfromthefollowingsource:Holzer,C.,Nguyen,H.,&Holzer,J.(2015).Texascounty-levelestimatesoftheprevalenceofseverementalhealthneedin2015.Dallas,TX:MeadowsMentalHealthPolicyInstitute.Byincorporatingspecificcounty-leveldemographics.Holzer’sestimateofSMIismoreprecisethanKessler’s.

MentalHealthCondition–ChildrenandYouth AgeRange Prevalence

SEDinPoverty 6–17 20,000At-RiskofOut-of-Home/Out-of-SchoolPlacement 6–17 2,000

SpecificDisorders–Youth(unlessotherwisenoted)23Depression 12–17 10,000BipolarDisorder 12–17 3,000Post-TraumaticStressDisorder 12–17 6,000SubstanceUseDisorders 12–17 10,000

Schizophrenia24 12–17 300

Obsessive-CompulsiveDisorder–Children/Youth25 6–17 2,000

EatingDisorders26 12–17 1,000Self-Injury/HarmingBehaviors 12–17 15,000ConductDisorder 12–17 8,000FirstEpisodePsychosis 12–17 70NumberofDeathsBySuicide2014 0-25 20SpecificDisorders–ChildrenOnlyAllAnxietyDisorders–Children 6–11 15,000Depression/AllMoodDisorders–Children 6–11 2,000Schizophrenia–ChildhoodOnset(beforeage12) 6–11 4Theprevioustablesbreakoutseveralspecificsubgroups:

• Adultswithhighlycomplexneedscaughtincyclesof“superutilization”:Theconcept23Kessler,R.C.,etal.(2012).Prevalence,persistence,andsociodemographiccorrelatesofDSM-IVdisordersintheNationalComorbiditySurveyReplication-AdolescentSupplement.ArchivesofGeneralPsychiatry,69,372-380.EstimatesforDepression,SubstanceUseDisorders,Post-TraumaticStressDisorder,andBipolarDisorderwerecalculatedbymultiplyingtheestimateofthe12-17populationbytheprevalenceestimateforeachrespectivedisorder.24Androutsos,C.(2012).Schizophreniainchildrenandadolescents:Relevanceanddifferentiationfromadultschizophrenia.Psychiatriki,23(Supl),82-93(originalarticleinGreek).Theestimateisthatamongadolescentsages13–18,0.23%meetcriteriaforthediagnosisofschizophrenia.AnotherstudyfromSwedenreportedthat0.54%ofadolescentsweretreatedforpsychoticdisordersatleastonceduringtheagesof13–19:Gillberg,C.etal.(2006).Teenagepsychoses-epidemiology,classification,andreducedoptimalityinthepre-,per-,andneonatalperiods.JournalofChildPsychologyandPsychiatry,27(1),87-98.25Kirkbride,J.B.,Jackson,D.,Perez,J.,Fowler,D.,Winton,F.,Coid,J.W.,Murray,R.M.,&Jones,P.B.(2013,February).Apopulation-levelpredictiontoolfortheincidenceoffirst-episodepsychosis:Translationalepidemiologybasedoncross-sectionaldata.BMJOpen,3(2),1–12.EstimatesoftheincidenceoffirstepisodepsychosisareextrapolatedfromstudiesbyKirkbrideandcolleaguesthatusedarangeofages(14-35)duringwhichthefirstepisodeofpsychosisislikelytooccur.26Swanson,etal.(2011).Prevalenceandcorrelatesofeatingdisordersinadolescents.ResultsfromtheNationalComorbiditySurveyReplicationAdolescentSupplement.ArchivesofGeneralPsychiatry,68(7),714–723.TheprevalenceestimateforeatingdisordersencompassesonlyAnorexiaNervosaandBulimiaNervosa.

of“superutilization”referstotheexperienceofabout700adultswithSMIwhohavethemostcomplexneeds(e.g.,mentalhealthplussubstanceuse,otherphysicalillnesses,housinginstability)andwhomsystemsrepeatedlyfailtoengageandhelp,despitetheprovisionofextremelyhighratesofservicesthroughhospitals(inpatientandemergencyservices)andjails.Thesepeopletendtohaveunmetneedsrelatedtomultiplechronicconditionsthatareinadequatelytreated(oradequatelytreatedfortooshortatime)and,asaresult,experiencerepeatacuteepisodesofillnessovermultipleyears.Discussionofsevereneedsoftenfocusesoninpatientbedutilizationoroveruseofjails,buttherealityisthatpeoplewithsevereneedsdonotstayverylonginthesesettings.Mostadultinpatientstayslastforlessthanaweek,andthevastmajorityofthosewhostaylongeratstatehospitalsareincareforweeksormonths,ratherthanyears.Asaresult,thevastmajorityofpeopleinneedareinthecommunity.However,notallofthe45,000adultsintheRioGrandeValleyareawiththemostsevereneeds(referredtoasseriousmentalillnessorSMI)areatequalriskofemergencyroomorjailuse.TwocarefulstudiesoftheproportionofadultswithSMIwhoareathighriskofhomelessness,emergencyroomuse,andinpatientuseeachyear27andthoseatriskofrepeatforensicinvolvement28suggestthatthenumberofadultsathighestrisk–agroupreferredtoashavinghighcomplexity–totalsapproximately700peopleperyear,ofwhomabout400needaforensically-focusedversionofsuchcare,suchasForensicAssertiveCommunityTreatment(FACT).29

• Childrenandyouthatriskofout-of-homeandout-of-districtplacements:Similarly,of

thenearly25,000childrenandyouthwiththemostsevereneeds(referredtoasseriousemotionaldisturbance,orSED),amuchsmallernumber(justunder2,000peryear)haveneedssevereenoughtoputthematriskofnotbeingabletoliveathomeorstayinschool.

• Firstepisodepsychosis:Notethatthenumberofpeoplewhodevelopschizophreniaisa

subsetofthepeopleforwhomaninitialpsychosisemerges.Whileapproximately70adolescentsandyoungadultseachyearwillmanifestafirstepisodeofpsychosis,30notalldevelopschizophrenia.However,thetotalnumberofpeoplewithschizophreniais

27Cuddeback,G.S.,Morrissey,J.P.,&Meyer,P.S.(2006).Howmanyassertivecommunitytreatmentteamsdoweneed?PsychiatricServices,57,1803-1806.28Cuddeback,G.S.,Morrissey,J.P.,&Cusack,K.J.(2008).Howmanyforensicassertivecommunitytreatmentteamsdoweneed?PsychiatricServices,59,205-208.29SomeindividualswouldqualifyforbothACTandFACT,sotheestimatesincludeanoverlapofabout100people.30Kirkbride,J.B.,Jackson,D.,etal.(2013).Apopulation-levelpredictiontoolfortheincidenceoffirst-episodepsychosis:Translationalepidemiologybasedoncross-sectionaldata.BMJOpen,3(2),1-12.

muchlarger(approximately5,000)becausemany,ifnotmost,peoplewithpsychosisfailtoreceivetimelyandeffectivetreatmentandthusexperiencethedisorderforlongperiodsoftime.

Manyoftherecommendationsinthisreportfocusonamuchsmallersubsetofneed–the55,000people(about35,000adultsand20,000childrenandyouth)inpoverty(under200%FPL)withthemostsevereneeds–asthebenchmarkofneedtobemetbythepublicbehavioralhealthtreatmentsystems.However,wealsorecommendthemorewidespreadimplementationofintegratedhealth(IBH)careinprimarycaresettingsthat,throughearlierdetectionandintervention,canreducethenumberofserious/severeconditionsthatinvolvesignificantreductionsinfunctioning.ThefollowingtableprovidesestimatesofSMIandSEDamongpeoplelivinginpovertybycountyandintheRGV(ValleyBaptistLegacyFoundationregion).

Twelve-MonthPrevalenceofAdultswithSMIandChildren/YouthwithSEDLivingatorBelow200%FPLforRioGrandeValley(RGV)AreaCountiesin201531

Region AdultswithSMI

SMIUnder200%FPL

Children&Youthwith

SEDUnder200%FPL SMI+SED

SMI+SEDUnder

200%FPLTexas 960,000 540,000 370,000 210,000 1,350,000 750,000Cameron 15,000 10,000 8,000 6,000 20,000 15,000Hidalgo 30,000 20,000 15,000 15,000 45,000 35,000Starr 2,000 2,000 1,000 700 3,000 2,000Willacy 800 600 300 200 1,000 800RioGrandeValley 45,000 35,000 25,000 20,000 70,000 55,000

ThetableonthefollowingpageshowstheestimatedprevalenceofalcoholanddrugdependenceacrosseachoftheRioGrandeValleycountiesincomparisontoTexasasawhole.Wearefocusingondependence(ratherthanbothuseanddependence)inordertoemphasizethenumberofpeoplewhoaremostinneedofsubstanceusedisordertreatmentservices.However,attendingtosubstanceusesometimesiscrucialtooveralltreatment.Forexample,whilespecificdataarenotreadilyavailable,MMHPIepidemiologicalexpertsestimatethatabout50%ofadultswithSMIhaveco-occurringsubstanceusedisorders.IntheRGV,that

31EstimatesofSMIandSEDaretakenfromthefollowingsource:Holzer,C.,Nguyen,H.,&Holzer,J.(2015).Texascounty-levelestimatesoftheprevalenceofseverementalhealthneedin2015.Dallas,TX:MeadowsMentalHealthPolicyInstitute.Becauseofrounding,thesumofroundedestimatesmaynotequaltheroundedsumofexactestimates.

wouldindicatethatnearly22,500adultswithSMIhaveaco-occurringsubstanceusedisorderthat,ifnottreatedinawaythatisintegratedwithmentalhealthtreatment,wouldsignificantlyinterferewiththeirrecovery.Twelve-MonthPrevalenceofAlcohol/DrugDependence,RioGrandeValley,201532

Region

EstimatedPrevalenceofAlcoholandDrugDependence

AdultsAlcohol AdultsDrug YouthAlcohol YouthDrug

Texas 630,000 300,000 25,000 40,000

Cameron 9,000 4,000 500 800

Hidalgo 15,000 8,000 1,000 2,000

Starr 1,000 700 70 100

Willacy 500 200 20 40

RioGrandeValley33

30,000 15,000 2,000 3,000

Finding NC-2: Core Public Outpatient System Capacity for Adults with Severe Needs

Thereisnocomprehensiveandcompleterepositoryofdataforalltheoutpatientmentalhealthservicesprovidedtoadultswholiveinpoverty.However,wedohavedataonLMHAservices,whichconstitutethevastmajorityofoutpatient,community-basedcareforpeoplewithSMI.MuchoftheanalysisinthissectionfocusesontheserviceareasoftheBorderRegionBehavioralHealthCenter(whichservesStarrCounty,plusthreeadditionalcounties),TropicalTexasBehavioralHealth(whichservesCameron,Hidalgo,andWillacycounties),andtwootherlocalmentalhealthauthority(LMHA)serviceareasingeographicallyanddemographicallysimilarregions.CaminoRealCommunityServices(CRCS)servesninecountiesinaprimarilyruralandfrontierareaofthestate,andCoastalPlainsCommunityCenter(CPCC)servesninecountiesinthecoastalbendregionofSouthTexas.

32CenterforBehavioralHealthStatisticsandQuality.(2015).BehavioralhealthtrendsintheUnitedStates:Resultsfromthe2014NationalSurveyonDrugUseandHealth.(HHSPublicationNo.SMA15-4927,NSDUHSeriesH-50).Retrievedfromhttps://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf(Estimateswereupdated,basedon2015population.)33County-levelalcoholanddrugdependenceestimatespresentedinthetableareroundedtoreflectthedegreeoferrorpresentwithintheprevalenceestimationmethodology.RioGrandeValleyprevalenceestimatetotalsarebasedonthesummationofunroundedcountyestimates,andinturn,donotreflectthesummationoftheroundedcountyestimatesshownabove.

Notethatthe12-monthprevalencedataforeachLMHAregionwithintheRioGrandeValleyareahavebeenincludedinsometables.BecausetheBorderRegionBehavioralHealthCenterservesalargeareaoutsideoftheValleyBaptistLegacyFoundation(VBLF)region(threecountiesinadditiontoStarr),thesumofthenumbersofpeoplewithSMIandSEDintheTropicalTexasBehavioralHealth(TTBH)andBorderRegionBehavioralHealthCenter(BRBHC)LMHAareasdonotmatchtheVBLFregiontotal.Additionally,someofthetablesshowthat,comparedtoTTBH,BRBHCservesaslightlyhigherpercentageofneedwithinitscatchmentarea.However,itshouldbenotedthat,comparedtoBRBHC,TTBHhasasignificantlylargernumberofpeopleinneedofservicesandlessfundingperperson,anditprovidesahigherlevelofserviceintensity.ThedatainthefollowingtablereflecttheservicesprovidedbyBRBHCandTTBH,whichdocumentthat26%ofthoseinneedofcareintheBRBHCcatchmentareaand24%ofthoseinneedofcareintheTTBHcatchmentareareceivedservicesacrossalloutpatientlevelsofcare(LOCs34).ThesepenetrationratesarelowerthantheratesofcomparisonLMHAs(forCaminoRealCommunityServices[CRCS],45%ofthoseinneedreceivedservices;forCoastalPlainsCommunityCenter[CPCC],59%ofthoseinneedreceivedservices).UnduplicatedNumberofAdultsWhoReceivedServicesbyLMHA

Adults

BorderRegionBehavioralHealth

Center(allcounties)*

TropicalTexasBehavioralHealth

CaminoRealCommunityServices

CoastalPlainsCommunity

Center

SMI200%FPL35

9,000 35,00036 4,000 5,000

AllLOCsServed37

2,360 8,067 1,922 2,900

34Inthisreport,LOCreferstoalevelofcaredefinedbytheDepartmentofStateHealthServices(DSHS)(nowHHSC)initsUtilizationManagementGuidelinesandManual.Seehttp://www.dshs.texas.gov/TRR/Utilization-Management-(UM)-Guidelines-and-Manual.aspx.35Dataisfor2015andwasobtainedfromDr.CharlesHolzer.Holzer,C.,Nguyen,H.,Holzer,J.(2016).Texascounty-levelestimatesoftheprevalenceofseverementalhealthneedin2015.Dallas,TX:MeadowsMentalHealthPolicyInstitute.36TheestimateforthenumberofindividualswithSMIbelow200%FPLwithintheTropicalTexasBehavioralHealthregion(35,000)isthesameastheestimatefortheRioGrandeValleyregion.ThisisbecauseStarrCounty,whichisincludedintheRGVareabutnotintheTropicalTexasBehavioralHealthArea,onlyhas1,700estimatedcasesofSMIbelow200%FPL.Thisnumberisnotsignificantenoughtochangetheroundedestimate.37Inthisreport,LOCreferstoalevelofcaredefinedbytheTexasHealthandHumanServicesCommission(HHSC)initsUtilizationManagementGuidelinesandManual.Estimatesarecalculatedbasedon2016data.Seehttp://www.dshs.texas.gov/TRR/Utilization-Management-(UM)-Guidelines-and-Manual.aspx.

Adults

BorderRegionBehavioralHealth

Center(allcounties)*

CoastalPlainsCommunity

Center

%inNeed 26% 24% 45% 59%*DataincludeallcountiesservedbyBRBHC,notsolelyStarrCounty.ThefollowingtableillustratesthepercapitafundinglevelforthebenchmarkLMHAs.RelativetoCRCSandCPCC,BRBHCandTTBHareconsiderablyunder-funded,whichhelpsexplaintheirlowerpenetrationrates.Thecolumnlabeled“PerCapitaFunding<200%FPL”providestheprospectivepercapitarateforadultsandchildren/youthlivinginpoverty.Thecolumnlabeled“PerCapitaSED/SMIFunding”providestheprospectivepercapitaratefortheestimatedSED/SMIpopulation.Inbothcases,TTBHisthelowest-fundedLMHA,or39thof39LMHAs.BRBHCissecondtolastineachcase.The2018waitlist,populationgrowth,enhancedwaitlistavoidance,andequityfundingdidnotimproveeitherLMHA’srelativestanding.PerCapitaFundingbyTTBH,BRBHCandComparisonLMHAsforFY2018-2019

LMHA PerCapitaFunding<200%FPL

PerCapitaSED/SMIFunding

BorderRegionBehavioralHealthCenter38 $30.30 $419.27

TropicalTexasBehavioralHealth39 $30.09 $417.39

CaminoRealCommunityServices40 $47.65 $706.93

CoastalPlainsCommunityCenter41 $68.97 $907.72

ThefollowingtableillustratesthedistributionofservicesacrosstheBehavioralHealthServicesSectionofHHSC-definedlevelsofcare(LOCs),showingcomparisonsacrosstheselectedLMHAs.HHSCcontractswithLMHAstoprovidedefinedLOCs,referredtoasTexasResiliencyandRecovery(TRR)levelsofcare.TheLOCsarecategorizedbygraduatedlevelsofintensitytomeetthevariouslevelsofserviceneedsofchildren,youth,andadultsenteringthepublicmentalhealthsystem.

38BorderRegionBehavioralHealthCenterservesJimHogg,Starr,Webb,andZapatacounties.39TropicalTexasBehavioralHealthservesCameron,Hidalgo,andWillacycounties.40CaminoRealCommunityServicesservesAtascosa,Dimmit,Frio,LaSalle,Karnes,Maverick,McMullen,Wilson,andZavalacounties.41CoastalPlainsCommunityCenterservesAransas,Bee,Brooks,Duval,JimWells,Kenedy,Kleberg,LiveOak,andSanPatriciocounties.

TherearefiveadultLOCsforongoingmentalhealthservices:• MedicationManagement(A1M):Thisisthelowestlevelofservice,typicallyinvolving

lessthananhourofcarepermonth,generallyforpeoplewhoarestableandinamaintenancephaseneedingonlymedication.LMHAsrarelydeliverthislevelofcare.

• SkillsTraining(A1S):Thisalsoinvolvesalowlevelofservice,combiningmedicationmanagementwithanhourortwoofpsychosocialrehabilitationandminimalcasemanagement.Thisisthemoretypicallevelofcaredeliveredtopeoplewhoareinastablephaseoftreatmentandonlyneedminimalsupport.

• MedicationandTherapy(A2):Thisaddstwotothreehoursofevidence-basedcounselingtotheservicemix.Thislevelofcareisforpeopleprimarilyinneedoftherapyfordepressionoranxiety(includingsevereanxiety,suchaspost-traumaticstress)inadditiontomedicationandminimalsupport.

• Team-BasedTreatment(A3):Thisisamoreintenselevelofcareforpeoplewithsevereneedsandsignificantgapsinfunctioningwhoareinneedofactivetreatmentandpsychosocialskillstraining.Mostpeoplewithseriousmentalillnesswhoarenotstablewouldneedthislevelofcare.

• AssertiveCommunityTreatment(ACT)(A4):Thisisthehighestlevelofserviceintensity,emphasizingpreventionofrepeatedpsychiatrichospitalizationsandcoordinatinganarrayofservicestomeetotherintensiveandcomplexneeds(e.g.,housingstability,ongoingjusticesysteminvolvement,co-occurringsubstanceuse).ACTisdesignedforpeoplewithseriousmentalillnesswhoarenotinvolvedwiththecriminaljusticesystembutstillcaughtincyclesof“superutilization,”asnotedaboveintheneedssectionofthisreport.42

Inadditiontothesefiveongoingtreatmentlevels,LMHAsalsoprovidetwolevelsofcrisissupport:

• CrisisResponse:Thisistheinitialresponsetoacrisisthroughbriefintervention,eitherbymobilecrisisteamsorthroughservicesatafacility,andcaninvolveuptosixdaysoffollow-up.

• Transitional:Thisinvolvesupto90daysofadditionalcrisistransitionservicesuntilthesituationisresolved.

Thetablebelowillustratesthat,relativetothecomparisoncounties,TTBHandBRBHCareprovidingmorecrisiscare,buttheyarenotservingmorepeopleinthehigherlevelsofongoingoutpatientcare.Infact,slightlylowerpercentagesofpeoplereceivingongoingoutpatientlevelsofcarethroughTTBHandBRBHCareservedatteam-basedcasemanagementandAssertiveCommunityTreatment(ACT)levelsofcare,relativetotheothertwocomparisonLMHAs.

42Cuddeback,G.S.,Morrissey,J.P.,&Meyer,P.S.(2006).Howmanyassertivecommunitytreatmentteamsdoweneed?PsychiatricServices,57,1803-1806.

ThehigherlevelofcrisisservicedeliveryintheRGVcanbepartiallyattributedtotheinnovativeandrobustcrisisresponsesystemofferedbyTTBH,whichincludesservicessuchasMobileCrisisOutreachTeams(MCOTs)andpartnershipswithlocallawenforcementthroughtheMentalHealthPeaceOfficer(MHOT)program.AdultLevelsofCareAnalysis,FY201643

LMHA/Region CrisisContinuum OngoingTreatmentLevels

LevelsofCare

CrisisResponse

CrisisTransition

MedicationManagement

SkillsTraining

Medications&Therapy

Team-Based ACT

TotalNon-Crisis

BRBHC 499 174 * 2,204 12 87 57 2,360

%ofLOCs 16% 6% <1% 93% 1% 4% 2% n/a

TTBH 2,944 233 97 5,855 584 1,419 112 7,970

%ofLOCs 26% 2% 1% 73% 7% 18% 1% n/aCaminoRealComm.Services

474 142 0 1,519 129 215 59 1,922

%ofLOCs 19% 6% 0% 79% 7% 11% 3% n/aCoastalPlainsComm.Ctr.

370 18 0 2,648 59 193 * 2,900

%ofLOCs 11% 1% 0% 91% 2% 7% <1% n/aMostimportantisthefactthatnotenoughpeoplewhoreceivecrisisservicessubsequentlyhaveaccesstothemoreintensiveteam-basedandACTlevelsofongoingoutpatientcare.Forexample,whilewehaveestimatedthatabout500peopleintheRGVneedaccesstoACTannually,44theACTComparativeAnalysisTableonpage19showsthatonlyabout39%ofpeopleinneedintheRGVareaactuallyreceiveACTeachyear.In2015,Dr.PaulRowanpublishedareportthatexaminedmentalhealthserviceutilizationpatternsamongadultswithSMIandtheirrespectivefederalpayersourcesbetween2010and

43Anotationof“*”indicatesfiveorfewerclientsreceivingthespecifiedlevelofcare.44Seetheestimateinthetable“ACTComparativeAnalysis–AdultswithSMIinPovertyKnowntoHaveReceivedACT”onpage19.Ina12-monthperiod,weestimatethat4.3%ofRGVadultswithSMIandlivinginpovertywillneedACTlevelofcare.

2012.45AbstractedfromRowan’sreport,thefollowingtablesummarizesthenumberofadultsonMedicaidwithSMIwhoreceivedinpatientandoroutpatientservicesacrosseachLMHAservicesarea.ThisdatadoesnotreflectthetotalnumberofadultsonMedicaidwithSMIwhoreceivedoutpatientmentalhealthservices;someadultswithSMImayhavereceivedtreatmentfromnon-LMHAproviders.UnduplicatedNumberofAdultswithMedicaidwhoReceivedBehavioral/MentalHealthServicesinEachLMHACatchmentArea,2012

LMHACatchmentArea

#ofAdultswithSMIReceivingBH

ServicesthroughMedicaid

#ofMedicaidAdultsReceiving

PsychiatricInpatientServices

#ofMedicaidAdultsReceivingMentalHealthOutpatient

ServicesthroughLMHA

BorderRegionBehavioralHealthCenter

3,392 125 928

15,841 908 2,910

2,601 51 733

CoastalPlainsCommunityCenter

3,438 203 897

AssertiveCommunityTreatment(ACT).ACTpenetrationcanbeexaminedusingtwodifferentlevels:(1)theneedforACTservicescanbebasedupontheestimatednumberofpeoplewithSMIat200%FPLor(2)theneedforACTservicesbasedupontheactualnumberofpeoplewithSMIservedwithinthepublicbehavioralhealthsystem.ThefollowingtablesummarizesthedegreeofACTpenetrationacrossLMHAsbasedontheproportionofconsumersinneedofACTamonglow-incomeindividualswithSMI.Onaverage,LMHAsacrossTexasmeet25%oftheestimatedneedforACTwhenconsideringtheneedamongpeoplewithSMIlivingbelow200%FPL.ThisanalyticapproachsuggeststhatBRBHCexceedstheTexasstatewidebenchmarkforACTservicesacrossLMHAs,whileTTBHisservingonly28%oftheestimatedneed.

45RowanPJ.(2015).SeriousandPersistentMentalIllnessinTexasMedicaid:DescriptiveAnalysisandPolicyOptions(FinalReport).PreparedforTheTexasInstituteforhealthcareQualityEfficiencyandtheMeadowsFoundation.

ACTComparativeAnalysis–AdultswithSMIwithinthePublicMentalHealthSystemKnowntoHaveReceivedACT

RegionNumberofAdultswithSMIServedinPublicSystem46

NeedACT47

PeopleReceivingACT48

PercentoftheNumberinNeedofACTWho

ReceivedACT49UnitedStates 3,850,000 170,000 61,215 37%Arizona 45,000 2,000 n/a n/aMaricopaCounty 30,000 1,000 2,093 160%California 380,000 15,000 6,282 38%Colorado 70,000 3,000 5,488 182%DenverCity–County 15,000 700 1,300 188%

Nebraska 10,000 500 115 23%NewYork 420,000 20,000 6,203 34%NewYorkCity 10,000 500 726 155%Texas 260,000 10,000 4,552 41%BorderRegionBehavioralHealthCenter

2000 100 57 57%

TropicalTexasBehavioralHealth 8,000 300 112 37%

CaminoRealCommunityServices 2,000 80 59 74%

CoastalPlainsCommunityCenter 3,000 100 n/a n/a

46Thestate-levelproportionofpeopleservedwithaseriousmentalillnessisreportedfromSAHMSA(2014)MentalHealthNOMS:CentralforMentalHealthServicesUniformReportingSystem.Retrievedfromhttp://www.samhsa.gov/data/us_map?map=1WecalculatedthenumberofpeoplewithSMIservedinasystembymultiplyingthereportedtotalnumberofadultsservedbythepercentageofpeopleidentifiedinasystemaslivingwithSMI.47BasedonananalysisbyCuddeback,G.S.,Morrissey,J.P.,&Meyer,P.S.(2006).Howmanyassertivecommunitytreatmentteamsdoweneed?PsychiatricServices,57,1803-1806.Forthepurposesofcomparison,thesefiguresonlyincludethoseadultswithhighlycomplexneedsinneedofACT;theydonotincludethoseinneedofForensicAssertiveCommunityTreatment(FACT).48State-levelfiguresarebasedonstateauthorizedmentalhealthservices,includingMedicaidenrollees,reportedintheSAMHSA’sNOMSsystemin2012.Retrievedfromhttp://media.samhsa.gov/dataoutcomes/urs/urs2012.aspx.http://media.samhsa.gov/dataoutcomes/urs/urs2012.aspx49Insomeinstances,thenumberofpeoplereceivingACTservicesexceedstheestimatednumberofpeopleinneedofACTlevelservices.Inthesecases,thepercentageofpeopleinneedofACTwhoreceivedtheseserviceswillbegreaterthanone-hundredpercent(100%).AlthoughtheACTestimationformulaappliedwithinthisanalysisisstandardized,ACTeligibilityandservicecapacityvaryacrossstatesandmunicipalregionsandlikelyincludeddifferentfactorsthatinfluencedACTservicefundingandperformanceinthoserespectiveregions.

Whenonlypeople“known”withinthepubliclyfundedbehavioralhealthsystemareexamined,TexasexceedsthenationalpercapitabenchmarkforACTservicescomparedtootherselectstatesandregions.CaminoRealCommunityServicesisapproachingabest-practicebenchmark,serving74%oftheestimatedACTneedinitsregion.Basedonthisanalysis,BRBHC’stwoACTteamsshouldbecapableofmeetingtheentireestimatedneedforACTserviceswithintheirregion.ThequalityofdeliveredACTservicesisalsoimportant.Best-practiceACTservices–includingthoseinTexas–seektosystematicallypromoteconsistentoutcomesacrossprogramsovertimethroughacomprehensiveprocessofinteractive,qualitativefidelitymonitoringusingbest-practicemeasures.SuchanapproachisparticularlycriticalbecausehighfidelityimplementationofprogramssuchasACTisapredictorofgoodoutcomes50andofsystem-widecostsavings.51Rigorousfidelityassessmentalsoprovidesabasisforneededservicedeliveryenhancementswithinacontinuousqualityimprovement(CQI)process.Ineffect,qualitativeclinicalservicesmonitoringwillhelpensurefidelitytotheACTmodel,evaluatewhethersettlementstipulationsarebeingmet,andcontributetoacontinuousqualityimprovementprocess.TTBHemploystheuseofthecurrentstate-of-the-artToolforMeasurementofAssertiveCommunityTreatment(TMACT)inmonitoringandreportingonthefidelityofitsoperatingACTteams.TheTMACTisthecurrentstandardinthefieldandrepresentsthebestcurrentlyknownwaytopromotehighqualityACTservices.52WhileTTBHusestheTMACTtoguideitsCQIprocess,mostTexasprovidersinsteadcontinuetousetheDartmouthAssertiveCommunityTreatmentScale(DACTS)developedinthelate1990s.53KeyadvantagesoftheTMACTmodelincludethefollowing:

• Morespecializedrequirementsforstaffingandrolefunctioningforpeer,housing,andsubstanceusespecialistsontheteam.

• Dynamiccaseloadmodelingthatallowscaseloadstoflexupordowndependingonlevelsofstaffing.ThisallowsmoreflexibleservicedeliverythantheTexasstandards,ascaseloadsforastandardteamof100couldmaintainfullfidelityandrangeashighas125(thusallowingformorecapacity,alongsidetheenhancedstaffingrequirements).

50Teague&Monroe-DeVita(inpress).Notbyoutcomesalone:Usingpeerevaluationtoensurefidelitytoevidence-basedAssertiveCommunityTreatment(ACT)practice.InJ.L.Magnabosco&R.W.Manderscheid(Eds.),Outcomesmeasurementinthehumanservices:Cross-cuttingissuesandmethods(2nded.).Washington,DC:NationalAssociationofSocialWorkersPress.51Seeforexample,Latimer,E.(1999).Economicimpactsofassertivecommunitytreatment:Areviewoftheliterature.CanadianJournalofPsychiatry,44,443-454.52TheTMACTiscurrentlythestandardusedinmanystatesforstatewideACTimplementation(e.g.,Delaware,Indiana,NorthCarolina,Pennsylvania,andWashington).53Monroe-DeVita,M.,Teague,G.B.,&Moser,L.L.(2011).TheTMACT:Anewtoolformeasuringfidelitytoassertivecommunitytreatment.JournaloftheAmericanPsychiatricNursesAssociation,17(1),17-29.

• TMACTalsoemphasizesmovementonandoffteams:- Itrequiresteamsoperatingbelowfullcapacity(TMACTStandardOS7)to“actively

[recruit]newconsumerswhocouldbenefitfromACT,includingassertiveoutreachtoreferralsites...[and]commonreferralsourcesandsitesoutsideofusualcommunitymentalhealthsettings(e.g.,stateandcommunityhospitals,ERs,prisons/jails,shelters,streetoutreach).”

- Italsorequiresteamstoworktograduateconsumerstolowerlevelsofcarethrough“regularassessmentofneedforACTservices[forcurrentteammembers],”“explicitcriteriaormarkersforneedtotransfertolessintensiveserviceoption[s],”and“gradualandindividualized”transition“withassuredcontinuityofcare”andmonitoringfollowingtransition,with“anoptiontoreturntoteamasneeded”(TMACTStandardOS9).54

SupportedHousing(SH).PermanentSupportiveHousingisanevidence-basedpracticethathelpspeoplewithmentalillnessesliveindependentlyinthecommunity.ItinvolvesawiderangeofapproachesandimplementationstrategiestoeffectivelymeetthehousingneedsofpeoplewithSMI.Supportedhousingmayincludesupervisedapartmentprograms,scatteredsiterentalassistance,andotherresidentialoptions.Theoverallgoalofsupportedhousingistohelppeoplefindpermanenthousingthatisintegratedsocially,reflectstheirpersonalpreferences,andencouragesempowermentandskillsdevelopment.Programstaffprovideanindividualized,flexible,andresponsivearrayofservices,supports,andlinkagestocommunityresources,whichmayincludesuchservicesasemploymentsupport,educationalopportunities,integratedtreatmentforco-occurringdisorders,recoveryplanning,andassistanceinbuildinglivingskills.Thelevelofsupportisexpectedtofluctuateovertime.HHSCdefinessupportedhousingas“[a]ctivitiestoassistindividualsinchoosing,obtaining,andmaintainingregular,integratedhousing.Servicesconsistofindividualizedassistanceinfindingandmovingintohabitable,regular,integrated(i.e.,nomorethan50%oftheunitsmaybeoccupiedbyindividualswithseriousmentalillness),andaffordablehousing.”Thetwomaincomponentsofsupportedhousingarethefollowing:

• FundsforrentalassistanceaspartofatransitiontoSection8,publichousing,oraplantoincreaseindividualincomesohousingwillbecomeaffordablewithoutassistance.

• Servicesandsupportstoassistwithlocating,movinginto,andmaintainingregularintegratedhousing.

54Monroe-DeVita,M.,Moser,L.L.&Teague,G.B.(2013).Thetoolformeasurementofassertivecommunitytreatment(TMACT).InM.P.McGovern,G.J.McHugo,R.E.Drake,G.R.Bond,&M.R.Merrens.(Eds.),Implementingevidence-basedpracticesinbehavioralhealth.CenterCity,MN:Hazelden.

OnemajorbarriertothedeliveryofsupportedhousinginTexasisthattheseservicesandsupportscannotbebilledtoMedicaidasrehabilitativeservices,thoughconcurrentrehabilitativetrainingcanbeprovided.Asaresult,thereisafinancialdisincentivetodeliverthisserviceinTexas. Thefollowingtableillustratesthataccesstosupportedhousingisverylowinmoststatesandcommunities,includingTexasandtheRGV.ClientsreceivingsupportedhousingservicesthroughTTBHresideinindependentapartmentsthroughouttheTTBHcatchmentarea(Cameron,Hidalgo,andWillacycounties).AdultswithSMIinPovertyKnowntoHaveReceivedSupportedHousing(SH)

Region/LMHA AdultSHNeed55 AdultsReceivingSH56

PercentofNeedReceivingSH

UnitedStates 3,550,000 75,875 2.40%

Arizona57 40,000 2,396 5.70%

DenverCity–County58 15,000 1,650 11.20%

NewYorkState59 430,000 22,895 5.40%

Texas 540,000 14,130 3%BorderRegionBehavioralHealthCenter 9,000 149 2%

TropicalTexasBehavioralHealth 35,000 832 3%

CaminoRealCommunityServices 4,000 221 5%

CoastalPlainsCommunityCenter 5,000 305 6%

55Whenwehavebenchmarksforevidence-basedpracticesoutsideofTexas,weusethetotalestimatednumberofpeoplewithSMIineachregion,applyinga58%factorbasedonTexasdatatoestimatethenumberwhoarelivinginpovertyinordertobetterfacilitatecomparisonstothecommunitiesoutsideofTexas.56Generally,state-levelfiguresarebasedonstateauthorizedmentalhealthservices,includingMedicaidenrollees,reportedintheSAMHSA’sNOMSsystemin2012.SubstanceAbuseandMentalHealthServicesAdministration.(2013,August28).2012CMHSuniformreportingsystemoutputtables.Retrievedfromhttp://media.samhsa.gov/dataoutcomes/urs/urs2012.aspxNewYorkState“ReceivedSH”datawereestimatedbasedonaveragelengthsofstayandquarterlycapacityandoccupancydata.TexasdataisforFY2015,andwasprovidedfromDSHS.57MercerGovernmentHumanServicesConsulting.(2014,June).Servicecapacityassessment:Prioritymentalhealthservices,2014.UnpublishedManuscript.Phoenix,AZ:MercerGovernmentHumanServicesConsulting.(StudyconductedfortheArizonaDepartmentofHealthServices/DivisionofBehavioralHealthServices.)58DatareceivedfromRoyStarksandKristiMockoftheMentalHealthCenterofDenver(personalcommunication,March2014).59NewYorkStateOfficeofMentalHealth.(2016).Residentialprogramindicatorsreport:NewYorkCounty(OnlineDashboard).RetrievedonJuly14,2017fromhttps://my.omh.ny.gov/analytics/saw.dll?PortalPages&PortalPath=%2Fshared%2FAdult%20Housing%2F_portal%2FAdult%20Housing&Page=RPI%20Reports&Action=Navigate&var1=dashboard.variables[%27pReportLevel%27]&val1=%22Regional%20Reports%22

SupportedEmployment(SE).SupportedEmploymentisanevidence-basedpracticethatpromotesrehabilitationandareturntomainstreamemploymentforindividualswithpsychiatricdisabilitiesinordertohelpthemgetandkeepcompetitiveemployment.SupportedEmploymentprogramsintegrateemploymentspecialistswithothermembersofthetreatmentteamtoensurethatemploymentisanintegralpartofthetreatmentplan.HHSCdefinesSupportedEmploymentas“competitiveemploymentinanintegratedworksetting,consistentwiththeconsumer'sstrengths,resources,priorities,concerns,abilities,capabilities,interests,andinformedchoice.”60AconsiderablebodyofresearchindicatesthatspecificSupportedEmploymentmodels,suchasIndependentPlacementandSupport(IPS),aresuccessfulinincreasingcompetitiveemploymentamongadultswithSMI.61Inaddition,theresearchconsistentlyshowsthatSEiseffectiveacrossabroadrangeofindividualfactors,suchasdiagnosis,age,gender,disabilitystatus,priorhospitalization,co-occurringsubstanceusedisorder,andeducation.62Asaresult,theresearchliteraturerecommendsprovidingSEtoallindividualswithmentalillnessesand/orco-occurringdisorderswhowanttowork,regardlessofpriorworkhistory,housingstatus,orotherpopulationcharacteristics.63Areviewofthreerandomizedcontrolledtrialsfoundthat,ingeneral,60-80%ofpeopleservedbyaSEmodelobtainatleastonecompetitivejob.64ResearchsuggeststhatabouthalfofadultswithSMIwanttowork.InTexas,SupportedEmploymentisnotabillableserviceinandofitself,eitherforMedicaid(throughfeeforserviceormanagedcareorganizations)orforstatefunds.Instead,manyservicesthatsupportapersongettingandkeepingemploymentcanbebilledunderrehabilitationasskillstrainingorpsychosocialrehabilitation.Formalvocationalrehabilitation(VR)servicesmustbecoordinatedwiththeDepartmentofAssistiveandRehabilitativeServices(DARS).OnecoordinationissueinvolvestheDARSintakeandeligibilityprocess,whichoftenentailssubstantialdelaysandworksoptimallyonlywheretherearestrongrelationships

60Retrievedfrom:https://hhs.texas.gov/node/4496161Drake,R.E.,Becker,D.R.,Clark,R.E.&Mueser,K.T.(1999).Researchontheindividualplacementandsupportmodelofsupportedemployment.PsychiatricQuarterly,70,289-301.62SubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)CenterforMentalHealthServices(CMHS)(2003).Evidence-basedpractices:Shapingmentalhealthservicestowardrecovery:Co-occurringdisorders:SupportedEmploymentimplementationresourcekit.Rockville,MD:U.S.DepartmentofHealthandHumanServices,SubstanceAbuseandMentalHealthServicesAdministration,CenterforMentalHealthServices.(SupportedEmploymentResourceKit).63Bond,G.R.,Becker,D.R.,Drake,R.E.,Rapp,C.A.,Meisler,N.,Lehman,A.F.,Bell,M.D.,&Blyler,C.R.(2001,March).Implementingsupportedemploymentasanevidence-basedpractice.PsychiatricServices,52(3),313-22.64NewFreedomCommissiononMentalHealth(2003).Achievingthepromise:TransformingmentalhealthcareinAmerica.Finalreport.Rockville,MD:DHHSPub.No.SMA-03-3832at41,citingDrake,R.E.,Becker,D.R.,Clark,R.E.,andMueser,K.T.(1999).Researchontheindividualplacementandsupportmodelofsupportedemployment.PsychiatricQuarterly,70,289-301.

betweenthementalhealthclinicianandtheDARSVRcounselor.Inalargesystem,thisisparticularlychallenging.Inaddition,TargetedCaseManagementisbillableunderMedicaid.TheMedicaid1915(i)StatePlanAmendmentthatTexasapprovedinlate2015providesamorecomprehensiveandformalSEbenefitforeligibleindividuals.65ThefollowingtableillustratesthatsomesystemshavemadeSEavailabletoarelativelyhighpercentageofadultswithSMI;ingeneral,Texasprovidesmorelimitedaccess.BRBHCandTTBHdocumentalowerfrequencyintheprovisionofSEservicesthancomparisoncenters,withzeroto4%ofindividualsinneedofSEreceivingtheservice.AdultswithSMIinPovertyKnowntoHaveReceivedSupportedEmployment(SE)66

Region/LMHA

AdultPopulationWithSMIinPoverty67

AdultsNeedingSE68

AdultsReceiving

PercentofNeed

ReceivingSE

UnitedStates 3,550,000 1,800,000 54,190 3%

Arizona 120,000 60,000 12,137 21%

MaricopaCounty70 70,000 35,000 7,366 20%

California 550,000 280,000 893 <1%

Colorado 120,000 60,000 1,380 2%

DenverCity–County71 15,000 7,000 680 9%

NewYork(state) 460,000 230,000 1,634 <1%

Texas 540,000 270,000 16,284 6%

65TexasDepartmentofStateHealthServices(n.d.).Homeandcommunity-basedservices–adultmentalhealthbillingguidelines,pages41-46.Retrievedfromhttps://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589993416onMay15,2015.66FY2015dataforLMHAsreceivedfromDSHS(personalcommunication,April13,2016).TexasdataarefromFY2015.DataforcommunitiesoutsideofTexasarefrom2013forArizonaandColorado;forNewYorkandCalifornia,populationdataarefrom2012anddataonthenumberofpeoplereceivingSupportedEmploymentarefrom2013.67AllTexasprevalenceandpopulationestimatesareroundedtoreflectuncertaintyintheunderlyingAmericanCommunitySurveypopulationestimates.Allpercentagesarecalculatedwithunroundedfigures.68TheunemploymentrateforpeoplewithSMIservedinpubliclyfundedmentalhealthsystemsisapproximately90%,butresearchshowsabout50%ofpeoplewithSMIwantvocationalhelp.TheserateswereappliedtoSMIprevalenceofeachregiontodetermineestimatedneedforSupportedEmployment.69State-levelfiguresarebasedonstateauthorizedmentalhealthservices,includingMedicaidenrollees,reportedintheSAMHSA’sNOMSsystemin2012.Retrievedfromhttp://media.samhsa.gov/dataoutcomes/urs/urs2012.aspx70MercerGovernmentHumanServicesConsulting.(2014,June).Servicecapacityassessment:Prioritymentalhealthservices,2014.(StudyconductedfortheArizonaDepartmentofHealthServices/DivisionofBehavioralHealthServices.)UnpublishedManuscript.Phoenix,AZ:MercerGovernmentHumanServicesConsulting.71DatareceivedfromRoyStarksandKristiMockoftheMentalHealthCenterofDenver(personalcommunication,March2014).

Region/LMHA

AdultPopulationWithSMIinPoverty67

AdultsNeedingSE68

AdultsReceiving

PercentofNeed

ReceivingSE

BorderRegionBehavioralHealthCenter 9,000 5,000 0 0%

TropicalTexasBehavioralHealth 35,000 15,000 645 4%

CaminoRealCommunityServices 4,000 2,000 232 11%

CoastalPlainsCommunityCenter 5,000 2,000 228 9%PeerSupport.Akeybestpracticeinservicedeliveryistheuseofpeersupportthroughcertifiedpeerspecialistsandfamilypartners.Certifiedpeerspecialistsareindividualswhohaveexperiencelivingwithaseriousmentalillnessandreceivingtreatment.Inthecaseoffamilypartners,theseindividualshaveparentedachildwithSED.Inbothcases,theyhavereceivedtrainingandcertificationtousetheirexperiencetohelpothersfeelasenseofhopeandtoassistwithpracticalsupportasthepeopletheyservegothroughasimilarexperience.Trainingpeersoffersanemploymentopportunityforindividualswithlivedexperienceofmentalillnessandexpandstheavailableworkforceinscarcelyresourcedareas.Texashasengagedinasignificanteffortduringthepastdecadetoexpandaccesstotrainingandcertificationofpeerspecialists(foradultswithSMI),familypartners(forfamiliesofchildrenwithSED),andrecoverycoaches(foradultswithSUD).The85thLegislatureapprovedMedicaidreimbursementforpeersupport,andrulestoallowthatwillbedevelopedinFY2018.Peersupporthasbeendesignatedasanevidence-basedmodelsince2007bythefederalCentersforMedicareandMedicaidServices,72andthereisgoodevidenceofitseffectiveness73andemergingevidenceofitscost-effectiveness.74However,Texashasrelativelyfewpeerproviderscomparedtootherstates.AccordingtotheSeptember2014DepartmentofStateHealthServicesreportonthementalhealthworkforceshortage,asofJanuary2014,Texashad333certifiedpeerspecialists,99certifiedfamilypartners,and“over300”recoverycoaches,for72SeeStateMedicaidDirectorLetter#07-011athttp://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD081507A.pdf73HoggFoundationforMentalHealth(2014,October).Peersupportservicesoutcomes.Davidson,L.,Bellamy,C.,Guy,K.,&Miller,R.(2012,June).Peersupportamongpersonswithseverementalillnesses:Areviewofevidenceandexperience.WorldPsychiatry,11(2),123-128.Sledge,W.,Lawless,M.,Sells,D.,Wieland,M.,O’Connell,M.,&Davidson,L.(2011.)Effectivenessofpeersupportinreducingreadmissionofpersonswithmultiplepsychiatrichospitalizations.PsychiatricServices,62(5),541-544.74Trachtenberg,M.,Parsonage,M.,Shepherd,G.,&Boardman,J.(2014.)Peersupportinmentalhealthcare:Isitgoodvalueformoney?CentreforMentalHealth.Retrievedfromhttp://www.centreformentalhealth.org.uk/pdfs/peer_support_value_for_money_2013.pdfPitt,V.,Lowe,D.,Hill,S.,Prictor,M.,Hetrick,S.E.,Ryan,R.,&Berends,L.(2013.)Consumer-providersofcareforadultclientsofstatutorymentalhealthservices.CochraneDatabaseSystematicReviews,3.Retrievedfromhttp://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004807.pub2/full

atotalofjustover700peerproviders(2.75per100,000Texans).75Bycomparison,Pennsylvaniahasover9.0peersper100,000population.76Thedatainthefollowingtableillustratethat,althoughTTBHhashiredmanytrainedpeerspecialists,thenumberofindividualscertifiedaspeerspecialistsintheRGVarea(per100,000individualswithSMIwhoareinneedofservices)issignificantlylowerthaninthecomparisonLMHAsselectedforthisreportandinTexasasawhole.Atthetimeofoursitevisits,TTBHhadhired22certifiedpeersandfamilypartners.BBHRCreportednopeerspecialistsin2015,but,atthetimeofthesitevisits,hadhiredtwofamilypartners.TrainedPeerSupportSpecialistsbyServiceArea,FY2015

Region/LMHA NeedforAdultsinPoverty

TrainedPeerSpecialists77

Specialistsper100,000SMIin

NeedTexas 540,000 622 115

BorderRegionBehavioralHealthCenter 9,000 0 0

TropicalTexasBehavioralHealth 35,000 22 67

CaminoRealCommunityServices 4,000 3 71

CoastalPlainsCommunityCenter 5,000 6 122Finding NC-3: Other Adult Services Public Outpatient and Crisis System Capacity

ThefollowingtablesummarizestheoveralladultservicecapacityacrossmajoroutpatientpublicmentalhealthservicesystemsintheRioGrandeValley.Ourcalculationofthenumberofunduplicatedindividualsservedinoutpatientsettingsindicatesthatthereiscapacityamongthethreemajorcomponentsofthesystem–BRBHC,TTBH,andtheotherMedicaidproviders–toservenearlytwothirds(about63%)oftheestimatednumberofadultswithSMIlivinginpoverty,atleastatsomelevelofoutpatientcare.However,asindicatedintheprevioussection,

75DepartmentofStateHealthServices(2014,September).ThementalhealthworkforceshortageinTexas.Retrievedfromhttps://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwib6Jrpv77VAhXHzVQKHRFnBVIQFggoMAA&url=https%3A%2F%2Fwww.dshs.texas.gov%2Flegislative%2F2014%2FAttachment1-HB1023-MH-Workforce-Report-HHSC.pdf&usg=AFQjCNE-QjrhsiI1P3EtN4LSMEEqRvipuA76MMHPIdatacollectedinternally.77ForFY2015,thisisthenumberoftrainedpeersupportspecialistsbycountyinLMHAcatchmentareas(notLMHAs).ThenumberofpeerspecialistswiththeLMHAsisdifferent.“TrainedPeerSpecialist”representsthenumberofpeerspecialistswhocompletedtrainingandcertificationbyOctober2015.Notalltrainedcertifiedpeerspecialistsarecurrentlyemployedaspeerspecialists.DataobtainedfromDr.StaceyManser,UniversityofTexas(personalcommunication,September9,2016).

formanyofthoseinneed,therighttypesandintensitiesofcare(AssertiveCommunityTreatment,SupportedEmployment,andsupportedhousing)arenotalwaysavailable.AdultsServedbyCorePublicProvidersvs.AdultsinNeedofCare,FY2014

AdultsServedRGVAreaCounties78

Comments

Need:AdultsinPovertywithSevereNeeds(SMI200%FPLPopulation)

35,000

ReceivedPublicMentalHealthOutpatientServicesatAnyLevel 21,762 Estimateofunduplicatedcasesservedby

coresystem.

LocalMentalHealthAuthority(TTBHandBRBHC79) 7,751 Estimateoftotalservedinongoinglevelsof

HealthDistrict 0

MedicaidFFSandHMO80 14,011

ThisistheunduplicatednumberofadultswithSMIservedin2012;levelofcarereceivedisnotclear.Datamorerecentthan2012arenotavailablefromHHSC,andwebelievethisrepresentsaconservativeestimateofcurrentservicelevels.

PercentofSevereNeedinPovertyServedbyCorePublicProviders 63% Notnecessarilyservedattherightlevelof

Finding NC-4: Core Public Outpatient System Capacity for Children and Youth with Severe Needs

ThefollowingtableshowsthenumberofchildrenandyouthwithSEDwhoreceivedongoingcarethroughoneofTexas’sspecifiedlevelsofcareinthetwoLMHAsintheVBLFservicearea.Thisnumberisrelativetotheestimatednumberofchildren/youthwithSEDlivingat/below200%ofthefederalpovertylevel(FPL)inotherregions.Itisimportanttonotethatsome,ifnotmany,childrenandyouthwhohaveSEDandwhoreceiveMedicaidcouldbereceiving78“RGVAreaCounties”includesdatafromthefour-countyregionincludedinthisassessment:Cameron,Hidalgo,Starr,andWillacy.79DataonnumberofadultsfromStarrCountyservedbytheBorderRegionBehavioralHealthCenterinFY2015receivedfromAldaRendonoftheBorderRegionBehavioralHealthCenter(personalcommunication,August17,2016).ToestimatethenumberofadultsfromStarrCountyservedinongoinglevelsofcarebytheLMHA,theproportionofthenumberofadultsservedinongoinglevelsofcarebyBRBHCinFY2015andthetotalnumberofadultsservedbyBRBHCinFY2015wasappliedtothetotalnumberofadultsservedbytheLMHAinStarrCountyinFY2015.80Rowan,P.J.,Begley,C.,Morgan,R.,Fu,S.,&Zhao,B.(2014,September).SeriousandpersistentmentalillnessinTexas:County-levelenrolleecharacteristicsofMedicaid-supportedSMIcare,Texas,2012.TheUniversityofTexasHealthSciencesCenteratHouston:SchoolofPublicHealth.Retrievedfromhttps://sph.uth.edu/research/centers/chsr/assets/RowanEtAlCyLevelMedicaidSPMIMar2015.pdf

treatmentfromothernon-LMHAproviders.Nevertheless,itappearsthatTTBHisachievingapenetrationratethatissomewhatlowerthancomparisonLMHAs,whileBRBHCisachievingacomparativelyhigherpenetrationrate.UnduplicatedNumberofChildrenandYouthwithSEDLivingatorBelow200%FPLWhoWereServedbytheLMHA(September2015toAugust2016)

LMHA/Region

TotalChild/Youth

PopulationinPoverty

Children/YouthwithSEDinPoverty

Children/YouthServedinOngoingTreatment81

PercentPercent

Medicaid82

50,000 5,000 2,439 50% 83%

200,000 20,000 4,827 26% 77%

20,000 2,000 855 44% 83%

CoastalPlainsCommunityCenter

20,000 2,000 931 48% 75%

ThenexttableprovidesacomparisonofthenumberofchildrenonMedicaid,andhowmanychildrenwereservedininpatientandoutpatientsettingsforeachLMHAregion.ChildrenonMedicaidwhoReceivedBehavioral/MentalHealthServicesbyVisitTypeinEachLMHACatchmentArea,201583

LMHA InpatientChildrenServed

Outpatient/ProfessionalChildrenServed

TotalChildrenServed

BorderRegionBehavioralHealthCenter 255 8,517 8,520

81“ChildrenServedinOngoingTreatment”datainthiscolumnaretheunduplicatednumberservedbytheLMHAacrossLOCsC1,C2,C3,andC4,aswellasCY(YESWaiver)andCYC(YoungChildServices).82PercentofchildrenservedbyLMHAreceivingMedicaidduringFY2015.DataprovidedbyDSHSonApril13,2016.83

DataobtainedfromTexasHealthandHumanServices,April2016.DatasourcesisAHQPClaimsUniverse,TMHP.ICD-10Diagnosescodeswereincludedbecauseclients’primarydiagnosesisbasedondiagnosisatdischarge.Diagnosiscodesexcludesubstanceabusediagnoses.Clientcountsarenotadditivebecauseclientsmaychangecountiesandagegroupsduringthefiscalyearandthusmayappearinmorethanonecategory.

LMHA InpatientChildrenServed

Outpatient/ProfessionalChildrenServed

TotalChildrenServed

TropicalTexasBehavioralHealth 1,503 38,689 38,698

CaminoRealCommunityServices 103 3,223 3,224

CoastalPlainsCommunityCenter 187 4,298 4,300

Before2013,onlyLMHAscouldbillMedicaidforMentalHealthRehabilitativeServicesandTargetedCaseManagement(TCM).In2013,SenateBill(SB)58,83rdLegislature,RegularSession,integratedMentalHealthRehabilitativeServicesandTCMintothestate’sMedicaidmanagedcareprogram–reimbursedthroughcapitated(orfixed,predetermined)rates–andenabledproviderentities,otherthanLMHAs,tobecomecredentialedandobtainreimbursementfortheprovisionoftheseservices.Thiswasanimportantfirststepinexpandingthecapacitytoprovidetheseservicesstatewide.OnlyLMHAsandproviderentitiesthatareorganizations–notindividualpractitioners–canbillforTCMandMentalHealthRehabilitativeServices.Since2013,anincreasingnumberofcommunity-basedorganizationsarebecomingcredentialedtoprovidetheseservices.The85thLegislaturepassedSB74tostreamlineandclarifycredentialingrequirements,andanassociatedHHSCrider(Rider172)provides$2millionforgrantstohelpproviders(includingbothLMHAsandnewproviders)expandcapacitytoprovidethemostintensivelevelofcaretohigh-needchildrenandyouthinthefostercaresystem.Aswithadults,allLMHAsinTexasprovidedefinedTexasResiliencyandRecovery(TRR)levelsofcare(LOCs)tochildrenandyouth.TheLOCsarecategorizedbygraduatedlevelsofintensitytomeetthevariouslevelsofserviceneedsofchildren,youth,andadultsenteringthepublicmentalhealthsystem.Therearefourprimarychild/youthLOCsforongoingmentalhealthservices:

• MedicationManagement(C1):Thisisthelowestlevelofservice,typicallyinvolvinglessthananhourofcarepermonth,generallyforchildrenandyouthwhoarestableandinamaintenancephaseneedingonlymedicationorlowlevelsofpsychosocialorcasemanagementsupports.AchildoryouthwithSEDwouldneedtoberelativelystabletoreceivethisLOC.

• TargetedServices(C2):ThisLOCaddstwotothreehoursoffamily/individualcounselingorskillstrainingtotheservicemix.Thisisforchildrenandyouthprimarilyinneedoftreatmentwithlowlevelsoffunctionalimpairment.AswithMedicationManagement,a

childoryouthwithSEDwouldneedtobefunctioningatarelativelystableleveltoreceivethisLOC.

• ComplexServices(C3):Thisisamoreintenselevelofcareforchildrenandyouthwithfunctionalimpairmentswhoareinneedofactivetreatmentandpsychosocialskillsinterventionsaimedatpreventingjuvenilejusticeinvolvement,expulsionfromschool,displacementfromhome,orworseningofsymptomsorbehaviors.MostchildrenandyouthwithSEDwhoarenotstablewouldneedthislevelofcare.

• IntensiveFamilyServices(C4):Thisisthehighestlevelofserviceintensityforchildrenandyouth,generallyforthosewithsignificantinvolvementwithmultiplechild/youthservingsystems.Itinvolvesintensivefamily-focusedtreatment(targetoftwoormorehoursperweekonaverage),generallydeliveredinthehomeorcommunity.Theleveloffunctionalimpairmentmustbehigh,resultingin(oratleastlikelytoresultin)juvenilejusticeinvolvement,expulsionfromschool,out-of-homeplacement,hospitalization,residentialtreatment,seriousinjurytoselforothers,ordeath.

Children,youth,andfamiliesalsohaveaccessthroughLMHAstotwospecializedlevelsofcare:

• YouthEmpowermentServices(YES)Waiver:YESWaiverservicesareavailableinagrowingnumberofTexascounties,includingthroughouttheRGV.LMHAscoordinatethecareandprovidehigh-fidelitywraparoundplanningandservicecoordination,buttheadditionalsupportsareprovidedbynon-LMHAproviders.YESWaiverhomeandcommunity-basedsupportsareonlyavailableforMedicaidrecipients.InadditiontoregularMedicaidservices,waiverparticipantsareeligibleforotherservicesasneeded,includingrespitecare,adaptiveaidsandsupports,communitylivingsupports,familysupports,minorhomemodifications,non-medicaltransportation,paraprofessionalservices,professionalservices,supportiveemploymentservices,supportivefamily-basedalternatives,andtransitionalservices.

• YoungChildServices(YC):Theseareservices,targetingchildrenagesthreetofiveyears,haveaparticularfocusontherelationshipbetweentheparentandchild.

Inadditiontotheseongoingtreatmentlevels,LMHAsalsoprovide:

• CrisisResponse:Thisistheinitialresponsetoacrisisthroughbriefintervention,eitherthroughmobilecrisisorservicesatafacility,andcaninvolveuptosixdaysoffollow-up.

• Transitional:Thisinvolvesupto90daysofadditionalcrisistransitionservicesuntilthesituationisresolved.

ThefollowingtableillustratesthatarelativelysmallerpercentageofchildrenandyouthinboththeBRBHCandTTBHserviceareasreceivecomplexservicesorintensivefamilyservices(only15%combinedforBRBHCand26%combinedforTTBH),comparedtoCaminoRealCommunityServices(55%together).Childrenandyouth(andfamilies)whoneedhighintensityservicesbut

donotreceivethemaremorelikelytoexperienceadverseoutcomes,includinghospitalization,juvenilejusticeinvolvement,protectiveservicesinvolvement,andsuicide.Child/YouthLevelsofCareAnalysis,FY201684

LMHA/Region CrisisContinuum OngoingTRRTreatmentLevels Specialized

LevelofCare85 Crisis Transition MedicationManagement

TargetedServices

ComplexServices

IntensiveFamily YES Young

185 24 158 1,650 344 14 8 265

%ofLOCs 6% 68% 14% 1% 0% 11%TropicalTexasBehavioralHealth

1,626 33 186 2,779 1,227 45 111 479

%ofLOCs 4% 58% 25% 1% 2% 10%CaminoRealCommunityServices

118 * 34 275 436 31 6 73

%ofLOCs 4% 32% 51% 4% 1% 9%CoastalPlainsCommunityCenter

54 0 78 684 92 7 13 57

%ofLOCs 8% 73% 10% 1% 1% 6%

Finding NC-5: Other Child and Youth Services Public Outpatient and Crisis System Capacity

Thefollowingtablesummarizestheoverallchild/youthservicecapacityforchildrenandyouthwiththemostsevereneeds(seriousemotionaldisturbancesorSED)acrossmajoroutpatientpublicmentalhealthservicesystemsintheRioGrandeValley.BecausethedataonMedicaiddonotdifferentiatebetweenlevelsofneed(mildtosevere)forpeopleserved,ourcalculationofthenumberofunduplicatedindividualsservedinoutpatientsettingsisexpressedasarangebasedonhigh(75%oftotalMedicaidservedwithSED)andlow(25%oftotalMedicaidservedwithSED)estimates.Acrossthetwomajorcomponentsofthepublicsystem(LMHAand

84Anotationof“*”indicatesfiveorfewerclientsreceivingthespecifiedLOC.85The“%ofLOCs”includeallLOCsforchildren’sservices.

Medicaid),thereiscurrentlycapacitytoservebetweenthreein10(29.4%)andsixin10(58.0%)childrenandyouthinneed,andinpoverty,atsomelevelofcare.ChildrenandYouthServedbyCorePublicProvidersvs.ChildrenandYouthinNeedofCare,FY2014

Children/YouthServedRGVAreaCounties86

Comments

Need:ChildrenandYouthinPovertywithSevereNeeds(SED200%FPLPopulation)

29,527

ReceivedPublicMentalHealthOutpatientServicesatAnyLevel

8,680(low)17,134(high)

EstimatedarangetoaccountforlackofspecificityregardingseverityforMedicaid.

LocalMentalHealthAuthority(TTBHandBRBHC87) 4,456 Estimateoftotalservedin

ongoinglevelsofcare.

HealthDistrict 0

MedicaidFFSandHMO8816,904Total4,226(low)

12,678(high)

ItisnotknownwhatproportionoftheseserviceswenttochildrenandyouthwithSEDorchildrenandyouthwithlesssevereneeds,sowemadehighandlowestimates.

86“RGVAreaCounties”includesdatafromthefour-countyregionincludedinthisassessment:Cameron,Hidalgo,Starr,andWillacy.87DataonnumberofchildrenandyouthfromStarrCountyservedbytheBorderRegionBehavioralHealthCenterinFY2015receivedfromAldaRendonoftheBorderRegionBehavioralHealthCenter(personalcommunication,August17,2016).ToestimatethenumberofchildrenandyouthfromStarrCountyservedinongoinglevelsofcarebytheLMHA,theproportionofthenumberofchildrenandyouthservedinongoinglevelsofcarebyBRBHCinFY2015andthetotalnumberofchildrenandyouthservedbyBRBHCinFY2015wasappliedtothenumberofchildrenandyouthservedbytheLMHAinStarrCountyinFY2015.88ThenumberofchildrenandyouthwithsevereneedswhowereservedthroughMedicaidFFSandHMOintheRGVareacounties(Cameron,Hidalgo,Starr,andWillacy)wasestimatedbasedontheproportionofchildrenandyouthreceivingpsychotropicmedicationsthroughMedicaid.ThestatewideestimateisbasedonthetotalunduplicatednumberofchildrenandyouthreceivingMedicaidmentalhealthservicesinFY2015(318,464)–TexasDSHS(personalcommunication,April13,2016).Here,psychotropicmedicationuseisappliedasaproxytoidentifychildrenandyouthwithsevereneeds.Amongchildrenandyouthservedwithmentalhealthservices,59.7%receivedpsychotropicmedicationsinFY2012–fromBecker,E.A.(2013).UTHSCAupdate.TexasHealthandHumanServicesCommission.(Slide11usesdatafromOfficeofStrategicDecisionSupport,XiaolingHuang.)ApplyingthisproportiontotheFY2015unduplicatedservicetotal,weestimatedthat190,123childrenandyouthreceivedpsychotropicmedicationsinFY2015.Finally,todeterminetheportionofchildrenandyouthintheRGVareacountiesfromthestatewideestimate,wedividedthenumberofchildrenandyouthlivinginpoverty(under200%FPL,190,123)withintheRGVareacountiesbythetotalnumberofsuchchildrenandyouthinTexas(under200%FPL,3,566,287).TheresultingproportionwasappliedtothestatewideestimateofchildrenandyouthonMedicaidwhowerereceivingpsychotropicmedication.

Children/YouthServedRGVAreaCounties86

Comments

PercentofSevereNeedinPovertyServedbyCorePublicProviders

44%(low)88%(high)

Notnecessarilyservedattherightlevelofcare.

Finding NC-6: Inpatient and Crisis System Capacity

AtthetimeMMHPIwasconductinginterviewsforthisassessment,publicandprivateinpatientcapacityinthecommunitywasreportedtobeabout400inpatientbedsinpublicandprivatehospitalsaspresentedininthefollowingtable.Asthisreportwasgoingtopress,itwasannouncedthatValleyBaptistMedicalCenter-BrownsvillewillbeclosingtheirbehavioralhealthinpatientunitinAugust2017.89Theinformationinthereportreflectsthestateofinpatientbedcapacitybeforethisannouncementwasmade.TheRioGrandeStateCenteristhestatehospitalfortheRioGrandeValley.SanAntonioStateHospitalalsoprovidesinpatientbedsforTTBH,whichhashadchallengeswithstatefacilitiesbeingondiversion,meaningtheydonotacceptpatients.TTBHhasnotbeenabletoaccesspublicinpatientbedswhenneededandaccordingtotheirassignedallotmentofbeds.Asaresult,TTBHspentabout$2.2MillionduringFY2016(fundedbyHHSC)tocontractwithlocalinpatientbedsatSouthTexasBehavioralHealth,ValleyBaptistMedicalCenter–Brownsville,andDoctorsHospitalRenaissancewithresources.Duringthissametimeperiod,TTBHreportedasignificantdecreaseinout-of-regioninpatienthospitalutilizationasaresultofcontractingwithlocalhospitals.Anaverageoffourindividualspermonthwerehospitalizedoutsidetheregion,downsignificantlyfromthenumbersin2015.LimitationsininpatientservicescapacityintheRGVforchildrenandyouthnecessitatedtransporttoAustinStateHospitalforacuteinpatientcare.NewbedsopenedinFY2017throughStrategicBehavioralHealth(PalmsBehavioralHealth),increasingaccessby94beds,includinganadolescentunit,whichisexpectedtofurtherreducetheneedforyouthtobetransportedtoAustinStateHospitalforacutecare.Yet,theconcentrationofallthepsychiatricbedsintwocountieslimitsaccessbecauseoftransportationbarriers.OneconsistentreportacrossstakeholdersisthattheRGVregionlackssufficientinpatientcapacitytoservethedemandofitspopulationbase.Thefollowingtableprovidesalistingofavailablebeds.89Asthisreportwasgoingtopress,ValleyBaptistMedicalCenter-Brownsvilleannouncedtheywillbeclosingthehospital’sinpatientuniteffectiveAugust20,2017,withnonewpatientsacceptedafterJuly31,2017.VBMC-Brownsvillenotedtheclosingwasdueto“achallengingreimbursementenvironment,increasingoperatingcostsandtheadditionofavailabletreatmentresourceswithinourcounty…”.VBMC-BrownsvillewillcontinueoperatingitsOutpatientIntensiveProgram.(Source:LettertoValleyBaptistCommunityregardingValleyBaptistBehavioralHealthFacilityClosure,July18,2017,LeslieBingham,CEO).

CapacityAmongAdultInpatientProvidersinRioGrandeValleyFour-CountyRegion

AdultsInpatientProvidersandFacilities90LocationofFacility

(City,County)PsychiatricBeds

DoctorsHospitalatRenaissance91 Edinburg,HidalgoCounty 87

RioGrandeStateCenter Harlingen,CameronCounty 55

SouthTexasBehavioralHealthCenter92 Edinburg,HidalgoCounty 134

StarrCountyMemorialHospital93 RioGrandeCity,StarrCounty 0

StrategicBehavioralHealth(PalmsBehavioralHealth)94(alsoprovidesbedsforyouthage13andolder)

Harlingen,CameronCounty 94

ValleyBaptistMedicalCenter-Harlingen95 Harlingen,CameronCounty 12

Ouranalysissuggeststhattheperceptionofpoorbedcapacityisafunctionoffourfactors:(1)thegeographicdistributionofpsychiatricbedscreatestransportationbarriersandlimitsaccess;(2)thereisalackofresourcesforinpatientcareforpeoplewithoutinsurance;(3)thereisalackofcoordinationamonginpatient,crisis,andemergencyroomprovidersatasystemslevel;and(4)therearelimitedresourcestoprovidecommunity-basedservicesthatcansupportlong-termcommunitystability,andlimitedinpatientdiversionandstep-downservices.WhiletheRGVregionhasmadeaconcertedeffortoverthepastdecadetodevelopitsbehavioralhealthcrisisservicesandcreatealternativestoincarcerationandpsychiatrichospitalization,crisisdiversionprogramstendtobefacilityspecific,focusingonthediversionneedsofagivenproviderorsubsetofprovidersratherthanthecommunityasawhole.Asaresult,thearrayofcrisisservicesdoesnotfunctionasasystemwithdefinedpathways,which

90Source:Unlessotherwisenoted,capacitydatacomesfromtheDSHS2014HospitalSurvey.91Source:LindaResendez(personalcommunication,January27,2017).92Source:SouthTexasBehavioralHealthCenterstaff(personalcommunication,April12,2016).93Source:StarrCountyMemorialHospitalstaff(personalcommunication,June14,2016).94Source:StrategicBehavioralHealth(PalmsBehavioralHealth)staff(personalcommunication,July28,2016).95SubsequenttoVBMC-Brownsvilleclosingitsinpatientunit,ValleyBaptistMedicalCenter-HarlingenannouncedonAugust30,2017theopeningofa12-bedinpatientgeriatricbehavioralhealthservicesunittomeettheneedsofolderadultsintheRGV.ValleyMorningStar.(2017,August30).GeriatricbehavioralhealthservicesnowavailableatValleyBaptist-Harlingen.Retrievedfrom:http://www.valleymorningstar.com/life/health_wellness/article_ea1f315c-8df6-11e7-b5f4-c7c305fd70c5.html

contributestoredundantbackupsthatpreventpeoplefromgettingtherightserviceattherighttime–including,attimes,psychiatrichospitalization.Developmentofacoordinatedcrisisresponsesystemacrossallpayers,includingMedicaid-managedcareorganizations(MCOs),isessentialtomakethebestuseoflimitedinpatientandotherhighcostresources.Notethatthecrisisarrayshouldideallybejointlyfundedacrossallpayers(e.g.,state,Medicaid,local,private)inordertobeefficientandeffectiveratherthanhavingeachfundingstreamsupportingaseparatecrisiscarecontinuum.IntheHHSCSunsetCommissionreport,Recommendation6.1forIssue6prioritizedsuchcross-payercrisiscoordination.96AdultInpatientCare

Lackofaccesstoinpatientbedsacrossthestateisaproblemthathasbeenstudiedindepth.InJanuary2015,twoimportantreportswerereleasedthatattemptedtodefinetheneedforinpatientbedsinthestateofTexas.ThesereportsyieldedestimatesthattheRGVregionneedsbetween261and304publiclyandprivatelyfundedbeds:

• Rider83StateHospitalLongTermPlan:ThisHHSCreportdrewagreatdealfromtheNovember2014consultingreportbyCannonDesign.97CannonDesignrecommendeddevelopmentof570bedsinthenearterm(andanadditional607bedstokeeppacewithpopulationgrowththrough2024),foranoverallstatewidenumberof5,424publiclyandprivatelyfundedbedsin2014.BasedontheproportionofTexasadultswithSMIlivingintheRGVregion,thissuggestsaneedfor261psychiatricbeds.

• HB3793Report:ThisDSHSreport98(AllocationofOutpatientMentalHealthServicesandBedsinStateHospitals)originatedfromthe83rdLegislature(HB3793),whichrequiredaplantoidentifyneedsforinpatientandoutpatientservicesforbothforensicandnon-forensicpopulations.ThelegislationrecommendedthataTaskForcecomprisingadiversestakeholdergroupadviseDSHSindeterminingtheneedanddevelopingaplantoaddressit.TheTaskForcerecommendedahigherlevelofneedforadditionalstatefundedbeds(1,500,versus607byCannonDesign).Usingthisestimateyieldsanoverallstatewideneedof6,325publiclyandprivatelyfundedbedsin2014.BasedontheproportionofTexasadultswithSMIintheRGVregion,thisestimatesuggestsaneedfor304psychiatricbeds.

96SunsetAdvisoryCommission(2015,February).Reporttothe84thLegislature(p.15).97CannonDesignetal.(2014).Analysisfortheten-yearplanfortheprovisionofservicestopersonsservedbystatepsychiatrichospitals:ConsultingservicesregardingDSHSRider83RFPfinalreport.Retrievedfrom:Retrievedfromhttps://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwidj9XYwL7VAhWH0FQKHdFyCMEQFggoMAA&url=https%3A%2F%2Fwww.dshs.texas.gov%2Fmhsa%2Freports%2FSPH-Report-2014.pdf&usg=AFQjCNGN68ButJ02hH0cTQDpeODSQa0bVg98DepartmentofStateHealthServices(2015,January).Allocationofoutpatientmentalhealthservicesandbedsinstatehospitals.Retrievedfrom:Retrievedfromhttps://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwidj9XYwL7VAhWH0FQKHdFyCMEQFggoMAA&url=https%3A%2F%2Fwww.dshs.texas.gov%2Fmhsa%2Freports%2FSPH-Report-2014.pdf&usg=AFQjCNGN68ButJ02hH0cTQDpeODSQa0bVg

WhilethestatereportsreviewedaboveindicatethattheRGVregionneedsbetween261and304publiclyandprivatelyfundedbeds,currentpublicandprivateinpatientcapacityinthecommunity(summarizedintheprevious“CapacityAmongAdultInpatientProvidersinRioGrandeValleyFour-CountyRegion”table)isreportedtobe382inpatientbeds.Atfirstglancethisnumberappearstobesufficient,butbecauseofmultiplecomplicatingfactors,itisnot.ThefigureonthefollowingpageshowsthelocationsofthehospitalswithpsychiatricbedcapacityintheRGVcountiesaswellasareaswhereadults(ages18andover)inpovertylive,bycensustract.NeitherStarrCountynorWillacyCountyhaspsychiatricinpatientbedsavailable,and,asshownonthemap,hospitalswithinpatientcapacityinCameronandHidalgocountiesareconcentratedinareaswithgenerallylowerratesofadultpoverty.PsychiatricBedAvailabilityandAdultPovertyCounts,201599

99PovertydataobtainedfromtheUSCensusBureau,AmericanCommunitySurvey2015Five-YearEstimates.TableS1701:PovertyStatusinthePast12Months.Retrievedfromhttps://factfinder.census.gov

AverageandmaximumdailybedutilizationdatawereavailableforRioGrandeStateCenterandDoctorsHospitalatRenaissance.100In2013,DoctorsHospitalatRenaissance(a87-bed-capacityinpatientfacility)hadanaveragedailyutilizationrateofjusteightbeds,withamaximumutilizationof17fortheyear.101Datarelevanttostatehospitalutilization(inthe“State-OperatedPsychiatricHospitalAverageLengthsofStaybyDaysandAgeGroup,FY2015”tablebelow)indicatethatTTBHandBRBHCcollectivelyhavefeweradmissionstostatehospitalsthanthecomparisonLMHAs,relativetothenumberofadultswithSMIinneedandthenumberofchildrenandyouthwithSEDinneedintheirrespectivecatchmentareas.TTBHhadthelowestratesofadmission,relativetothenumberofpeopleinneedforbothchildren/youthandadults/olderadults.State-OperatedPsychiatricHospitalAdmissionsbyAge,FY2015102

AgeGroup TropicalTexasBH

BorderRegionBHC CaminoReal CoastalPlains

Child/Youth 45 26 16 19

SED200%FPL 20,000 5,000 2,000 2,000

Admissions/SED200%FPL 0.24% 0.54% 0.83% 0.97%

Adult 695 219 98 150

Geriatric 6 1 2 1

SMI200%FPL 35,000 9,000 4,000 5,000

Admissions/SMI200%FPL 2.10% 2.42% 2.30% 3.04%

CountyboundariesobtainedfromUSCensusBureau.(n.d.)GeographyCartographicBoundaryShapefiles–Counties.Cb_2015_us_county_500k(shapefile).Retrievedfromhttps://www.census.gov/geo/maps-data/data/cbf/cbf_counties.htmlPsychiatricbedcapacityforRioGrandeStateCenterobtainedfromtheAmericanHospitalAssociation,2014AnnualSurveyofHospitals.Psychiatricbedcapacityforallotherhospitalsobtainedviapersonalcommunication.100Utilizationdatawereavailablefortwoadditionalinpatienthospitals;however,thecalculatedaveragedailyuseandmaximumdailyusewereminimal.101Dataweredrawnfromthe2013TexasHealthCareInformationCollection(THCIC)HospitalDischargedataset,asanalyzedbyMMHPI.102DatareceivedfromTexasDSHS(personalcommunication,April13,2016).DataareforLMHAs.

State-OperatedPsychiatricHospitalAverageLengthsofStaybyDaysandAgeGroup,FY2015103

AgeGroup TropicalTexasBH

BorderRegionBHC CaminoReal CoastalPlains

Adult 45 33 32 31

Geriatric 87 n/a 139 6

Child/Youth 54 38 27 59Anothermajorindicatorofsystemneedsinvolvestheaveragelengthsofstayinpublicinpatientfacilitiesacrosspopulationagegroups.Withtheexceptionofolderadults,TTBHhadthehighestaveragelengthsofstayamongallLMHAsintheanalysis(asshownintheprevioustable)andthehighestnumberhospitaldaysacrosseachpopulationgroup(asshowninthetableonthefollowingpage).ThelengthofstayfortheirolderadultconsumerswassecondhighestamongLMHAsforwhomdatawereavailable.Thelackofaccesstostep-downservicesandhousingislikelyacontributingfactortothehigherlengthofstay.BRBHC’saveragelengthsofstaywereaboutaveragerelativetotheotherLMHAs.State-OperatedPsychiatricHospitalDaysbyAge,FY2015104

AgeGroupTropicalTexasBH

BorderRegionBHC

CaminoReal CoastalPlains

Adult 31,275 7,227 3,136 4,650

Daysper1,000inNeed 946 797.7 736.7 942.2

SMIPopulation<200%FPL 35,000 9,000 4,000 5,000

Geriatric 522 n/a 278 6

Daysper1,000inNeed 15.8 n/a 65.3 1.2

Child/Adolescent 2,430 988 432 1,121

Daysper1,000inNeed 85.8 131.3 147.6 375.5

SEDPopulation<200%FPL 20,000 5,000 2,000 2,000Finding NC-7: Public Funds Available for Behavioral Health Services

ExpendituresforbehavioralhealthservicesincludethetotalmentalhealthfundingprovidedtothecountieswithintheVBLFcatchmentareathatareservedbyBRBHCandTTBHaswellasSUD

103DatareceivedfromTexasDSHS(personalcommunication,April13,2016).DataareforLMHAs.104DatareceivedfromTexasDSHS(personalcommunication,April13,2016).DataareforLMHAs.DatawerecalculatedbymultiplyingthenumberofadmissionsinFY2015bytheaveragelengthofstay.

servicesfundingandestimatesofMedicaidfundingforinpatientandoutpatientcare,jailandemergencyroomcosts,othercriminal/juvenilejusticecosts,andcostsrelatedtoschool-basedservicesandchildwelfareservices.WhileinformationisavailableforgeneralrevenueandotherfundingthroughthetwoLMHAs,spendinginformationisnotavailableforthebroadersystem.Asaresult,weelectednottopublishactualspendingfigures.However,basedonourreviewsofavailabledataandkeyinformantinterviews,itwasclearthatcoordinatedplanningacrossthemajorpayersforpublicmentalhealth–stategeneralrevenue,Medicaid,DeliverySystemReformIncentivePayment(DSRIP),countyexpenditures,andlocalprivatefunders(bothfoundationsandcontributorstouncompensatedcare)–islacking,despitehowessentialsuchcoordinationcanbetomakethebestuseoftheseconsiderable,thoughlimited,resourcesspentacrosstheRGVcurrently.MMHPIhasdevelopedcostestimatesfortwosetsofcostsassociatedwithalackofadequatefundingand/orcoordinationacrossfunding:costsofprovidingcareinjailandcostsofprovidingcareinemergencyroomsettings,whicharesummarizedinthenexttable,bycounty,for2015,themostrecentyearforwhichdatawereavailable.Notethatadisproportionateshareofthesecostsisdrivenbyrepeatuseofthesesettingsbytheapproximately800adultswithhighlycomplexneedswhobecometrappedincyclesof“super-utilization,”withabout500inneedofintensivebehavioralhealthtreatmentandabout400inneedofforensically-focusedintensivebehavioralhealthtreatment(withasmallamountofoverlapbetweenthetwogroups).OtherCostsRelatedtoMentalHealthNeedsforRGVFour-CountyRegion,CY2015

County105 EstimatedCountyJailCosts

EstimatedMHEmergencyRoomCosts106 Total

Cameron $7,850,000 $10,250,000 $18,100,000

Hidalgo $14,900,000 $18,750,000 $33,650,000

Starr $1,400,000 $1,550,000 $2,950,000

Willacy $480,000 N/A $480,000

Total $24,630,000 $30,550,000 $55,180,000

105MeadowsMentalHealthPolicyInstituteandTexasConferenceofUrbanCounties.(2015).Surveyofcountybehavioralhealthutilization.UnpublishedDocument.Dallas,TX:MeadowsMentalHealthPolicyInstitute.Estimateswerebasedona2012TexasHealthCareInformationCollectionhospitalsurveyof580hospitalsandcostsfroma2013DallasFortWorthHospitalCouncilFoundationreport.Allestimateshavebeenupdatedto2015byadjustingfortheincreasedpopulationofpeoplewithseriousmentalillnessaswellastherisingcostsofmedicalandotherservicecosts.106Estimatedcostsareformentalhealthonlyanddonotincludecostsassociatedwithtreatmentforissuesrelatedtosubstanceusedisorders(SUD).

Notethatthis$55million,whichrepresentsonlyaportionofthebehavioralhealth-relatedcostsinnon-behavioralhealthsettingsandsystems,canbeconsideredanopportunitycostforthecurrentsystemthatcanpotentiallysupportinvestmentinamoreefficientandeffectivecrisisresponsesystemandcontinuumofcrisisandjaildiversionservices.SB292andHB13,passedduringthe85thLegislativesessionandapprovedbyGovernorAbbott,offergrantfundingthatcansupportlocalcollaborationtoimproveaccesstoservices.Finding NC-8: Funding for Veterans’ Services

FundingforveteransservedbytheTexasValleyCoastalBendHealthCareSystem(VA-TVCBHCS)forthefourVBLFcountiestotals$175,769,000forallmedicalcare,includingbehavioralhealthcare.ThepercentageoftheveteranpopulationservedbyVA-TVCBHCSisaboutaveragecomparedtootherstatesandTexascounties.Fundingspecifictobehavioralhealthconditionswasnotavailable.Behavioralhealthservicesincludearangeofoutpatienttreatmentsthataretargetedtotheneedsofveterans.BehavioralhealthinpatientcareisalsoabenefitcoveredbytheVAandprovidedatvarioushospitalsintheRGV.VeteransServedbytheTexasValleyCoastalBendHealthCareSystem(VA-TVCBHCS)inFY2015,byCounty107

CountyTotal

VeteranPopulation108

EstimatedNumberofVA-

EnrolledVeterans109

NumberofUniquePatients

ReceivingCare

PercentofVeteran

PopulationServed

TotalVASpendingonMedicalCare

Cameron 17,418 7,316 6,721 39% $75,718,000

Hidalgo 23,374 9,817 8,787 38% $91,733,000

Starr 890 374 360 40% $3,735,000

Willacy 867 364 332 38% $4,583,000

Total 42,549 17,871 16,200 38% $175,769,000

ThesefiguresrepresentthetotalveteranpopulationintheRGV,thoseestimatedtobeenrolledintheVAsystem,thenumberofuniquepatientsreceivinganyhealthcare(notsolelybehavioralhealthcare),thepercentoftheveteranpopulationserved,andthetotalVA107U.S.DepartmentofVeteransAffairs.(2016,June7).Summaryofexpendituresbystateforfiscalyear2015.Retrievedfromhttps://www.va.gov/vetdata/Expenditures.asp108VeteranpopulationestimatesareforSeptember30,2015.109TheseestimatesarebasedonBagalman,E.(2014,June3).ThenumberofveteransthatuseVAhealthcareservices:Afactsheet.CongressionalResearchService(CongressionalResearchReportR43479).Retrievedfromhttps://fas.org/sgp/crs/misc/R43579.pdfThisfactsheetreportedthatasofFY2014,VA-enrolledveteransrepresented42%ofthetotalproportionofthetotalveteranpopulationnationally.

spendingonanymedicalcarebyRGVcounty.Spendingonbehavioralhealthserviceswasnotavailable.ThepercentageofveteransservedintheRGVisslightlybelowtheaverageproportion(42%)oftheveteranpopulationservednationally.110Thestigmaofhavingamentalillnessorsubstanceusedisorderhindersveterans’accesstoservicesbecausethepersonalorsocietalperceptionofweaknessconflictswiththemilitaryexpectationofaccomplishingthemissionregardlessofpersonaldiscomfort.Mentalhealthorsubstanceuseconditionsmaybemisunderstoodbyveteransandtheirfamiliesasaweaknessorself-pityratherthanatreatableillness.Veteransalsofaceaddeddifficultyinaccessingservicesbecauseofthelackofreadilyavailable,trauma-informedoutreachandtreatmentthatiscompetentinworkingwiththemilitaryculture. Major System Level Findings and Recommendations

TheRioGrandeValley(RGV)isadynamic,growingregionwithexpandingeconomicopportunity.However,behavioralhealthservicesforthepopulationasawhole–notjustthosereceivingtheseservicesfromthepublicsector–havealwaysbeenlimitedandarenotkeepingpacewiththecommunity’spopulationandeconomicgrowth.TheMeadowsMentalHealthPolicyInstitute(MMHPI)evaluationteamidentifiednumerousexamplesacrosstheRGVofoutstandingprogramsandleaderswhoaredeeplycommittedtothepopulationstheyserve–manyofwhichareamongthebestpracticeswehaveobservedanywhereacrossTexas.Welearnedaboutexcellentexamplesofcollaborationandinvestmentinnewwaysofworkingtogethertoaddressthehealthneedsoftheentirepopulation,aswellasanemergingconsensusontheneedforcounty-levelplanning.Atthesametime,therearesignificantservicegapsthatcanbeattributedtolimitsinavailablecapacityforcountyplanning.Whilethereisbroadrecognitionofthevalueofregionalcollaboration,inaregionofover1millionpeople,itisclearthateachcountyandthecommunitieswithinthemhavetheirowncultures,challenges,andneedssothatbuildingcollaborationsevenwithinlocalcommunitieswilltakeeffortandtime.Furthermore,fortheimmediatefuture,effortstobringpeoplefromacrossthecountiestogethertopromotemulti-countycollaborationswillneedgreaterfocusonsharinglessonslearnedandpromotingspecificlearningcollaborativesratherthanonactualcollaborativeefforts.Withfourcountyadministrations,numerouscitiesandtowns,37schooldistricts,twoLMHAs,fiveinpatientpsychiatricprograms,andthreefederallyqualifiedhealthcenters(FQHCs)managingpublicservices–alongwithdiversesubstanceusedisordertreatmentproviders,largehealthsystemswithvaryinglevelsofcapacitytoaddressbehavioralhealthneeds,andadiversearrayofprivateoutpatienttreatmentproviders–thereismuchthatcanbeshared.111Butthechallengesofthe110ibid.111RioGrandeValleyLinkingEconomicandAcademicDevelopment(LEAD).(2015).Targetingthefuture:2015labormarketinformationreport–ananalysisoftheemerginglabormarketintheRioGrandeValley.Retrievedfromhttp://techpreprgv.com/pdf/2015.RGV.LEAD.LMI-Report.pdf

nearfuturewillrequiremorefocusedsystemdevelopmentandcollaborativeeffortsatthecountylevel.Toassistwithservicedevelopmentandintra-andinter-countycollaboration,wewouldliketoemphasizetheopportunitiesresultingfromlegislationpassedduringthe85thLegislativeSessionandsignedbyGovernorAbbott.

• SB292createsagrantprogramwith$37.5millioninfundingtoreducerecidivism,arrest,andincarcerationamongindividualswithmentalillness.ThisfundingcanbeveryhelpfulinaddressingissuesrelatedtoindividualswithSMIwhoareinvolvedinthejusticesystem,especiallyrelatedtosomeofthebarriers(identifiedlaterinthisreport)toaccessingservicesaswellasneworfurtherimplementation(dependingonthecounty)oftheSequentialInterceptModel,whichdescribesdiversionstrategiesforjustice-involvedindividualsthroughinterventionsalongaseriesofinterceptionpoints.112

• HB13createsagrantprogramwith$30millioninfundingtoprovideincentivesforstate-localcollaborationstosupportmentalhealthinitiatives.Oneofthechallengesofcollaborationishavingfundstosupportplanning.ThislegislationmaybeveryusefultotheRGVcountiesinterestedinpursuingfurthercollaboration.

• SB74streamlinescredentialingrequirementsforproviderstoimproveaccesstobehavioralhealthservicesforchildrenandyouthwithhighneeds.

• SB1,thestatebudget,includes$2milliontoestablishagrantprogramtoincreaseaccesstohigh-qualitytreatmentforchildrenandyouthwithhighneedswhoareinvolvedinthechild/youthwelfaresystem,apopulationthatisunderservedthroughoutthecountiesintheRGV.

Inperformingsystemassessments,MMHPIrecognizesthatsuccessfulcountysystemshavetheabilitytocollaborateinmanagingresourcestobettermeettheneedsofthepopulationstheyserve.Weknowthisisthecaseforbehavioralhealthsystemsaswellassystemsthataddressothercommunityneedssuchashealth,housing,water,andtransportation.Wealsoknowthatnomatterhowsuitableourrecommendationsare,theydependontheabilityofthelocalcommunitiestoimplementthemaspartofalong-termstrategicprocess.Therefore,oneofthefirstthingswelookatinasystemassessmentistheextenttowhichthesystemhastheabilitytodevelopacollaborativeapproachtofocusonbehavioralhealthandwhetherthatcollaborationcanbeorganized,empowered,andstructuredtocarryouta

112Munetz,M.R.,Griffin,P.A.(2006).UseoftheSequentialInterceptModelasanapproachtodecriminalizationofpeoplewithseriousmentalillness.PsychiatricServices,57(4),544-559.

strategicimprovementprocessforthepopulationasawhole.OneexampleofsuccessfulcollaborationistheUnidosContralaDiabetes(UCD)“collectiveimpact”efforttopreventnewcasesofdiabetesinlow-incomeandunderservedpeopleintheRioGrandeValley.ThiseffortisbeingfundedbyMethodistHealthcareMinistriesandtheValleyBaptistLegacyFoundation.TheUTSchoolofPublicHealth-BrownsvilleandProyectoJuanDiegoaretheBackboneOrganizationsfortheeffort.UCDbringstogethernumerousserviceproviders,socialserviceagencies,insurancecompanies,andotherstakeholders.OtherexamplescanbefoundincountybehavioralhealthinitiativesinvolvingcollaborationamongtheLMHAsandotherproviders,whichhaveresultedinexemplaryservices,thedevelopmentoftaskforcesandcommittees,andtheprocurementofgrantsthatincreasedaccesstoservices.MMHPIhasfoundthatthedevelopmentofacounty-levelbehavioralhealthleadershipteam(BHLT)thatisstructured,organized,andempoweredtocarryoutinitiativeshasbeenasuccessfulstrategyinplanningpopulation-basedbehavioralhealthservicesinotherpartsofTexasandacrossthenation.WhilethegoalistomaximizetheuseofresourcesacrosstheRGV,itsgeographyandcomplexitymakesreachingthisgoalchallenging.ThissituationisnotuniquetotheRGV.Thereareveryfewmulti-countycollaborativesacrossTexas.Furthermore,HidalgoandCameroncountiesaretwoofthetop15highest-populatedcountiesinTexas,andweknowofnolargecountiesinthestateengagedinanysubstantivebehavioralhealthcollaborationthatgoesbeyondthebordersofasinglecounty.Werecommendinsteadthattheregionbeginwithdevelopingcounty-levelefforts,cross-countylearning,andinitiativesforsharinglessonslearned.Asweoutlinethefollowingfindingsrelatedtoeachsub-populationinneedofbehavioralhealthcare,ourrecommendationsemphasizeastep-wiseapproachtoformingcounty-levelBHLTsthatbuildonthesuccessesofeachcountyandtheirserviceproviders.System Level Findings (SF)

County-LevelPlanningNeedsSystemLevelFindingSF-1:Withintheoverallbehavioralhealthsystem,therearesignificantareasofstrength,includingthedevelopmentofnewprogramsandservices.Wealsoidentifiedpotentialimprovementsrelatedtooverallneedsincounty-levelcollaborationandopportunitiesfortheseimprovementswithineachmajorservicedeliveryarea:crisis,adultmentalhealthsystemofcare,children’ssystemofcare(includingjuvenilejusticeandchildwelfare),andthesubstanceusedisordercontinuumaswellasbehavioralhealthserviceswithinthehealth,criminaljustice,andhousingsystems.SystemLevelFindingSF-2:Thereareexamplesofsignificantcollaborationamongindividualprovidersandcounties,yetorganizedplanningattheregionalleveldoesnotcurrentlymakesensegiventhesizeandcomplexityoftheRGV.However,thereisalackoforganizedcollaborativeplanningatthecountylevelacrossallbehavioralhealthpopulations(publicand

private,mentalhealthandSUD,inpatientandoutpatient,andspecialtypopulations)thatsupportsthesharedmanagementofbehavioralhealthresourcesandsystemswithineachcounty,includingthosethataddressmildtomoderateaswellasmoreseriousbehavioralhealthconditions.Thisinvolvesbothalackofbroadcollaborativeplanningacrosscountyandprovidersystemsaswellasalackofresourcesupporttocarryouttheworkoftheplanning.Thelackofformal,system-widecollaborativestructureswithsharedvaluesandacustomerorientationforallbehavioralhealthpopulationslimitspositivechange.OthercountiesinTexashavebeguntodevelopbehavioralhealthleadershipteams(BHLTs).BHLTsarecomposedofcross-systemrepresentationofleadershipandstakeholdersfromorganizationsthroughoutacountysuchasbehavioralhealthservices,LMHAs,psychiatricinpatientunits,substanceusedisordertreatmentproviders,publichealth,socialservices,education,justice,cityandcountygovernment,thefaithcommunity,nonprofitservices,areabusinesses,andindividualswithlivedexperienceofmentalillnessand/orsubstanceusedisorders(SUDs).TheBHLTmembersengageinacollaborativeefforttoadoptamissionandcorevalues,identifypriorityareas,developasetofdeliverables,andformworkgroupstomeetgoalstheyhavedevelopedthatareaimedatbestidentifyingandaddressingbehavioralhealthneedsintheircommunity.Onlyfiveofthe10biggestTexascounties–Dallas,Denton,ElPaso,Tarrant,andTravis–haveBHLTsinplace.BexarCountyisintheprocessofdevelopingone,butCollin,FortBend,andHarrisCountiesonlyhavesmaller,morefocusedeffortsinplace.Initiativesinsmallerregions,likeMidlandCounty,SmithCounty,andthecountiesofthePanhandlehavebeguntotakeshape,buttheyalsofacechallengeswithresourcelimitationsandconflictsbetweenmembers.BHLTstakeeffortanddedicatedresources,buteventheprocessofformationcanhelpbeginadialoguethatisfocusedonpopulationhealthneeds,sharedvaluesandpurpose,andcollaborativeeffortstoworktogethertoimprovesystemresponsivenessandeffectiveness.SystemLevelFindingSF-3:Therearesignificantlimitationsinthecurrentcapacityforbehavioralhealthservicesforallpopulations,andevenmoresoforuninsuredandundocumentedindividualsandfamilies.Therearelimitedservicesavailableintheregionforthemanyindividualsaffectedbymentalillnessand/orSUDinwaysthatmayleadsignificantlytopooroutcomesandhighcosts.Thereislimitedaccesstoprivateprovidersthathavethecapacitytoserveindividualswithcomplexneeds.TherearealsomorepsychiatristsininpatientsettingsthanoutpatientsettingsforthegeneralpopulationseekingmentalhealthcarebeyondLMHAs.Thefrequentlackofpsychiatryinoutpatientserviceslimitsservicecapacitysignificantly.SystemLevelFindingSF-4:Becauseoftheabsenceofasystem-widefocusoncounty-levelplanningforbehavioralhealthservices,thereisasignificantpopulationhealthchallengein

eachcountyinRGV.Theabsenceofformal,systematic,county-levelplanningeffortsfocusedonbehavioralhealthleadstoinefficienciesinsystemdesign,requiringeachfundertodevelopaparallelsetofservicesforitsownpopulation,ratherthanprovidingamorealignedcontinuumofservicesthatmightbeavailableformorepeople.Theleadagenciesforeachmajorpublicfundingsourcelackahigh-levelforumatthecountylevelforcoordinatedbehavioralhealthplanningandsystem-levelefforts(e.g.,a“behavioralhealthleadershipteam”).Familiesandbusinessleadersoftendonotknowwheretogethelp–orwhoisultimatelyresponsibleforensuringthathelpisavailable–fortheirlovedonesortheiremployees.SystemLevelFindingSF-5:Whiletherearesomeexcellentcountybehavioralhealthplanninginitiatives,thelackofvisibilityofbehavioralhealthatthehighestcountylevelsisasignificantgap.Asconvener,thecountycanpromoteavisionforcountyservicesandhastheauthoritytomakeimportantdecisionsthatindividualcountyorganizationscannotaddress.AsastrongleaderinCameron,Hidalgo,andWillacycounties,TTBHcantakealeadingrole,butevenitcannottakeonthesoleroleasleadofaBHLTbecauseofitsprimaryfocusonadultsandchildrenandyouthwiththemostseriousbehavioralhealthconditions.BRBHCisinasimilarposition.Inorderforcounty-levelplanningeffortstobecomemorecomprehensiveandfocusedacrosspopulations,theyneedtheinvolvementofcountyleadershipaswellastopleadersfromallkeyhealthandbehavioralhealthproviders.SystemLevelFindingSF-6:Cross-payerandcross-countycollaborationishamperedbyafocusonmaximizingtheuseofseparatefundingstreams.Thereislittlecoordinationonmaximizingstateandfederalfundsandgrantsacrossfundingstreams,andtherearenocounty-levelplanningeffortsatallthataddresstheuseofprivateinsurancefunding,althoughsomeinsurershaveexpressedaneedformorecollaboration.Whilelocalcollaborationcannotcontroltherulesofpayers,collaborativeplanningcanfocusonhowtotakefulladvantageoftheseseparatefundingstreamswithinthecounties,theRegionalHealthPartnership,Medicaidmanagedcareorganizations,hospitalsystems,andotherproviders.Itisalsopossibletoinfluencethefundingprioritiesofpayerswhencollaborativesystemshavethedatatodemonstrategapsandneeds.SystemLevelFindingSF-7:Becauseofgapsinsystem-widebehavioralhealthplanningeffortsatthecountylevel,individualprovidersmustnegotiatesystemdevelopmentstrategiesandcollaborationthatrequireabroadersetofpartners.Thisoftenresultsinchallengesandconfusionaboutwhoisresponsibleforprovidingservicesandtransportationforindividualswhohavehighutilizationofemergencydepartment(ED)andinpatientservicesand/orcomeintocontactwithlawenforcement.Aligningmultipletypesoflimitedresourcestomeettheoverallserviceneedsandexpectationsofthecommunityasawholeisanimportantprogramplanningissuethatrequirestheinvestmentandunderstandingofmultiplepartiesandconsequentlyrequiresbroadersystemplanningandcommitment.

SystemLevelFindingSF-8:Customer-orientedcontinuousqualityimprovement(CQI)isasystemandorganizationalmanagementprocessbywhichcustomerexperiencesandoutcomesarecentral,andallsystempartnersworktogetherwithinaCQIchangecycleframeworktoimprovesystemresponsivenessandperformance.WhileindividualprovidershaveeffectiveCQIprocesses,countybehavioralhealthcaresystemsdonothaveroutinemechanismsatanyleveltoengageincustomer-orientedCQI.CrisisDeliverySystemSystemLevelFindingSF-9:Whiletherearesomeexcellentcrisisinterventionservices,therearenocomprehensivecounty-widecrisisinterventionprograms.ThecrisisinterventionprogramsforTTBHcountiesandforStarrCountythroughBRBHCarestrong,andTTBHhasimplementedaninnovativemodel–theMentalHealth(Peace)OfficersTeam(MHOT)–tosupplementitsMobileCrisisOutreachProgram.However,therearesignificantgapsincrisisservicessuchascrisisrespiteandotherdiversionservices.Forprivatepractitionersandhospitals,thereisnodefinedcrisissystemthattracksindividualsthroughtheresolutionoftheircrises.SystemLevelFindingSF-10:CrisisdiversionservicesintheRGVareveryunderdevelopedcomparedtothenumberofinpatientbedsandforthesizeoftheregion.Two2015reportsyieldedestimatesthattheRGVregionneededbetween261and304publiclyandprivatelyfundedinpatientbeds.Currentpublicandprivateinpatientcapacity,assummarizedpreviouslyinthetable“CapacityAmongAdultInpatientProvidersinRioGrandeValleyFour-CountyRegion”onpage32,showscapacityofover400inpatientbeds.Whilethisnumbermayappeartobesufficientgiventheestimatedneedforinpatientbedsprovidedinthecitedreports,thelackofdiversionservicesandcrisisbedsputsaddedstrainonexistinginpatientcapacitythroughouttheRGVregion.TheWoodGroupoperatesa16-bedcrisisresidentialprogramunderacontractwithTTBH.TheprogramhasbeenoperatingfornearlytenyearsandistheonlycrisisdiversionprogramintheRioGrandeValley.Thisprogram,locatedalongsidetransitionalhousing,doesnothaveenoughcrisisbedstoaddresstheneedfordiversionservicesacrosstheRGV.Itsupportsindividualsthroughacrisisbutdoesnothaveintensivetreatmentservicesavailable.WhileBRBHCisindiscussionswithStarrCountyMemorialHospitaltodevelopeitheracrisisdiversionprogramoraninpatientprogramforadultsandyouth,crisisbedsarepresentlylimitedtoasinglelocation(atTheWoodGroup)fortheentireregion.TheneedforcrisisrespiteisespeciallyacuteinStarrCounty;StarrMemorialHospital,whichhastheprimaryemergencydepartment(ED)usedinStarrCounty,hasexpressedinterestinprovidingthesecrisisservicesiffundingwereavailable.TheStarrCountyhospitaldistrictfacessignificantchallengeswithEDspaceandthecountyisconfrontedwithlimitedtransportationresourcesandexcessivedemandsonlawenforcement’stime,allofwhichcontributetoindividualsbeingtakentojailratherthantravellongdistancestoinpatient

facilities.Thisresultsinover800individualsperyearthroughoutRGVbecomingtrappedinacycleofrelyingoncrisisservices,emergencydepartments,jails,andinpatientprograms,orbecominghomeless,ultimatelycontributingto“superutilization.”Asnotedabove,SB292,passedduringthe85thLegislativeSessionandsignedbyGovernorAbbott,createsagrantprogramwith$37.5millioninfundingtoreducerecidivism,arrest,andincarcerationamongindividualswithmentalillness.Thisfundingcanbeveryhelpfulinaddressingthisissue,particularlyforindividualswithSMIwhoareinvolvedinthejusticesystem.SystemFindingSF-11:Thereisanopportunitytoprovidemoreintensiveservicesatthecurrentcrisisrespiteprogramandtoprovidemoreintensivecasemanagementservicesandprogrammingaspartoftheoverallcrisiscontinuum.TheTransitionalCareClinicinSanAntonio,operatedbytheUTHealthScienceCenter,helpsindividualstransitionfromhospitalcaretothecommunityandisanexampleofwhatcouldpossiblybedevelopedintheRGV.113SystemLevelFindingSF-12:ThecurrentcrisisdiversionservicearrayatTheWoodGroupincludeslimitedMedicaidbillableservices(i.e.,assistedliving),evenforclientswhoareonMedicaid.WhileTTBHprovidesandbillsforafewservicesprovidedtoclientswhoarestayingatTheWoodGroupfacility(e.g.,TargetedCaseManagement,rehabilitation),thereisnocurrentmechanismforworkingcollaborativelywithMedicaidmanagedcareorganizations(MCOs)toestablishexpandeddiversionservicesthatwouldbeclinicallyandfinanciallyadvantageoustoprovidersandclients.AdultDeliverySystemSystemLevelFindingSF-13:TheRGV’sadultmentalhealthsystemofcareforindividualswithseriousmentalillnesshasanarrayofservicesdevelopedthroughTTBHforthreecounties.BRBHChasdevelopedanarrayofservicesforStarrCounty,itsonlycountylocatedintheRGV.Itshouldbenotedthattherearetwodistinctsystemsofcare–onefortheTTBHserviceareaandtheotherfortheBRBHCservicearea.Whilesomeproviderswillservecountiesregion-wide,especiallyinpatientprovidersandsomeSUDproviders,thehistoricaldevelopmentoftwoLMHAsservingtheRioGrandeValleyhasessentiallyresultedintwoseparatesystemsofcare.Therearealsootherkeyproviderscontributingtoadultcommunityservices,includingBehavioralHealthSolutionsofSouthTexas(BHSST),theVA-TexasValleyCoastalBendHealthCareSystem,andTheWoodGroup.Asaresultofconstraintsonbothresourcesandcollaboration,thecapacityofalltheseservicesiswellbelowwhatisneeded.Atthesametime,thereareopportunitiesforimprovementsinthedeliveryofbehavioralhealthservicestoadults,whichcanbesupportedbythe85thLegislature’sincreaseinpublicmentalhealthfundingfortheregionby$3.5million(90%ofthatgoingtoTTBH),notincludinganyadditionalfundsthat

113UniversityofTexas–SanAntonioDepartmentofPsychiatry.(2017,March).Transitionalcareclinic.Retrievedfromhttp://psychiatry.uthscsa.edu/CRRT/tcc/

canbeaccessedthroughthenewstate-localpartnershipgrants(e.g.,HB13,SB292,SB74rider)andcontinuationofexistingstate-localgrantprograms(HealthCollaborativehomelessnessgrantsandTexasVeteran+FamilyAlliancegrants).SystemLevelFindingSF-14:Capacitytoprovidecasemanagementandintensivecasemanagementfollowingacrisisarelackingacrosstheregion,butakeygapisthelackofongoingcareforadultswithhighlycomplexhealthneedswhoaretrappedin“superutilizationofservices,”repeatedlytransitioningfrominpatientandcrisisservices,particularlythe700peoplewithincomesunder200%ofthefederalpovertylevel(FPL)whohavecomplexneeds.WhileTTBHprovidesshort-termcasemanagementpostcrisesandBRBHprovidesfollowup,whenresourcesareavailable,forindividualswhousetheircrisissystems,therearelimitedlong-termresourcesfortheLMHAs’targetpopulationsandfewornoresourcesforthegeneralpopulationwithbehavioralhealthneedswhoaretreatedinemergencydepartments,arehospitalized,resideathomelessshelters,orareheldinjails(exceptwherecountiesorpolicedepartmentshaveagreementswiththeLMHAstoprovideservicestoindividualsinjails).Asnotedearlierinthisreport,500peopleneednon-forensicintensivetreatmentand400needforensically-focusedintensivetreatment.114ThedataunderFindingNC-1aboveunderscorethedramaticlackofintensivetreatmentcapacityforadults,particularlyforindividualswithcomplexneedswhoarecaughtin“super-utilization”ofcrisis,emergencyroom,andinpatientservices.Itislikelythatmorecapacityinthisarea(bothintensivetreatmentandhousingsupports)thattargetspeoplewiththehighestneedswhoareusinginpatientcare,couldreducepressureoninpatientfacilitiesaswellastheflowofpeoplewithSMIintocountyjails.ThenewresourcesthatwillbeavailableinFY2018underthenewSB292grantprogramcanbeusedtoaddressthisgap,ifprioritizedbytheLMHAsandlocalcounties(whomustcollaborateontheprogram).SystemLevelFindingSF-15:Withonepublicandfourprivatepsychiatrichospitals,theregionhasincreaseditsbedcapacityby94bedsinthelastyeartoabout382psychiatricbedsintotal.BasedontheCannonDesign115andHB3793reports116,theneedforpsychiatricbedsin

114SomeindividualswouldqualifyforbothAssertiveCommunityTreatment(ACT)andForensicAssertiveCommunityTreatment(FACT).Asaresult,theestimatesincludeanoverlapofabout137people.115CannonDesignetal.(2014).Analysisfortheten-yearplanfortheprovisionofservicestopersonsservedbystatepsychiatrichospitals:ConsultingservicesregardingDSHSRider83RFPfinalreport.Retrievedfromhttps://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwidj9XYwL7VAhWH0FQKHdFyCMEQFggoMAA&url=https%3A%2F%2Fwww.dshs.texas.gov%2Fmhsa%2Freports%2FSPH-Report-2014.pdf&usg=AFQjCNGN68ButJ02hH0cTQDpeODSQa0bVg116DepartmentofStateHealthServices(2015,January).Allocationofoutpatientmentalhealthservicesandbedsinstatehospitals.Retrievedfrom:Retrievedfromhttps://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwidj9XYwL7VAhWH0FQKHd

theRGVregionisbetween261and304.Therefore,while382bedsappearsufficient,becauseofmultiplecomplicatingfactorsitisnot.PalmsBehavioralHealthaddedthe94inpatientbedstotheregion,includingadolescentbeds.Yet,thereremainsconcernaboutthebreakdownofneedandcapacityacrosspopulationsthatwouldbenefitfromcountyplanningandcollaborationacrosscounties.Asshownonthemapofhospitalsservicesearlierinthisreport,neitherStarrnorWillacyCountyhaspsychiatricinpatientbedsavailable,andhospitalswithinpatientcapacityinCameronandHidalgocountiesareconcentratedinareaswithgenerallylowerratesofadultpoverty.Furthermore,theRGVlacksthearrayofservicesnecessarytoavoidrelianceoninpatientcare.Therearesignificantgapsinservicesforotherlevelsofcareinadditiontothegapsinthecrisissystemnotedabove.Forexample,accesstoroutinecare–medicationmanagement,ongoingcasemanagement,andtreatmentservices–ishinderedbywaitinglists.Relatedtoscreeningforinpatientcare,TTBHhasinitiatedmedicalclearancethroughitsintegratedcareclinicsandtheMHOT/MCOT.However,theresourcestoprovidemedicalclearanceduringnightsandweekendsislimited,oftenresultinginindividualswaitinginemergencydepartmentsovernightorlonger.Thisischallengingforemergencydepartments,police,andsheriffdepartmentsthatwaitwithindividualsinemergencydepartments,aswellasfortheMHOT/MCOTandtheBRBHCcrisisprogram.Thereisalsoaneedforstep-downprogramsthatoffersupportservicesforindividualsleavingintensiveinpatientcare.Thegapinstep-downprogramsresultsinlongerinpatientstays.Therearealsosignificantneedsforsupportedhousingservicesinallcounties.BothLMHAshaveexpandedresearch-basedpracticesandintegratedbehavioralhealthandphysicalhealthinitiatives.TTBHhasdecidedtofocusprimarilyontheexpansionofresearch-basedandbestpractices,usingnationalprotocolsandstandards.However,theregionhasalimitednumberoflicensedclinicians,includingpsychiatriststhatareavailableforserviceprovision,training,andsupervisionofqualifiedmentalhealthprofessionals(QMHPs),whoprovidemostofthedirectcareservices.Thislackoflicensedcliniciansmakesitchallengingtoprovideongoingsupervisionandtrainingaswellasimplementresearch-basedpractices,integratedcareinitiatives,andbestpractice.Inaddition,thereisnoroutinemechanismthatallowsserviceproviderstoplanhowtocoordinatetheirservicessothatexistingresourcesareusedefficientlyandpeoplewhoaskforhelpcaneasilygettotherightplace.Whiletheseandotherareasofimprovementaretiedtoworkforcechallengesandalackofresources,thereareopportunitiestoimprovecollaboration,teamwork,andthequalityofservicesprovided.Forexample,thegrantprogramscreatedwithSB292(describedinintroductorypartofSystemLevelRecommendations)canbeusedtoestablishlocalcollaboratives,whichcanbolstertheavailabilityofqualitymentalhealthservices

FyCMEQFggoMAA&url=https%3A%2F%2Fwww.dshs.texas.gov%2Fmhsa%2Freports%2FSPH-Report-2014.pdf&usg=AFQjCNGN68ButJ02hH0cTQDpeODSQa0bVg

toeffectivelydivertindividualsfromjailaswellasemergencyroomsandhospitalssincemanyindividualswhobecomeinvolvedinthejailsystemhavealsobeenpatientsofthelocalERsandhospitals.SystemLevelFindingSF-16:Servicesforadultswithmildtomoderatebehavioralhealthneedshavealsonotkeptpacewithpopulationgrowth.NeitherTTBHnorBRBHCcanaddresstheneedsofthispopulationbecauseoftheirmandatetofocusonindividualswiththemostseriousmentalhealthconditions.Careofindividualswithmildtomoderateneedsisachallengeforsocialservicesorganizations,suchasCatholicCharities,thatprovideanarrayofnon-mentalhealthservices.GiventhelimitedbehavioralhealthworkforcethroughouttheRGVregion(andthestateasawhole),integratedbehavioralhealthcare(IBH)isakeystrategyforaddressingthesegapsinserviceprovisionforindividualswithmildtomoderatebehavioralhealthneeds.IBHprovidesaholisticapproachtoanindividual’scare,wherebothphysicalandbehavioralhealthneedsareaddressedthroughevidence-based,person-centeredpracticesinordertomoresignificantlyandsustainablyimprovetheoverallhealthofindividualsbeingserved.ByimplementinganIBHmodelwithinprimarycareprovidersettings,individualswithmildtomoderatebehavioralhealthcareneedscanhaveaccesstobehavioralhealthassessmentandtreatmentthroughtheirprimarycarephysicianwithoutrequiringreferraltoaspecialtyclinic.SystemLevelFindingSF-17:Thereisnoeffectivecontinuumofcarebetweeninpatientservicesandcommunity-basedoutpatientservices,eitherforstep-downordiversionservices.Thislevelofsupportisakeycomponentinensuringthesuccessfultransitionofindividualsfrominpatientcaretocommunity-basedservices.Somefacilitieshavethecapacityandwillingness,withappropriatesupport,toconsiderdevelopingelementsofsuchacontinuum.GrantprogramscreatedfromnewlegislationprovideopportunitiesfortheRGVcommunitytoexplorewaystoaddressthisgapinthecontinuumofcarethroughcounty-basedcollaborativeefforts.SB292providessupportfordiversioneffortstoreducetherecidivismofindividualswithmentalillnessfromcyclingthroughjailandinpatientservices,andHB13providessupportmorebroadlyforcommunityhealthprogramsfocusedonserviceprovisionandtreatmentthatwilladdressgapsinlocalcommunities.Bothprogramsprovideopportunitiestosupportfacilitiesableandwillingtocontributetothedevelopmentofservicesandprogramsneededtofillthesegapsinthecontinuumofcare.SystemLevelFindingSF-18:TheRGVhasnofacilitiesthatarecurrentlyofferingacontinuumofpsychiatricemergencycareinthearea.Additionally,crisisrespiteprogrammingintheRGV,providedbyTheWoodGroupundercontractwithTTBH,issupportivetotheindividual,butdoesnotprovidetheintensivelevelofcarethatsomeindividualsrequire.Consequently,individualseitherendupinanemergencydepartmentoraninpatientbed.Crisisbedsarelocatedalongsidetransitionallivingbeds,which,alongwithalackofhousingalternatives,

contributestothetendencyforindividualstostaylongerthanthetypicalcrisisperiodof72hoursandlimitsaccesstothecrisisrespitebeds.Co-OccurringMentalHealthandSubstanceUseDisorderDeliverySystemSystemLevelFindingSF-19:AsineverybehavioralhealthsystemacrossTexasandthenation,thecontinuumofsubstanceusedisorder(SUD)servicesforadults,youth,andchildrenintheRGVisunderdeveloped,withsignificantgapsinthecontinuumofSUDservicesforindividualsofallages,withorwithoutco-occurringdisorders(COD).However,theRGVisfortunatetohaveastrongcoreofproviderswiththepotentialtoexpandandimprovecoordinationofservicesandcareamongproviders.TTBHhasrecentlybeenassignedtheresponsibilityfortheOutreach,Screening,AssessmentandReferral(OSAR)functionandhasexpandeditssubstanceusetreatmentprogramsignificantly.BehavioralHealthSolutionsofSouthTexas(BHSST),formerlytheOSAR,serves19counties(includingStarrCounty),primarilyfocusingonsubstanceuseandco-occurringdisorders.BHSSTalsohasfacilitatedRecoveryOrientedSystemsofCare(ROSC)meetingsforSUDstakeholdersandcontinuestobearesourcetotheRGV.BRBHCalsoprovidessubstanceuseandCOD-capabletreatment.TheJohnAustinPeñaMemorialCenter(JAPCorPeñaCenter),acollaborationbetweentheUniversityofTexasRioGrandeValleySchoolofMedicine(UT-RGVSOM)andtheHidalgoCountyHealthDepartment,offersprimaryhealthcaretoyouthages12to18yearswhoareatriskformedical,mentalhealth(behavioralissues,attention-deficit/hyperactivitydisorder,andangermanagement),andappetite-drivenconditions(alcohol,drugs,tobacco,etc.).Thisnewlydevelopedprogram,whichreceivesmostofitsreferralsfromthejuvenilejusticesystem,haspotentialtoexpandfurtherandroundoutthecontinuumofcare.Continuityofcarefollowinginpatienttreatmentisachallenge,mainlybecauseoflimitsinavailableresources.Thelackofstep-downprogramsthatoffersupportservicesforadultsandyouthleavingintensiveinpatientcareresultsinlongerinpatientstays.AndwhilesomeresidentialservicesareavailableforindividualswithSUD,thereisasignificantgapinresidentiallevelsofcare–asrecommendedbytheAmericanSocietyofAdditionMedicine(ASAM)–forindividualswithsubstanceusedisorders.Itisimportanttonotethatsubstanceuseisprevalent,especiallyuseofopioids,cocaine,methamphetamine,syntheticmarijuana,andotherdrugs.Theneedformedication-assistedtherapies,whichcombinesmedicinewithbehavioraltherapiestotreatopioidabuse,isalsoasignificantneed.Therearealsosignificantneedsforsupportedhousingservicesinallcounties.Althoughthereisanarrayofoutpatientandinpatientservices,providersdonotroutinelycoordinatewitheachothertocreateacontinuumofservicesatthecountylevel.Forexample,PalmsBehavioralHealthisplanningtoimplementintensiveoutpatientprogram(IOP)servicesforadolescentsandadultswithdualdiagnoses,suchasmentalillnessandchemical

dependency,yettheValleyBaptistMedicalCenter(VBMC)isalreadyprovidingsimilarservices.Giventheregion’soverallscarcityofproviders,itwillbeimportanttoassesstheneedforthesetypesofprogramsinordertoavoidduplicationofservices.ThereisemergingcollaborationtobringtogethersomementalhealthandSUDproviders;however,thislikelyneedsadditionalsupportforsystem-wideplanning.Anadditionalopportunityforexpandingtreatmentservices,specificallyforindividualswithopioidusedisorders,comesfromthepassingofthefederal21stCenturyCuresAct.TheCuresActallocates$485millioningrantstoprovidesupporttostatesforthepreventionandtreatmentofopioidaddictions.117InMay2017,theTexasHealthandHumanServicesCommission(HHSC)wasawarded$27.4millioningrantfundsthroughtheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)toprovidefocusedpreventionandtreatmentacrossthestate.Thisfundingwillbeusedtoaccomplishsuchgoalsasexpandingcapacityandaccesstotreatment,increasingtrainingforproviders,enhancingrecoveryandpeersupportservices,andboostingoutreachactivities.ThesefundswillprovideHHSCwithanopportunitytoimplementpreventionandtreatmentservicesthroughcontractamendmentswithexistingproviderorganizationsandLMHAs,aswellasnewcontractswithuniversitiesinvestedinimprovingservicesinthisarea.118SystemLevelFindingSF-20:BasedonnationalprevalencedataandinterviewswithprovidersintheRGV,individualswithco-occurringpsychiatricandsubstanceusedisorders(COPSD)representmorethanhalfofthepeoplewithsevereneedsacrosssettingsintheRGVandalargenumberoftheoverallpopulationinneed.TTBHisintheprocessofdevelopingastrongsystemforintegratingmentalhealthandsubstanceusedisordertreatment,whichwouldserveabout500individualsacrossitsprogramsandcouldbecomeamodelcontinuumofCOPSDservicesfortheRGV.AnewDirectorofSubstanceUseDisordersServicesbeganworkatTTBHinJanuary2016andisexpandingtrainingonASAMlevelsofcare,motivationalinterviewing,andresearch-informedCOPSDapproachesbasedonfederalstandards.Thisprogram,withappropriateresources,hasthepotentialtoworkwithotherprovidersacrosstheRGVtoimprovecapacityandexpertiseinprovidingco-occurringservices,buildarecovery-orientedcontinuumofservicesthatofferintegrated(notparallel)COPSDinterventions,andexpandrecoverycoaching.DoctorsHospitalatRenaissancehasadedicatedco-occurringdisorders(COD)unitandValleyBaptistMedicalCenterhasthecapabilitytoworkwithindividualswithCOD,whichisastrength.

117U.S.DepartmentofHealth&HumanServices.(2017,April19).Trumpadministrationawardsgrantstostatestocombatopioidcrisis.Retrievedfrom:https://www.hhs.gov/about/news/2017/04/19/trump-administration-awards-grants-states-combat-opioid-crisis.html118TexasHealthandHumanServices.(2017,May19).Texasreceives$27.4milliongranttocombatopioidaddiction.Retrievedfrom:https://hhs.texas.gov/about-hhs/communications-events/news-releases/2017/05/texas-receives-27-4-million-grant-combat-opioid-addiction

Children,YouthandFamiliesDeliverySystemSystemLevelFindingSF-21:Behavioralhealthcaredeliverysystemsforchildren,youthandfamilyservicesintheTTBHcountiesandBRBHC/StarrCountyarealsoseparatesystems.Theyprovidearelativelystrongbaseofevidence-basedservicesandbestpracticestobuilduponandexpand,thoughoverallcapacityisunderdevelopedthroughouttheRGV,justasitisthroughoutTexasandthenation.Asnotedinthecapacityfindings,theRGVhasabout58,800childrenandyouthwhohavemildtomoderateneedseachyear.AswithmostofTexasandthenation,mostprimarycarepracticesacrosstheRGVarenotintegratedandthevastmajorityofchildrenandyouthwithmildtomoderateneedshavechallengesaccessingcare.School-basedcareisavailableinsomeofthe37schooldistrictsthroughtheLMHAs,but,giventheregion’slargenumberofschools(andtheircautioninpartneringwithmentalhealthprograms),itisdifficulttoprovideservicesforallschoolswithintheschooldistricts.SystemLevelFindingSF-22:Thereisalackofcommunity-basedcareforchildrenandyouthwiththemostintensiveneeds.Theseintensivefamilyservicesareintendedtomeettheneedsofchildrenandyouthwhoareinvolvedwithmultiplechild-servingagenciesorwhoareatsignificantriskofbeingremovedfromtheirhomeorschool.Approximately,onlyonein50childrenandyouthwiththeseneedsnowreceivesuchcare,butTTBHandBRBHhavesoundprogramsonwhichtobuild.SB74streamlinesregulationsthatmayenableotherproviderstoaddressthesecomplexneedsaswell(forexample,theJohnAustinPeñaCenter).EventhoughMedicaidcurrentlycoversthecostsoftheseservicesformost(butcertainlynotall)children,youth,andfamilieswithintensiveneeds,providersdonothavethestart-upfundsneededtoexpandcapacitytoprovideintensivecommunity-basedcare.Theprimarybarriertoincreasingaccesstointensivecommunity-andfamily-basedservicesisone-timestart-upcosts,whichMMHPIhasestimatedatapproximately$5,000perchildserviceslot.Poststart-up,mostservicesforchildrenandyouthinpovertycanbecoveredbyMedicaid.Thenewstatefundingof$2.0millionprovidedwithSB74canbematchedtooffsetstart-upcosts.TTBHhasdevelopedastrongwraparoundprogramthroughtheYESMedicaidWaiverprogramforyouthwiththehighestneeds.Wraparoundisaservicecoordinationfunctionthat,whencombinedwitheffectivetreatment,hasgoodoutcomes.TheTTBHwraparoundprogramcollaboratedwiththeTexasInstituteforExcellenceinMentalHealthandwithWashingtonStateUniversityontrainingandcertification.Thewraparoundsupervisoriscertified.Thewraparoundteamwentthroughasixtonine-monthprocessoffidelitymonitoring,whichwilllikelyleadtotheirbecomingthefirstprogramtobecertifiedinnation.Atthetimeofthereview,thewraparoundprogramserved178children,youth,andfamiliesinthreecounties,119

119ThesenumbersvaryfromTable13onutilizationofservicesbylevelofcare(LOC)becausethatdataisforFY2015andthedateofthesitevisitwasin2016whentheprogramhadgrownsignificantly.

whileanother235children,youth,andfamiliesareonaninquirylist.TTBHisreluctanttocalltheinquirylistawaitinglistbecauseofthelengthoftimefamiliesmustwaittoaccesstheseservices.MMHPIestimatesthatapproximately1,000children,youth,andtheirfamilieswouldbenefitfromwraparoundfacilitationandassociatedintensivechildandfamilytreatment.ThisleavesasignificantgapinservicesintheRGV.120TTBHalsoprovidesthefollowingkeyevidence-basedpracticesandtracksfidelitythroughtheirqualitymanagementprogram:(1)PreparingAdolescentsforYoungAdulthood;(2)AggressionReplacementTraining;(3)SeekingSafety;(4)cognitive-behavioraltherapy(CBT);(5)ParentChildInteractionTherapy(PCIT);(6)Trauma-FocusedCBT;(7)ASSIST–AppliedSuicideInterventionTraining(atwo-daytraining).;and(8)MentalHealthFirstAid.TTBHalsoco-locatesstaffinschoolsandhassharedpositionswithjuvenileprobation,includingoneatjuveniledetentionfacilities.Inaddition,TTBHhasaspecializedcaseloadforfosterchildrenandyouthwiththegoaltoexpediteaccesstocare.Yet,theproportionofchildren,youthandfamiliesservedbyTTBHwas15%ofthepopulationinneed(2015figures,asnotedearlieronTable13).BRBHCprovideswraparoundservicesthroughtheYESMedicaidWaiverinStarrCountythroughitsChild,AdolescentandParentsServicesProgram(CAP),whichalsoincludesfamilysupportservices.In2015,BRBHCwasservingabout28%ofchildren,youth,andfamiliesinneed,asnotedearlieronTable13.Overall,therearesignificantgapsinservicesforchildrenandyouthinvolvedinmultiplesystems(mentalhealth,juvenilejustice,andchildwelfare),andtheregion’sresourcesdonotaddresstheneedsforchildren/youthwithSED(under200%oftheFPL)inthefour-countyregionwhoneedintensivecareatanygiventime.SystemLevelFindingSF-23:Accesstocrisisrespiteandlong-terminpatientcareforchildrenandyouthisverylimited–familiesmustfrequentlytraveltoAustinorSanAntoniotoobtainlong-terminpatientcarefortheirchildren.TTBHcontractswiththreelocalinpatienthospitalstoobtaincrisisstabilizationservicesforchildrenandyouth.WiththeopeningofPalmsBehavioralHealth(Palms)anditsdevelopmentofanadolescentunit,additionalservicesareavailable.Atthesametime,whiletraveltoPalmsiseasierthantravelingtoAustin,accessislimitedbytransportationbarriersanddistancetothecountieswithintheRGV.However,there

120MeadowsMentalHealthPolicyInstitute(2015).Estimatingthepercentageoflower-incomeyouthwithsevereemotionaldisturbanceswhoneedtime-limited,intensivehome/family/community-basedservices.Unpublisheddocumentsanddata.Basedonworkinmultiplestatesthathavedevelopedcommunity-basedservicearraysinresponsetosystemassessmentsandEarlyandPeriodicScreening,DiagnosticandTreatment(EPSDT)legalsettlements(WA,MA,CT,NE,andPA),andbasedontheinputofleadingnationalexpertsontheneedforwraparoundservices.

arecurrentlynodesignatedstatehospitalbedsintheRGVforchildrenandyouth.Asaresult,familiesseekingextendedandlonger-termcarefortheirchildrenaremostoftentransferredandadmittedtoSanAntonioStateHospital(SASH)orAustinStateHospital(ASH).SystemLevelFindingSF-24:Servicesforchildrenandyouthwithmildtomoderatebehavioralhealthneedshavenotkeptpacewithpopulationgrowth.ThisresultsinpooreroutcomeswhenthesechildrenandyouthhaveotherchallengeswithSUDs,school,thejuvenilejusticesystem,andoverallhealth.Families,schoolsystems,andsocialserviceagenciesexperiencethebruntoflimitedresourcesforthispopulation.PreventionSystemLevelFindingSF-25:Historically,BehavioralHealthSolutionsofSouthTexashasprovidedstrongleadershipandthePreventionResourceCenterhasprovidedregionaldatatoidentifypreventionneeds,bothofwhicharestrengths.ManysmallSUDpreventioninitiativesintheRGV,suchastheCameronandWillacyCountyCourtAppointedSpecialAdvocates(CASA),areaddressingSUDprevention.Whiletheseeffortsareuseful,theydonothaveenoughresourcestoprovidethestructureformoresystematicpreventionimprovementsthatincludeholisticinterventionsthatwouldhaveanimpactonfamiliesacrossgenerations.SystemLevelFindingSF-26:In2014,thenumberofdeathsbysuicideper100,000peopleintheRGVrangedfrom6.6forCameronCountyto6.8forHidalgoand9.6forStarrCounty.121Yet,therearenoorganizedsuicidepreventionactivitieswithinlargehealthsystemsintheregion.WhileMentalHealthFirstAidhasbeenofferedthroughoutmanyoftheschoolsystems,thereisnoholistic/universalpreventionapproachatacountyorlocallevelthattargetsbothadultsandschoolageyouth,noranyindicationofastrongschool-basedculturetoaddressyouthsuicideprevention.IntegratedCareIntegratedbehavioralhealth(IBH)representsaparadigmshiftinbothprimarycareandspecialtybehavioralhealthcaresettings.IBHentailsmoreroutineattentiontobehavioralhealthamongprimarycareprovidersandothermedicallytrainedstaff,aswellasskillfulattentiontobehavioralaspectsofwhataretypicallyconsidered“physical”disorders,suchasinsomnia,diabetes,andobesity.Similarly,inspecialtybehavioralhealthsettingsthatserveadultswithseriousmentalillnesses,IBHhascreatedanewunderstandingoftheoverallhealthofthepeoplebeingserved,offeringthepotentialtoextendhealth,wellness,andlifeexpectancy.

121DatawerenotavailableforWillacyCounty.Thestatewiderateper100,000peoplewas12in2014.Source:TexasDepartmentofStateHealthServices.(2016,September23).Texashealthdata:DeathsofTexasresidents,2014.Retrievedfromhttp://soupfin.tdh.state.tx.us/death10.htm

IncollaborationwiththeSt.David’sFoundation,MMHPIdevelopedareporttitledBestPracticesinIntegratedBehavioralHealth:IdentifyingandImplementingCoreComponents.122Thereport,publishedinAugust2016,identifiedsevencorecomponentsofIBHthatcanbeusedtodeterminetheextenttowhichphysicalhealthandbehavioralhealthcareisintegrated(versussimplyco-located)forpatients.Thereportoffersaroadmapforproviders,funders,advocates,andpolicymakersinterestedinpromotingIBHandworkingsystematicallytowardachievingitspromise.Earlydetectionandinterventionisanimportantfactorinthesuccessfultreatmentofbehavioralhealthconditions.InmanyIBHsettings(particularlyprimarycare),thebehavioralhealthneedsofclientsaretypicallyinthemildtomoderaterange,ofteninvolvingdepressionand/oranxiety.IntheUnitedStates,oneinfiveadults(20%)willexperienceaclinicallysignificantformofdepressionintheirlifetime,123andabout7.5%oftheUSworkforcehasdepressioninanyyear.124Whilemorethan80%ofpeoplewithdepressioncanbetreatedsuccessfullywithmedication,psychotherapy,oracombinationofboth,lessthan22%receiveadequatecare.125IntheRGVregion,about182,300adultsand58,800childrenhavemildtomoderatebehavioralhealthneeds126butareunabletohavetheseneedsaddressedbytheLMHAsbecauseofthestatemandateforLMHAs(suchasTTBHandBRBHC)tofocusonpopulationswiththemostseriousbehavioralhealthissues.IBHprovidesanopportunityforindividualswithmildtomoderatebehavioralhealthneedstohavethoseneedsassessedandtreated“in-place”inaprimarycaresettingwithouttheneedtorefertoaspecialtybehavioralhealthprovider.A2016MMHPIreporttitledIncreasingtheCost-EffectivenessofDepressionTreatmentwithCollaborativeCare127foundthatintegratingpsychiatricconsultationintomedicalsettings,withaccountabilityforoutcomesandcosts,improvesbothmentalhealthandmedicaltreatment122Toaccessthisreport,pleaseusethislink:http://texasstateofmind.org/wp-content/uploads/2016/09/Meadows_IBHreport_FINAL_9.8.16.pdf.123Kessler,R.C.,et.al.(2005).Lifetimeprevalenceandage-of-onsetdistributionsofDSM-IVdisordersintheNationalComorbiditySurveyReplication.ArchivesofGeneralPsychiatry,62,593-603.Formajordepressionalone,thechanceofhavingthediagnosisatsomepointinone’slifeisoneinsix.124Kessler,R.C.,Merikangas,R.,&Wang,P.(April2008).Theprevalenceandcorrelatesofworkplacedepressioninthenationalcomorbiditysurveyreplication.JournalofOccupationalandEnvironmentalMedicine,50(4),381-390.125Kessler,R.,etal.(2003).Theepidemiologyofmajordepressivedisorder:Resultsfromthenationalcomorbiditystudyreplication(NCS-R).JournaloftheAmericanMedicalAssociation,289(23),3095-3105.126NationalestimatesofprevalenceandseveritybreakoutsaredrawnfromKessler,R.C.,etal.(2005).Prevalence,severity,andcomorbidityoftwelve-monthDSM-IVdisordersintheNationalComorbiditySurveyReplication(NCS_R).ArchivesofGenPsychiatry,62(6),617-627.Thedataarefromastudywithadults.127Toaccessthereport,pleaseusethislink:http://www.texasstateofmind.org/wp-content/uploads/2016/01/Increasing-the-Cost-Effectiveness-of-Depression-Treatment-with-Collaborative-Care-2016_03_15.pdf.

outcomeswhileultimatelyreducingthecostofcare.128Onestudyfrom2007showedthatindividualswhoreceivedtreatmentfordepressionhad23%lessabsenteeismandonlyonethirdasmanymisseddaysofwork.129Inaddition,thestudywentontoreportthateffectivedepressiontreatmentledtoaneconomicbenefitof$1,982associatedwithimprovedproductivityatworkand$619perpersonassociatedwithreducedabsenteeism,amountsthatarehigherintoday’sdollars.Inthisway,IBHishelpingprovidersandfundersmovepastoutdatedunderstandingsofhealthneeds,interventionapproaches,andlimitationsontherangeofpotentialsettingsinwhichIBHcanbesuccessfullyimplementedtoimprovehealthoutcomesandreducecostsassociatedwithalackofadequatetreatment.IntegratedBehavioralHealth(IBH)FindingsSystemLevelFinding27:ThereisastrongcommitmenttoIBHamongmanyprovidersintheregion,withmanyimplementingsimilaroratleastcomplementaryapproachestocare.ThiscommitmentissharedbyMethodistHealthcareMinistries,theValleyBaptistLegacyFoundation,andotherimportanthealthsystemleadersintheregion,andsetsthestageformoreintentionalcollaborationamongprovidersatseveraldifferentlevels.SystemLevelFinding28:AnencouragingarrayofIBHprogrammingandservicedeliveryhasemergedintheRGV,includingevidence-basedIBHmodels,suchastheCollaborativeCareandPrimaryCareBehavioralHealth(PCBH)models.Exquisitelydesignedtrainingprogramsandambitiousintegratedprogrammingaredevelopinginsomelocations.SystemLevelFinding29:Whilenearlyallsitesshowevidenceofrudimentaryaspectsofintegratedcare(including,forexample,universalscreeningandtestingforbehavioralhealthorphysicalhealthconditions),muchmoredevelopmentisneededforthemoreadvancedaspectsofintegratedcare,suchaspopulationhealthmanagementandthedevelopmentofmorepreciseprotocolsandsharedclinicalpathwaysthatcanservetomakecaretrulyintegratedandwell-organized.SystemLevelFinding30:NotallproviderscanmeettheIBHneedsofallpeopleintheirsettingsand,especiallygiventheuniversally-citedshortageofbehavioralhealthproviders,thereisaneedforcross-providercollaborationtoensurethattherightpeoplereceivetherightcareintherightlocation.Asmentionedabove,providersnowknowenoughaboutIBHto

128SeetheWashingtonStateInstituteforPublicPolicyathttp://www.wsipp.wa.gov/BenefitCostforarecentreviewofstudiesthatconcludedintegratedmentalhealth/physicalhealthcareinprimarycaresettingsiscost-effective.129Donohur,J.M.,&Pincus,H.A.(2007).Reducingthesocietalburdenofdepression:Areviewofeconomiccosts,qualityofcareandeffectsoftreatment.Pharmacoeconomics,25(1),7-24.

systematicallycollaborateinthisway,yetfewmemorandaofunderstandingexistbetweenprovidersandmostindicatedtousthatcollaborativeeffortshavemostlydiedoutorfailed.CriminalJusticeDeliverySystemSystemLevelFindingSF-31:Individualswithbehavioralhealthneedsareover-representedandhighlyprevalentinallaspectsofthecriminaljusticesystem,includinglawenforcement,jails,detention,courts,probation,andparole.Ofparticularconcernarethe700peopletrappedincyclesof“super-utilization”thatusejails,particularlythe400withprimarilyforensicneeds.Therearesomenotablestrengthsinthesystemsdevelopedtoservetheseindividuals,includingtheMentalHealthPeaceOfficersTeam(MHOT)atTTBH(fundedthroughDSRIPandlawenforcementcontributionsfromsomecountiesandpolicedepartments).MHOTisamodelprogramforinitialcrises,butitneedstoexpandtoprovidecoverageacrosstheRGV24hoursaday,seven(7)daysaweek,365daysayearaswellasinitiatecollaborationwithmedicalfirstresponderstoprovideonsitetreatmentoptions.AdditionalopportunitiesforlocalcollaborationstoimplementprogramsfordivertingindividualswithmentalhealthneedsfromthejusticesystemareprovidedthroughtheSB292grantprogram,withafocusonbothreducingrecidivisminjailsanddecreasingwaittimesforforensicbedsatstatehospitals.Forpeoplereturningtothecommunityfromprison,theTexasCorrectionalOfficeonOffenderswithMedicalorMentalImpairments(TCOOMMI)providesintensivecasemanagement(50individuals),transitioncasemanagementforthoseonprobation(75individuals),andthesupervisionofparolees(75individuals),butmorecasemanagementoptionsareneeded.SystemLevelFindingSF-32:Somecountysheriffsandpolicedepartmentshavedevelopedeffectivestrategiesforcollaboration,includingthosethatfundaMentalHealthPeaceOfficersTeam(MHOT).Forexample,thePharrPoliceDepartmentprovidesanidealmodelforcollaborationbetweenthejusticesystemandserviceprovidersthathasyieldedpromisingresults.However,theseprogramsneedtobebroughttoscaleandimplementedinotherareasoftheRGV.Givencurrentgapsincapacity,lengthywaittimes,andinsomecasesalackofsafespacesatemergencydepartments(EDs)tohelpindividualsde-escalatefrombehavioralhealthcrises,acrosstheRGVitisstilleasierforsomeofficerstoarrestandjailtheseindividualsinsteadoftakingthemtoanemergencydepartment.SystemLevelFindingSF-33:Multipleissueshamperidentificationandcoordinationofcareforpeopleenteringthecriminaljusticesystem:

• AccesstosupportedhousingandSupportedEmploymentisverylimitedforjustice-involvedindividualsbecauseofthelimitedhousingstockandthedualstigma(beingmentallyillandalsoinvolvedwiththejusticesystem)theseindividualsface.

• Forpeoplewhoarenewtothejusticesystemandforwhombehavioralhealthdata

havenotbeenenteredintothesystem,post-arrestjaildiversionisoftennotpossiblesinceaContinuityofCareQuerywouldnotrevealtheirbehavioralhealthcondition.

• Therearediversepracticesindifferentcountiesandpolicedepartments,confusionovertransportationresponsibilities,andalackofresourcesforlicensedclinicalconsultationandcasemanagement.

• Therearealsosignificantgapsinothercrisisservicesthatneedtobeavailableatsequentialinterceptpoints(wherethejusticesystemandindividualswithbehavioralhealthconditionsinteract).Noneofthefourcountieshavecompletedacomprehensivesequentialinterceptanalysisofthebehavioralhealth/criminaljusticeinterceptpointsthatcouldbenefitfrommoreeffectivecollaborationandservicecoordination.

Veterans’ServicesDeliverySystemSystemLevelFindingSF-34:WhilethereisawidearrayofservicesavailabletoveteransthroughtheTexasValleyCoastalBendHealthCareSystem(VA-TVCBHCS)andotherproviders,therearesignificantchallengesforveteransinaccessingservices.Thestigmaofhavingamentalillnessorsubstanceusedisorderisabarrierforveteransinaccessingservicesbecausethepersonalorsocietalperceptionofweaknessisanathematothemilitarymaximofaccomplishingthemissionregardlessofpersonaldiscomfort.Mentalhealthorsubstanceuseconditionscanalsobemisunderstoodbyveteransandtheirfamiliesasweaknessorself-pityratherthantreatableillnesses.Inaddition,thelackofreadilyavailableoutreachandtreatmentthatistrauma-informedandcompetentinworkingwiththemilitaryculturecontributestobarriersveteransfaceinaccessingservices.Transportationisalsoasignificantchallengeforthispopulation.Onthepositiveside,thereisgoodcollaborationbetweenVA-TVCBHCSandTTBH,whichoperatesaveteran’sdrop-inprograminCameronCountyandisexpandingservicesinHidalgoCountythroughtheTexasVeterans+FamilyAllianceprogram.ThereisalsoeffectivecollaborationbetweenVA-TVCBHCSandtheDepartmentofPsychiatryatUT-RGVtosupportaresidencyprogramin2017,providetele-mentalhealth,anddevelopspecializedpsychiatryservices(e.g.,electroconvulsivetherapy).HousingNeedsSystemLevelFindingSF-35:ThehousingstockthroughouttheRGVisverylimitedandtheneedforsupportedhousingisessential,especiallyforadultswithseriousmentalillnessandyouthtransitioningtoindependentlivingfromfostercareortheirfamilyhome,aswellasforveteranswithbehavioralhealthchallenges.WhileaccesstosupportedhousingservicesacrossTexasislow,stateLMHAdatafromFY2015showthatTTBHandBRBHCservedthelowestpercentageofindividualsinneedwhencomparedtoothersimilarLMHAs.AsshownpreviouslyintheAdultswithSMI(200%FPL)KnowntoHaveReceivedSupportedHousingtable,TTBH

providedthisservicetoapproximately2%ofthepopulationinneedwithinthecatchmentarea(about671individuals),andBRBHCservedapproximately1.3%ofindividualsinneedwithintheircatchmentarea(about120individuals).Thereisalsoaneedforsoberlivinghousingcoupledwithaccesstorecoverysupportsandservicescapableoffullyaddressingco-occurringneeds.TheapproachtohousingadoptedbytheVAandunderconsiderationbyTTBHistheHousingFirstModel,whichfocusesonassistingpeoplewithobtainingahomewithouttheconditionoftreatment.Thismodelprovidesapositiveincentivetoengageintreatment.WhileBRBHC,TTBH,andtheVAhaveattemptedtoprovideindividualswithsupportivehousingmodelsthatincludeanapartmentorhomeaswellasothersupportstohelpthemremainintheirhomes,thereisaneedforthebroaderRGVregiontoaddressthehousingshortagethroughlocalandcounty-levelplanning.AsnotedpreviouslyinfindingsrelatedtoSUD,therealsoisasignificantneedforASAMresidentiallevelsofcare,particularlyhalf-wayhousesandsupportivelivingenvironments.WorkforceNeedsSystemLevelFindingSF-36:Therearesignificantworkforcegapsforallproviders(especiallythosewhospeakSpanish),includingpsychiatristsandotherlicensedmentalhealthandSUDprofessionals.Thishasanimpactonboththecapacityoftheseprovidertypesandthesupervisionandtrainingofqualifiedmentalhealthprofessionals(QMHPs)workingintheLMHAsandpromotores/communityhealthworkersmorebroadly.Thestate’scurrentlicensingstandardsmakeitchallengingtolicensenewstaff,includingpsychiatrists.SB674,whichwassignedintostatelawfollowingthe85thLegislativeSession,expeditesthelicensingprocessforpsychiatristswhoarealreadylicensedandingoodstandingtopracticemedicineinanotherstate.Thiswillallowpsychiatristsrecruitedfromoutofstatetobefast-trackedthroughapprovalprocessestobelicensedforpracticeinTexas.WhiletheQMHPstaffattheLMHAs(forwhomlicensureisnotrequired)areoftenbi-cultural,bi-lingual,andeducatedintheRGV,theopportunitiesforthemtolearnthroughon-the-jobtrainingaremorelimitedbecauseoftheabsenceoflicensedpersonnel.SystemLevelFindingSF-37:Relianceoncertifiedpeerspecialiststoprovidesupportsforadultsandyouth,andcertifiedfamilypartnerstoassistfamiliesofyouthwithbehavioralhealthconditions,isabestpracticethatisstronglyembeddedwithinTTBHandneededthroughouttheadultandchild/youthsystemsofcare.BRBHChasbegunofferingthesesupportsthroughfamilypartners.TTBHhasmodeledtheeffectiveuseofpeersthroughoutitssystem,includingitspeer-rundrop-incenters,itsAssertiveCommunityTreatment(ACT)program,andotherservices.PeersandfamilypartnersparticipateintreatmentteammeetingsandtheirvaluablecontributionswerenotedbypsychiatristsandotherlicensedcliniciansatTTBH.Thereisaneedtosharethelessonslearnedbypeersandfamilymembersacrosstheadultandchild/youthsystemsofcare,includingthejusticesystem.Theuseofpeersembodiesarecoveryorientationthatneedstobeinfusedwithinalllevelsofcareandforallbehavioral

healthpopulations.HB1486,whichwaspassedduringthe85thLegislativeSessionanddevelopedthroughtheeffortsoftheSelectCommitteeonMentalHealth,establishesguidelinesforthedevelopmentoftrainingandcertificationrequirementsforpeersupportspecialists.Additionally,providerorganizationswillnowbeabletobillMedicaiddirectlyforpeersupportservices,ratherthanusingtherehabilitationservicesbillingcodefortheseservices.TransportationNeedsSystemLevelFindingSF-38:LimitationsoftransportationsystemsthatcrosscitiesandtownsintheRGVcontributetopooraccesstoservices.Whiletherearesomeoutreachservicesanduseofmobilevanstoprovidecasemanagementandothersupports,accesstobusesandotherpublictransportationislimited.Individualsgenerallymustrelyonpersonalvehiclesfortransportationtobehavioralhealthcareservices.Someprovidershavevansthatpickupknownclients,suchastheTTBHdrop-inprogramsandtheVeteran’sAdministrationTexasValleyCoastalBendHealthCareSystem,whichisuseful,butdoesnotassistindividualswhohaveyettoconnectwithservices.UseofTelemedicineSystemLevelFindingSF-39:Theuseoftelemedicine,akeyresourceinalargegeographicareawithlimitedavailabilityoflicensedbehavioralhealthprofessionals,hasexpandedthroughouttheRGV,butaccesstoboardcertifiedpsychiatrists,especiallythosefluentinSpanish,andotherlicensedprofessionalsremainsachallenge.Also,providershavechallengeswithorientingstafftobestpracticeproceduresfortelemedicineandwithusingsomeoftheequipment.State Level Findings Related to LMHAs (STF)

StateLevelFindingSTF-1:ThemechanismHHSCusestorebaseitscapacitytargetsfortheLMHAs,especiallywhentheyexceedtheircapacity,presentssomechallenges.Forexample,ifTTBHserves135%oftheirtargetedcapacityandthenextyearDSHSincreasesthetargetcapacityto135%withoutabudgetincrease,TTBHmustcontinuetostretchitsresourcestoprovidethegreatercapacity.Ratherthanreceivinganadjustmenttoaccommodatemoreindividuals,TTBHreceivesthesamefundingwitharequirementtomaintainthehighercapacity.ThisapproachisunsustainableandineffectpunishesTTBHforitsinnovationandoutreach.StateLevelFindingSTF-2:TheHHSCClinicalManagementforBehavioralHealthServices(CMBHS)system,aweb-basedclinicalrecordkeepingsystemforstate-contractedcommunitymentalhealthandsubstanceusedisorderserviceproviders,requiresdualentryandcreateserrorsandextraworkforproviders.Whileitisnotuncommonforstatestohavedual

informationsystemsforstate-fundedandMedicaid-fundedservices,thisapproachisoutdatedandinconsistentwithinsuranceapproachesandemergingvalue-basedpaymentstrategies.Major System Level Recommendations (SR)

County-LevelPlanningSystemRecommendationSR-1:Toaddressgapsrelatedtoalackofsystem-levelcoordinationineachcounty,developorstrengthenexistingcounty-levelcollaborativeeffortsandformcomprehensivebehavioralhealthleadershipteams(BHLTs),usingsupportfromtheValleyBaptistLegacyFoundation(LegacyFoundation)and/orthe$30millioningrantfundingfromHB13toprovideincentivesforstate-localcollaborationsonmentalhealth.Theteamsshouldfocusonthebehavioralhealthneedsofthewholepopulationofeachcounty,includingadedicatedposition(atleasthalf-time)tosupportthecollaborativeefforts.Theseeffortsshouldbuildonexistingcountycollaborationstocapitalizeoncurrentinvestmentsofpeopleandtime.Countieswillneedtodeterminethestrongeststartingplacesforcounty-widecollaborations.Membershipcouldincludeadesignatedseniorleaderofthecountyandallkeyleadersofcountyservices(e.g.,sheriffandlocallawenforcement,juvenilejustice,childandadultprotectiveservices,countymedical/publichealth)thatinterceptwithbehavioralhealthissues,managedcareorganizations(MCOs)thatservethecounty,federallyqualifiedhealthcenters(FQHCs),primarycareandbehavioralhealthproviders,hospitals,theRecoveryOrientedSystemsofCare(ROSC)participants,othercurrentcounty-specificplanninggroupssuchastheCameronCountyMentalHealthTaskForceandcommunitypreventionpartnerships,representativesoftheschooldistricts,consumersandfamilymembers,andotherstakeholders.Usingthefindingsfromthisreport,identifytheprioritiesthateachcountyneedstoaddress.WeofferthisrecommendationbecauseofthecomplexityoftheRGVandtheneedtodevelopastep-wiseprocesstoformingorganizedcollaborativeeffortswithineachcountyandsharestrategiesacrosstheregion.TwoexistingBHLTsthatexemplifysuccessfulcollaborationsaretheDentonCountyBehavioralHealthLeadershipTeam(DCBHLT)130andthePanhandleBehavioralHealthAlliance(PBHA):131

• TheDCBHLTwasestablishedin2014throughacollaborationbetweenUnitedWayofDentonCountyandtheDentonCountyCitizen’sCouncilonMentalHealth,withassistanceprovidedbyMMHPI.TheDCBHLTadoptedavisionof“ComprehensivebehavioralhealthforeverypersoninDentonCounty,”andsinceitsinceptionhasaccomplishedanumberofgoals:ItdevelopedamentalhealthresourcedirectoryforDentonCounty;launchedtheVeteranCommunityNavigatorProgram,apilotcasemanagementprogramprovidingcentralizedintakeandassistancetoveteransincrisis,throughthestate’sTexasVeterans+FamilyAlliance(TV+FA)program;partnerswiththe

130FormoreinformationontheDentonCountyBehavioralHealthLeadershipTeam,see:www.dentoncountybhlt.org131FormoreinformationonthePanhandleBehavioralhealthAlliance,see:panhandlebehavioralhealthalliance.org

MilitaryVeteranPeerNetwork(MVPN)toconductVeteranCulturalCompetencyTraining;andpartnerswithMMHPIintheOkaytoSay™campaign(okaytosay.org),acommunity-driveninitiativetoincreasetheawarenessthatmostmentalillnessesaretreatableandoffermessagesofhopeandrecoverytoTexansandtheirfamilies.

• ThePBHAformedin2016withabroadgroupofstakeholdersrepresentingthebehavioralhealthservicedeliverysystemof26countiesintheTexasPanhandleregion.ThePBHApartneredwithMMHPIin2016toconductabehavioralhealthsystemsassessmentinthePanhandleregiontoidentifyspecificareasofneedandopportunitiesforgrowth.PBHAadoptedthemissionstatement,“ThePBHAcollectivelybuildssystemsthatimprovethebehavioralhealthlife-cycleofcareforallpeopleoftheTexasPanhandle,”andselectedthreeareasoffocusfortheirworkinpromotingbehavioralhealthandwellnessinthecommunity:1)Accesstobehavioralhealthcareandalignmentwithphysicalhealthcare;2)Workforceandrecruitmentforbehavioralhealthprofessionals;and3)Preventionandearlyinterventionforbehavioralhealthproblems.Inadditiontotheseareasoffocus,PBHAhasalsopartneredwithMMHPIinbringingtheOkaytoSay™campaigntothelocalcommunity.

SystemRecommendationSR-2:ThrougheachcountyBHLT,developa“cultureofcollaboration”thatemphasizesaninclusivecommunity-widebehavioralhealthsystemcollaborationbasedonsharedvalues.Thiscollaborativeeffortshouldbeguidedbythepremisethatthebehavioralhealthneedsoftheentirepopulationaretheresponsibilityofallcommunities,anditshouldbeasharedprioritytowelcomepeopleinneed–andeachother–asprioritycustomersofoneanother.Toaccomplishthis,thecountyplanningeffortcouldworktoengageallfunders,includingMedicaidmanagedcareorganizations,healthplans,healthsystems,employers,etc.,aswellasothersmentionedinSR-1above.SystemRecommendationSR-3:ThecountyBHLTsshoulddevelopandarticulateavisionofwhatthebehavioralhealthsystemshouldlooklike–ifitwerefullyresponsivetotheneedsidentifiedinthisreport–tosupportindividualswithbehavioralhealthissuesinhavingsafeandproductivelivesinthecommunityandintheirhome,family,faith,work,orschool.Theresultsofthisassessmentshouldinformthatvision;however,thevisioncannotbeestablishedbyanexternalreview–itmustbedevelopedcollaborativelybythecountyBHLTs,withextensiveinputfromstakeholdersrepresentingadults,olderadults,andchildren,youth,andyoungadults.Thefollowingfigureprovidesanexampleofanidealsystemicapproachtobehavioralhealth.

SystemicApproachestoBehavioralHealthServiceDelivery

SystemRecommendationSR-4:Oncethevisionisestablished,eachcountyBHLTshouldcreateaprioritizedtimelineforincrementaldevelopmentofstrategiestoaddresssystemgapsoveramulti-yearperiod.Theprioritiesforsub-populationsidentifiedinthisreportcouldbeastartingplaceforthecountyBHLTs.SystemRecommendationSR-5:Developworkgroupstoaddressareasofhighestpriority,basedontheprioritiesofthecountyBHLTsandtherecommendationsinthisreport.ItmaytakesometimeforeachcountyBHLTtoformandprioritizeitsgoals.However,thefindingsandrecommendationsinthisreportpointtoseveralareas,allofwhichcannotbeaddressedatonceandwilltaketimetoimplement.Examplesofsub-populationsandprojectsthatwouldbenefitfromincreasedcollaborationarelistedbelow.

• Individualsofallagesusingthecrisissystemwouldbenefitfromimprovedcollaborationtoaddressthegapsincrisisservicesforadults,childrenandyouth,andolderadults,suchasdiversion,crisisrespite,andcarecoordination.Otherexamplesofcounty-levelcollaborations,basedonthefindingsinthisreport,butnotinorderofpriority,arelistedbelow.- Adultswithcomplexneedstrappedin“super-utilization,”cyclingthroughrepeat

episodesofemergencydepartment(ED),hospitalandjailuse;- Adultsandtransitionageyouthinneedofhousing,focusingonhousing

development;- Childrenandyouthwithseriousemotionaldisorders(SEDs)andthehighestlevel

ofneedstoworkonaligningthechildren’ssystemsofcareandexpandingaccessto

evidence-basedintensivementalhealthservicesandwraparoundinitiatives;- Individualsinneedofalcoholandsubstanceusedisorder(SUD)treatmentand

prevention,toexpandalcoholandSUDservices,includingresidentialtreatment;- Individualswithcomplexmedicalneeds,includingalignmentwiththeRegional

HealthPartnershipandTheUniversityofTexasSchoolofPublicHealth–BrownsvilleRegionalCampustopromotebroaderdisseminationofprimaryhealthandbehavioralhealthintegration(thiscollaborationcouldincludeBRBHC,TTBH,theFQHCs,VA-TCBHCS,andotherhealthcareproviders);and

- Collaborationsthatcouldaddressworkforceissues.ThesuccessofeachBHLTwilldependontheinvestmentbyeachcountyanditsstakeholders,andtheircommitmenttoworksystematicallytoaddresschallengesthatarebestaddressedbyacollaborativeeffortatthecountylevel.SystemRecommendationSR-6:ThroughthecountyBHLTs,andutilizingthedataprovidedinthisreport,developafinancialblueprintthatmapspublic(stateandlocal)andprivatefundingsourcesforservicestoidentifytheamountofavailableresources,typesofservices,targetpopulations,andlocationofservices.Then,identifyhoweachservicefitsintoregionalandcountysystemsofcareforadultsandolderadults;children,youthandyoungadults;andspecialneedspopulationssuchasveteransandindividualswhoarehomeless.Akeycomponentofthisstrategyshouldbetomakefulluseofnewandexistinglocal-statepartnershipopportunities.Threebillspassedduringthe85thLegislativeSessionhavecreatednewopportunitiestoaddresstheunmetneedsofindividualswithmentalillnessintheRGV:

• SB292wasestablishedwiththeintentoffundingprogramsthatwillreducerecidivism,arrests,andincarcerationofindividualswithmentalillnesstokeepthemfromcyclingthroughcountyjailsandthestatepsychiatrichospitalsystem.Theprogramprovidesmatchinggrantstocounty-basedcollaborativesandallowsflexibilityforcommunitiestodeterminewhatservicesandsupportsaremostneededtosolvelocalneeds.Thefirstyearoffundingforthisprogramisallocatedspecificallyforcommunitycollaborativesthatincludehighlypopulatedurbancountiesof250,000ormore,withthesecondyearallocating20percentoffundsforcollaborativesthatincludelesspopulatedruralcountiesoflessthan250,000.Grantrecipientsarerequiredtomeeta1:1local-statematchforcountiesover250,000anda1:2local-statematchforsmallercountiesunderthispopulationlevel.

• HB13wasestablishedwiththeintentoffundingprogramsthatwillhelpaddressgapsinmentalhealthservicesandtreatmentinlocalcommunities.Thisprogramprovidesmatchinggrantstosupportcommunitymentalhealthprogramsthatprovideservicesandtreatmenttoindividualsexperiencingmentalillness.WhileSB292hasafocusonurbancollaborativesinitsfirstyear,HB13hasagreaterfocusonfundingrural

communities–50percentofthefundsarereservedforprogramslocatedincountieswithapopulationoflessthan250,000.

• SB74clarifiestherequirementsforentitiesthatwanttobecomeTargetedCaseManagementandMentalHealthRehabilitativeServicesproviders.Thisbilliscloselytiedtotheallocationof$2millioninthestatebudget(SB1)toestablishastatewidegrantprogramtoincreaseaccesstoTargetedCaseManagementandMentalHealthRehabilitativeServicesforchildrenandyouthwithhighneedsinfostercare.Theintentofthisbudgetallocationistofundstart-upandtrainingcostsforproviderstoincreasetheircapacitytoservethesechildrenandyouth.ThegrantprogramisfocusedonprovidingfundingtoentitiesthatareworkingtowardeitherbecomingTargetedCaseManagementandMentalHealthRehabilitativeServicesprovidersforchildrenandyouthwithhighneedsinfostercare,ortoexpandtheirexistingcapacitytoprovidethesetypesofservices.

Additionally,twoexistingstateprogramsprovideopportunitiestosecurefundsforsupportinglocalcollaborationsfocusedonmentalhealthserviceprovision:

• TheTexasVeterans+FamilyAlliance(TV+FA)programwascreatedbySB55inthe84thLegislativeSessionwiththepurposeofsupportingcommunitymentalhealthprogramsthatprovideservicesandtreatmenttoveteransandtheirfamilies.Apilotprogramwaslaunchedinlate2015,withselectedawardeesbeginningtheirprogramminginthesummerof2016,withoperationsupportedbyatotalof$1millioninpublicfunds(witha1:1matchinlocal,privateandin-kindfunds).Thesecondphase,whichinitiatedthefullprogram,providedtworoundsofawardsin2016and2017,offeringupto$10millioninstatedollars(which,again,wouldbematched1:1inlocal,private,andin-kindfunds).The85thLegislatureapprovedcontinuedfundingoftheprogramat$20millionoverthenextbiennium.

• TheHealthCommunityCollaborative(HCC)Program132wascreatedbySB58duringthe83rdLegislativeSessionwiththepurposeofestablishingorexpandingcommunitycollaborativesthatbringthepublicandprivatesectorstogethertoprovideservicestopeopleexperiencinghomelessnessandmentalillness.TheDepartmentofStateHealthServiceswastaskedwithawardingamaximumoffivegrantstomunicipalitieswithincountieswithapopulationofmorethanonemillion.Initsfirsttwofiscalyears(2014through2016),DSHSawardedmorethan$51millioningrantstoAustinTravisCountyIntegralCare(ATCIC),theCityofDallas,theCoalitionfortheHomelessofHouston,HavenforHope–SanAntonio,andMyHealthMyResources(MHMR)ofTarrantCounty.The84thLegislaturerequiredtheallocationofupto$25millioningeneralrevenueoverthebienniumtofundcollaborativegrantswithinthisprogram.

132TexasHealthandHumanServicesCommission(2017,January).Reportonthehealthycommunitycollaborativeprogramforfiscalyear2016.

SystemRecommendations:SR-7:AspartofcountyBHLTplanning,developastrategytoaddressthestigmaassociatedwithmentalillnessandSUD,includingstigmaforveteranswhohavebehavioralhealthconditions.Multipleapproachescouldbepursuedwithaqualityimprovementfocus.Forexample,becausetransportationissueslimitaccesstoservicesforveterans,oneusefulstrategywouldbetocollaboratewiththeVA-TVCBHCStoidentifywhereveteransliveintheRGVandthenmapaccesstoproviders.Followingthisstep,thecountyBHLTscouldfocusondevelopinganexpandedprovidernetworktoserveveterans.Transportationgapscouldalsobereferredtoeachcounty’stransportationplanninggroup.Morebroadly,MMHPI’sOkaytoSay™campaigncanbeutilizedasaresourceforaddressingbarrierstomentalhealthtreatmentrelatedtostigma.OkaytoSay™isacommunity-basedcampaignlaunchedbyMMHPIanditspartnerstoincreasepublicawarenessthatmostmentalillnessesaretreatableandtoofferamessageofhopeandrecoverytoTexansandtheirfamilies.ThegoalofOkaytoSay™istochangetheconversationandperceptionsaroundmentalillness,whichultimatelycanleadtoincreasedunderstanding,advocacy,andsupportforthosewithmentalillness;improvedaccesstocommunityservicesfordiagnosisandtreatment;andacceleratedprogressinthequalityanddeliveryofmentalhealthcare.CrisisDeliverySystemSystemRecommendationSR-8:Thehighestpriorityforenhancedcounty-level(andpossiblyevensomecross-county)collaborationisthecrisissystem,specificallythedevelopmentofacomprehensive,regionalintegratedcrisissystemacrossallmajorpublicpayers,hospitalproviders,behavioralhealthproviders(mentalhealthandsubstanceusedisorder),firstresponders,andthejusticesystem.Thesystemshouldprovideaccesstoarangeofcrisisservices,includingcrisisdiversionandalternativestoinpatientservicesandjails.Protocolsandproceduresforaccessingservicesmustbeclearlywrittenandsharedamongallparties.Similarly,protocolsfordivertingindividualsfromemergencydepartmentsandrestrictiveinpatientcareshouldbewidelysharedandtransparent.Thishighpriorityshouldbeaddressedimmediatelyaspartofplanningtoaccessstate-localpartnershipfundsunderSB292;thegoalofthisprogram(whichisexpectedtobeginprovidinggrantfundinginearly2018,requiringa1:1local-statematchforcountiesover250,000anda1:2local-statematchforsmallercounties)istoreducerecidivism,arrests,andincarcerationamongindividualswithmentalillnessandtoreducewaittimeforforensiccommitments.SB292requirestheformationofacommunitycollaborative(orcollaboratives;aminimumofacounty,aLMHA,andahospitaldistrict,ifany,aswellasotherlocalentitiesdesignatedbythecollaborativesmembers)toplanandsubmitproposalsforfunding.ThislegislationpresentsopportunitiesforthedevelopmentofneededservicesthroughouttheRioGrandeValley,including:

• Theestablishmentorexpansionofcrisisdiversionservices;• Expansionofcrisisrespiteservices;• ProvisionofAssertiveCommunityTreatment(ACT)andForensicAssertiveCommunity

Treatment(FACT);• Creationofmultidisciplinaryrapidresponseteams;• Developmentofalternativesolutionstocompetencyrestorationinstatehospitals,such

asoutpatientcompetencyrestoration,inpatientcompetencyrestorationinasettingotherthanastatehospital,orjail-basedcompetencyrestoration;

• Intensivementalhealthorsubstanceusedisordertreatmentservices;• Continuityofcareservicesforindividualsbeingreleasedfromstatehospital;and• Provisionoflocalcommunitybeds(communityhospital,crisis,respite,orresidential).

Severalexamplesofsuccessfuljaildiversionprogramshavebeenimplementedinregionsacrossthestate.InDallasCounty,alocalcollaboration133hasbegunimplementingtheuseofMultidisciplinaryResponseTeams(basedonthesuccessfulmodelinColoradoSprings).ThismodelcreatesapartnershipbetweenEMS,police,andlocalmentalhealthprovidersbydevelopingteamswhorespondasasingleunit(ofthree)tothesceneofmentalhealthcrises.Italsoexpandsoptionsforaddressingnotonlythecrisisathand,butalsofactorscontributingtothecycleofchroniccrisisandcriminaljusticesysteminvolvement.OneexampleofanidealjaildiversionprogramistheHarkerHeightsPoliceDepartmentHealthyHomesProgram.Thisprojectembedsclinicianswithinthepolicedepartmentandallowsforeitheranimmediateresponseonscenein“pre-crisis”situationsorreferralsfrompatrolmentohomesorpeopleforwhomtheyhaveincreasingconcerns.TheHealthHomesProgram’soverarchingpurposeistolinkareasocialserviceorganizationsandcommunityresourcestofamilieswhowouldbenefitmostfromthem.Theprogramoffersadirectlinktoarearesources,solution-focusedinterventions,crisis/griefcounseling,domesticviolencesupport,welfarechecks,andin-homeinterventionplanning.Theprogramalsoexpandstheavailablebehavioralhealthworkforcebyusingintern-levelcliniciansfromlocaluniversitiestofilltheneedforlicensedcliniciansontheresponseteam.134Fundingtoprovideinpatient,outpatient,andjail-basedrestorationtocompetencyserviceshavethepotentialtoalleviatethelongwaittimesforservicesthatcontributetoextensivejailtimeorinpatientutilization.TheneedforcrisisrespiteisespeciallyacuteinStarrCounty;StarrMemorialHospital,whichhastheprimaryemergencydepartment(ED)usedinStarrCounty,hasexpressedinterestinprovidingthesecrisisservicesiffundingwereavailable.TheStarrCountyhospitaldistrictfacessignificantchallengeswithEDspaceandthecountyisconfrontedwithlimitedtransportation

133Formoreinformationonthedevelopmentofthisinitiative,see:http://www.tmcec.com/files/6314/6245/8577/03_-_Wagner_BINDER_Stepping_UP.pdf134CityofHarkerHeights.(n.d.).HealthyHomes.Retrievedfrom:http://www.ci.harker-heights.tx.us/index.php/healthy-homes

resourcesandexcessivedemandsonlawenforcement’stime,allofwhichcontributetoindividualsbeingtakentojailratherthaninpatientcare.Afullcrisisarrayofservices,asoutlinedinMMHPI’sreporttoSt.David’sFoundation,ideallyincludesacontinuumofservicesspecificallycreatedwiththeintentiontostabilizeandimprovetheindividual’ssymptomsandfacilitateengagementintreatmentintheleastrestrictivesettingpossible.Thebestpracticeincrisisservicesincludesthefollowingcomponents:(1)psychiatricemergencycenters,(2)hospitalemergencydepartments,(3)23-hourcrisisstabilization/observationbeds,(4)inpatientpsychiatriccare,(5)short-termcrisisresidentialandcrisisstabilizationservices,(6)emergencymedicalservices,(7)mobilecrisisservices,(8)24/7crisishotlines,(9)warmlines,(10)psychiatricadvanceddirectives,(11)peercrisisservices,and(12)transportation.135Anydevelopmentofadditionalinpatientcapacityshouldoccurwithinthecontextofdevelopingthecrisisservicearray.InpatientfacilitiesshouldconsiderworkingcollaborativelywithotherprovidersintheRGVtorefinetheirassessmentofgapsinservicesforkeysub-populationsinthecountiesinordertobestaligninpatientcapacitywithgeographicalandpopulationneedsandpotentiallyestablishcomponentsofthecrisiscontinuum.

• SystemRecommendationSR-8a:Establishcounty-basedcollaborativestofocusonthehighestpriorityneedsfirstandobtainasmuchfundingaspossiblefortheSB292grantprogram’sallowableservices.Subsequently,countyandcross-countycrisiscollaborationshouldconsiderinvestinginfocusedstrategicplanningtodevelopabusinessplanforabroadarrayofcrisisdiversionandstep-downservices,includingexpandingongoingintensiveservices(ACT/FACT)forfrequentcrisissystemusers,short-termcrisisresidentialcapacity,andambulatoryintensivecrisisinterventionservicesthatareavailablethroughouttheRGV.ConsiderlocatingtheseservicesatStarrMemorialHospitalinRioGrandeCity.Asnotedinthefindingssectionofthisreport,theTransitionalCareClinicinSanAntonio,operatedbytheUTHealthScienceCenter,isamodelthat(provideditisaccompaniedbyaplanforsustainability)wouldbeveryusefulintheRGV.136

• SystemRecommendationSR-8b:InadditiontoplanningforSB292fundingandservices,county-levelcrisiscollaborationcouldalsofocusonacutecarecoordination,involvingBRBHC,TTBH,acutecarehospitals,VA-TVCBHCS,andMCOcarecoordination.Coordinationeffortswouldfocusondevelopingroutinetrackingandcoordinationtoresolvecontinuityofcareissuesandengageindividualsexperiencingacrisiswhoareatriskoffallingthroughthecracks.

135MeadowsMentalHealthPolicyInstitute.(2016,December).BehavioralHealthCrisisServices:AComponentoftheContinuumofCare.AustinTX:St.David’sFoundation.RetrievedonJuly11,2017fromhttp://texasstateofmind.org/wp-content/uploads/2015/11/MMHPI_CrisisReport_FINAL_032217.pdf136UniversityofTexas–SanAntonioDepartmentofPsychiatry.(2017,March).Transitionalcareclinic.Retrievedfromhttp://psychiatry.uthscsa.edu/CRRT/tcc/

• SystemLevelRecommendationSR-8c:Incorporatecrisisdiversionbedswithinaproactivecontinuumofcrisisintervention,sothatintensivecrisiscasemanagement(e.g.,usingmodelslikeCriticalTimeIntervention)andskill-basedprogrammingcanbeincorporatedintothecontinuumandincludedintheprovisionofbothdiversionservicesandstep-downcrisisbeds.TheneedforcrisisdiversionbedsisamongthehighestneedsintheRGVandshouldbeapriorityforSB292fundingintheBRBHCandTTBHRGVserviceareas.GiventhecurrentlowcostofTheWoodGroupservicemodels,engagingMedicaidMCOsandotherinsurersinpurchasingtheselevelsofcareandexpandingthemtootherpartsoftheRGVwouldbenefitall.However,thecrisisrespiteprogramsshouldfirstbeseparatedfromtransitionallivingprograms(whichtendtouseupcrisisrespitebedcapacity)beforebeingexpanded.

AdultMentalHealthandCriminalJusticeDeliverySystemsSystemRecommendationSR-9:Basedoninformationforadultswithincomesunder200%ofthefederalpovertylevel(FPL),thecountyBHLTsshouldalsoprioritizethedevelopmentofsufficientcapacitytoprovideongoingcarefortheadultswithhighlycomplexneedswhoarecaughtincyclesof“superutilization”ofcrisis,jail,emergencyroom,inpatient,andhomelessservices.TyingthistoSB292,immediatelybeginplanningacollaborativetobidonresourcesforAssertiveCommunityTreatmentandForensicAssertiveCommunityTreatmentteamswithoutreach,andevidence-basedmodelsforthoseindividualswithhighutilizationofserviceswhocurrentlyareunsuccessfulinnegotiatingtransitionsbetweenlevelsofcareorwhoarenotabletomaintainconnectionswithusualservices.Resourcesshouldalsobetargetedtotheestablishmentofinterdisciplinaryrapidresponseteamstoreducelawenforcement’sinvolvementwithmentalhealthemergencies,whichwouldallowexpansionofcurrentcrisisinterventioncapabilities.Byaddressingtheneedsofadultswith“super-utilization,”individualswillbenefitfromimprovedqualityoflifeandthe“system”willbenefitfromdecreasedutilizationandcostsaswellasdecreasedchallengesassociatedwithrepeatedlyseeingthesameindividualsusescarceresources.SystemRecommendationSR-10:Giventheexpenseofinpatientcare,considerdevelopingastrategicplanforutilizationofinpatientbedcapacityacrosstheentireRGVregionthatfocusesontheneedsoftheentirepopulationandmatchesgapsinservices.Anydevelopmentofadditionalinpatientcapacityshouldoccurwithinthecontextofthisplanning.InpatientfacilitiesshouldconsiderworkingcollaborativelywithotherprovidersintheRGVtorefinetheirassessmentofgapsinservicesforkeysub-populationsacrosstheregioninordertobestaligninpatientandoutpatientcapacitywithgeographicalandpopulationneeds.SystemRecommendationSR-11:AtthecountyBHLTlevel,considerdevelopingastrategicplanforimplementingoutpatientservicesforadultswithmildtomoderatebehavioralhealth

needswhooftenrelyonsocialservicesorganizationsthatprovideanarrayofservices,butnotspecificallymentalhealthservices.ThefocusshouldconsiderindividualswithMedicaid,Medicare,otherinsurance,ornoinsurance.Co-OccurringMentalHealthandSubstanceUseDisorderDeliverySystemSystemRecommendationSR-12:AtthecountyBHLTlevel,considerdevelopingastrategicplanforanexpandedarrayofsubstanceusedisorder(SUD)services–includingco-occurringservicesandtheAmericanSocietyofAddictionMedicine(ASAM)levelofcareresidentialsubstanceabuseprograms–intheRGVforindividualswithMedicaid,Medicare,otherinsurance,ornoinsurance.ThisshouldinvolvecreatinganorganizedcollaborationamongSUDproviderssothateffortsforcollaborationandimprovementareintegratedratherthanoccurringseparately.Asmentionedpreviously,considerengagingtheROSCandthepreventioncoalitionsincountyBHLTactivities.Child,YouthandFamiliesDeliverySystemSystemRecommendationSR-13:BuildingontheworkofTTBHChildren’sSystemofCare(CSOC)andtheirexistingcollaborationwithjuvenilejusticeandchildprotectiveservices,developaplanningprocesswithineachofthecountiesintheRGVthatinvolvesallchildandfamilyservingproviders,and,workingwithallmajorpayersandprovidersthroughoutthecounties,expandthismodeltoservemorechildrenandyouth.Akeyprioritywithinthisplanningprocessshouldbetoexpandimplementationofintensivehomeandcommunity-basedsupports(includingevidence-basedmodels)forchildrenandyouthathighestriskofout-of-homeplacement,wraparoundplanningthattakesfulladvantageofYESWaiverfunding,earlyinterventionservicesforseverementalillnessmanifestinginadolescence(includingbestpracticefirstepisodepsychosisservices),andschool-basedandschool-linkedservicestomaximizeaccesstocareandbegintoaddressthe“school-to-prisonpipeline.”Atrauma-informedcareapproachshouldalsobeincludedintheCSOCplanningprocess.ChildrenandyouthacrossTexasandthenationtypicallyendupininpatientcareandresidentialtreatmenttoooften.Itisimportanttounderstandthattheselevelsofcarearenotplacesforongoingtreatment–theyarespecializedsettingsdesignedtoaddresseitheracuteneeds(inpatientcare)oraninabilitytoresideathome(residentialtreatment).Toensurechildrenandyouthreceivetherightlevelofcarefortheirbehavioralhealthneeds,MMHPIhasdevelopedamapofthe“idealsystemofcareforpediatricmentalhealth.”Thisidealsystemcanbeorganizedintofourcomponentsbasedonthelevelofintervention:

• Component1isIntegratedBehavioralHealthCareinapediatricprimarycaresetting.Itisestimatedthatuptotwo-thirdsofpediatricbehavioralhealthcareneeds(particularlyforchildrenandyouthwithmildtomoderatebehavioralhealthneeds)canbemetina

pediatriccaresettingwiththerightintegrationsupports.137Schoolclinicsprovideanaturalopportunitytoembedintegratedprimarycareforidentifyingandassistingchildrenandyouthwithbehavioralhealthconcerns.138

• Component2isSpecialtyBehavioralHealthCare,whichisprovidedbyspecialistsinseparateclinicalsettings.Thislevelofcareismostappropriateforaboutonefourthofchildrenandyouthwithmorecomplexbehavioralhealthneeds,suchasbipolardisorder,post-traumaticstressdisorder,andotherconditionsrequiringspecializedinterventions.

• Component3isRehabilitationandIntensiveServices,whichencompassesservicesprovidedtochildrenandyouthwhosebehavioralhealthconditionsaresoseverethattheyimpairfunctioningacrossmultiplelifedomainsandrequireevidence-basedrehabilitationinadditiontospecializedtreatmentoftheunderlyingmentalhealthdisorder.Theintentoftheseservicesistoprovidethelevelofclinicalinterventionandsupportnecessarytosuccessfullyreturneachchildoryouthtoahealthydevelopmentalpathwithinhisorherhomeorcommunity.

• Component4istheCrisisContinuum,whichincludesmobileteamsthatcanrespondtoarangeofurgentneedsoutsideofthenormaldeliveryofcare,andacontinuumofplacementoptionsrangingfromcrisisrespitetoacuteinpatientcare.Acrisiscontinuumforchildrenandyouthwouldincludeelementssuchascoordinationwithemergencymedicalservices,crisistelehealthandphonesupports,andanarrayofcrisisplacementstailoredtotheneedsandresourcesofthelocalsystemofcare.

WhilethisarraydoesnotcurrentlyexistinanycountyinTexas,somecomponentsexistintheRioGrandeValleyregionacrossthementalhealth,childwelfare,andjuvenilejusticesystems,buttheyrequireimprovedcoordination.PreventionSystemRecommendationSR-14:ExistingpreventionnetworkscanbegintoengageinthecountyBHLTs’preventionplanning.Further,countyandlocalpreventioneffortscanmovefromfocusingonSUDtobeingmoreholisticbyalsoaddressingmentalhealth,suicideprevention,andtrauma.Trauma-informedeffortstobuildresiliencycanhelppreventmultipletypesofbehavioralhealthconditionsaswellasbreakthecycleofmulti-generationaltrauma.ThroughthecountyBHLTs,considerdevelopingabroadersetofpreventionstrategiestoaddressthebehavioralhealth(mentalhealthandsubstanceusedisorders)needsofchildren,

137Straus,J.H.,&Sarvet,B.(2014).Behavioralhealthcareforchildren:TheMassachusettsChildPsychiatryAccessProject.HealthAffairs,33(12),2153–2161.138Murphy,D.,Stratford,B.,Gooze,R.,Bringewatt,Cooper,P.M.,Carney,R.,Rojas,A.(2014).Arethechildrenwell?Amodelandrecommendationsforpromotingthementalwellnessofthenation’syoungpeople.RobertWoodJohnsonFoundation,pages6–7.

youth,andfamiliesasearlyaspossible.Thisincludeschildren,youth,andfamilies(withincomeslessthan200%ofFPL)thathavemildtomoderatebehavioralhealthneeds,thosewithfirstepisodepsychosis,andmotherswithdepression(40to60percentoflowincomewomenhavesometypeofdepression),whichpresentsasignificantearlyrisktochilddevelopment.139EducateallprovidersontreatingMedicaideligiblemotherswithdepression,andtheirchildren(MedicaidrecentlyagreedtofundtheseservicesinitsMay2016bulletin).140UT-RGV,BRBHC,TTBHdirectorsofOSAR,ROSC,andthepreventioncoalitionsshouldparticipateinthiscounty-levelBHLTplanning.IntegratedBehavioralHealthCareDeliverySystemSystemRecommendationSR-15:IntegratedBehavioralHealth(IBH)offersthemostpromiseforexpandingcapacitytotreatmentalhealthandsubstanceusedisordersmoreroutinelyandinthemostcost-effectivemanner,particularlyforthe182,300adultsand58,000childrenwithmildtomoderateneeds.KeystepstoconsiderinpursuingincreasedIBHcapacityincludethefollowing:

• AtthecountyBHLTlevel,developanoverarchingstrategyforintegratedcaretoaddressprioritypopulationsinordertosupportcost-effectivedevelopmentofimprovedIBHwithinhealthcare.Engagelargesystems,includinguniversitysystemsandhospitaldistricts,torecognizethehighprevalenceofcomorbidbehavioralhealthneedsintheirexistingmedicalpopulationsaswellasthecontributionofbehavioralhealthtohighhealthcostsandpooroutcomesamongindividualswithseriousphysicalillnessesanddisabilities.ThisisanimportantstartingplaceforunderstandingthatIBHisasystemicapproachthatcanmakebetteruseofexistingresourcesandengagelargehealthsystemsandhealthplansindevelopingalong-termstrategytopursueanddevelopIBH.MMHPIhasdevelopedawhitepaper,inpartnershipwiththeDavid’sFoundation,titled“BestPracticesinIntegratedBehavioralHealth:IdentifyingandImplementingCoreComponents.”141ThiswhitepaperidentifiesanddescribesthevariousmodelsandcorecomponentsofIBH,offeringaroadmapforproviders,funders,advocatesandpolicymakersinterestedinpromotingIBHandworkingsystematicallytowardachievingitspromise.

• Developnewstrategiestocoordinatecarebetweenandamongproviderstoreduce

139Earls,M.(2010).Clinicalreport–Incorporatingrecognitionandmanagementofperinatalandpostpartumdepressionintopediatricpractice.AmericanAcademyofPediatrics.Retrievedfrom:http://pediatrics.aappublications.org/content/early/2010/10/25/peds.2010-2348140CentersforMedicaid&MedicareServices.(2016,May11).Maternaldepressionscreeningandtreatment:AcriticalroleforMedicaidinthecareofmothersandchildren.Baltimore,MD:DepartmentofHealthandHumanServices,CenterforMedicaid&CHIPServicesInformationBulletin.Retrievedfromhttps://www.medicaid.gov/federal-policy-guidance/downloads/cib051116.pdf141MeadowsMentalHealthPolicyInstitute(2016,August).Bestpracticesinintegratedbehavioralhealth:identifyingandimplementingcorecomponents.AustinTX:St.David’sFoundation.

potentialserviceduplicationrelatedtomedicalclearanceandothercarecoordinationneeds(e.g.,betweenTTBHprimarycareclinicsandSuClinicaandotherFQHCs).

• Morebroadly,effortsshouldbeexploredtolinkindividualbehavioralhealthpractitionersinthecommunity(boththosewhoseepeoplewithinsuranceandtheabilitytoself-payandthosewhooffercareonaslidingfeescale)withprimarycarepracticesinordertoexpandthereachofboth.Further,IBHimpliesnotjust“parallel”referralsfromprimarycareproviderstobehavioralhealthproviders,butalsoembeddingbehavioralhealthconsultation(usinglimitedbehavioralhealthresources)intotheprimarycarepracticeteamsothatthewholeprimaryhealthteamhasexpandedabilitytorespondtobehavioralhealthneedsdirectly.

• Acrosstheboard,behavioralhealthservicedeliveryneedstoshiftmorefromaprivatepractice,stand-alonetherapymodeltomoresystemicapproachesthatinclude:- Earlydetectionandroutinecareinprimarycaresettings,includingFQHCs,

coordinatedwithbehavioralhealthproviders;- Outcome-drivenandperson-centeredtreatmentinoutpatientbehavioralhealthand

otherspecialtycaresettings;- Inpatientcarethatisembeddedwithinacomprehensivecontinuumofcrisisservices

intheRGVforlife-threateningandotheracutetreatmentneeds;- Coordinationofinpatientcarewithinanetworkoflinkagestoleadingproviders

acrossTexas,includingacademicmedicalcentersthatpromotebestpracticesanddriveinnovation.

SystemRecommendationSR-16:AllIBHproviderscouldexaminethepossibilityofdevelopingmoreteam-basedcareforpeoplewiththemostchallengingco-occurringconditionsencounteredintheirsettings.Team-basedIBHcareprogramshavebeenimplementedbyseveralorganizations,includingthedevelopmentofanIMPACTprogramforolderadultsattheRioGrandeStateCenter,thephysicalhealth/behavioralhealth(PH/BH)homeforpeoplewithdiabetesandbehavioralhealthconditionsatSuClínica,andsomestrongelementsofateam-basedapproachatTTBH.Additionally,MethodistHealthcareMinistriesofSouthTexas,Inc.andtheValleyBaptistLegacyFoundationfundtheSíTexas:SocialInnovationforaHealthySouthTexas(SíTexas)project,whichfocusesonIBHmodelsthateffectivelyimprovehealthoutcomesforpoverty,depression,diabetes,obesity,andotherassociatedriskfactors.SíTexassub-granteesoperateoutofeightorganizations,fiveofwhicharelocatedintheRGV(TTBH,NuestraClinicadelValle,HopeFamilyHealthCenter,TheUniversityofTexasSchoolofPublicHealth-Brownsville,andUTRGV).142Whileisolatedexamples(suchasthoselistedabove)ofteam-basedmodelsareevident,theuseofteamsingeneralthroughoutRGVproviderorganizationsislimited.

142MethodistHealthcareMinistriesofSouthTexas,Inc.(n.d.).Grantmaking–SíTexasproject.Retrievedfrom:http://www.mhm.org/grantmaking/sitexas.

SystemRecommendationSR-17:Eachindividualprovider–andproviderswithineachcountycollectively–needtodevelopapopulationhealthmanagementapproachtoservingpeoplewithco-occurringPH/BHconditions.TheFourQuadrantModel,describedlaterinthisreport,canbeusedasanefficientproblem-solvingmethodtobeginidentifyingthenumberofpeoplefallingintoeachofseveralclinicalsub-populations,thecurrentcapacitytomeettheirneedsthroughtheimplementationofappropriateIBHmodels,andthenumberofnewprograms(andstaff)neededtomeettheirneeds.Inaddition:

• SystemRecommendationSR-17a:Patientregistriesandother,simple-to-adoptpopulationhealthmanagementtechnologiescouldbeusedmorewidelyintheRGV’sIBHprograms.

• SystemRecommendationSR-17b:Someprovidershavespecialprogramsorevenwholeclinicsitesdedicatedtospecificclinicalpopulations(e.g.,women’shealthorpediatrics),andthesesitesrepresentexcellentvenuesforthedevelopmentofpopulationhealthapproachesthattargetspecificco-occurringbehavioralhealthandphysicalhealthneeds.SpecificmodelsaredevelopinginTexasforkeyclinicalpopulations,suchastheDallas-areaintegratedcareprogramforfostercarechildrenandyouthwithcomplexco-occurringphysicalhealthandbehavioralhealthconditions.

SystemRecommendationSR-18:Screening,assessing,andreferringpeopletotheappropriateIBHprogramoftenwillrequireproviderstocollaborate.Inparticular,itwouldbeusefulforprimarycareproviderstodevelopmemorandaofunderstanding(MOUs)withLMHAs(particularlyTTBH)thatoutlinetargetpopulations;co-locationofstaffarrangements;referralpractices;sharedresources,particularlyrelatedtotelepsychiatry;clinicaldatasharingprotocols;andmanagementofpsychiatriccrises.TheMOUsalsoshouldaddressprimarycareprotocolsforsharedpatientsinordertomaximizecarecoordinationandminimizeduplicationofmedicalcare.SystemRecommendationSR-19:EffortstoimplementRecommendation17,above,couldbefacilitatedbythedevelopmentofanIBHlearningcollaborativeintheRGV.Providersandtrainingprograms,suchastheoneprovidedbyUT-RGV,couldfollowacollectiveimpactmodel,suchasUnidosContralaDiabetes(UCD),asavehicleforsharingbestpracticesandengaginginregion-widepopulationhealthmanagement.UCDfocusesonpreventingdiabetesinlow-incomeandunderservedpopulationsandsupportsintegratedcareasameanstodoso.ThisgroupprovidesapotentialmodelforcollaborationacrossRGVproviders.Theregion’sleadersandexpertsinIBHcandevelopthisIBH-focusedcollaborativeandalsohaverepresentationintheUCDprograminordertoensurepropercoordinationacrosstheregion.Inaddition:

• SystemRecommendationSR-19a:AnIBHsubgroupofUnidosContraDiabetesshouldrigorouslyexaminetheIBHworkforceintheregionandmakeplansforenhancingit.ThisisalreadyhappeningthroughUnidosContraDiabetes,andmanytrainingprogramsareaddressingtheneed.Thegroupcouldalsotrackthenumberofprimarycare

providers–manyofwhomcanbetrainedthroughembeddedbehavioralhealthspecialistsanddirectorsofbehavioralhealth–whoattainabasiclevelofIBHcompetency.Inaddition,thegroupshouldsetandformallytrackgoalsfortraining(andretainingintheregion)familyphysicians,nursepractitioners,psychiatrists,psychiatricnursepractitioners,psychologists,socialworkers,licensedprofessionalcounselors,andlicensedsubstanceusedisordercounselors.

• SystemRecommendationSR-19b:TheIBHsubgroupshouldalsotracktheprevalenceofneedforIBHinprimarycareandspecialtybehavioralhealthsettingsbyagegroup(child/youth,adult,andolderadult),relativetotheregion’scapacitytomeetthatneed.Itshouldsetmulti-yeargoalsforincreasingthepercentageofneedmet,clarifyandperiodicallyupdatethestrategiesthatwillbeemployed(includingworkforcerelatedstrategies–seeabove),andtrackthepercentageofneedmet.

• SystemRecommendationSR-19c.TheIBHsubgroupshouldalsotrackoutcomesassociatedwithenhancedIBH,including,forexample,suicideratespercapitaandbyagegroup,potentiallypreventableemergencyroomandhospitalvisitsandreadmissions,andotherindicatorsofwell-beingasmeasuredbytheBehavioralRiskFactorSurveillanceSystem(BRFSS)andotherongoingmeasuresintheregion.

• SystemRecommendationSR-19d:Becausemanyprovidershave,orsoonwillhave,expertiseintheimplementationofspecificevidence-basedIBHmodels,aswellasintargetedbehavioralhealthandwellnessinterventions,thelearningcollaborativeshouldcompilealistofregionalexpertise,tracktheimplementationofIBHevidence-basedmodelsacrosstheregion,hostanannualIBHconference,anddevelopatrainingandconsultationcalendarorschedulefordisseminatingandadoptingIBHbestpractices.ThegroupshouldeventuallymovebeyondafocusonIBHprogrammodels(e.g.,CollaborativeCareandPrimaryCareBehavioralHealthmodels)andsharebestpracticesinimplementingsharedclinicalpathways,suchasdiabetes-depressioncare,metabolicsyndrome-seriousmentalillnesscare,andintegratedbehavioralmedicineapproachestosuchcommonmaladiesasinsomnia,headaches,andasthma.

Veterans’ServicesDeliverySystemSystemRecommendationSR-20:Immediatelyexploreopportunitiestoworkthroughcollaborative(s)toobtainfundingunderthenextroundoftheexistingTexasVeteran+FamiliesAllianceandthenewHB13grantprogramsforexpansionofneededveteranservicesandsupports.Oneitemtoexploreinparticularwouldbesupportivehousingmodelstoprovidehousingstabilityforveterans(andothers)withcomplexneedswhoarecaughtincyclesofhighutilizationofemergencydepartmentservicesandinpatientcare.TheASAMlevelsofresidentialcareshouldalsobeconsideredforveterans(andothers)whomaybeinvolvedwiththecriminaljusticesystembecauseofsubstanceuse/sobrietyissues.Theneedforsoberlivinghousingisalsocritical.Inaddition,buildingontheeffortsofTTBHandtheVeteransAdministration–

TexasValleyCoastalBendHealthCaresystem(VA-TVCBHCS),continuetotrainprofessionalsandpeersonbestpracticesintrauma-basedcareandoutreachservicesforveterans.SystemRecommendationSR-21:AspartofcountyBHLTplanning,developastrategytoaddressthestigmaassociatedwithmentalillnessandSUD,includingstigmaforveteranswhohavebehavioralhealthconditionsandarereluctanttoseekservices.OkaytoSayÔcanbearesourceforassistingcounty-levelBHLTsinaccomplishingthisgoal.ThecampaignemphasizesthatmostmentalillnessesaretreatableandoffersamessageofhopeandrecoverytoTexansandtheirfamilies.OkaytoSayÔprovidesanopportunityforlocalcommunitiestopartnerwithMMHPIinprovidingamechanismforstartinglocalconversationsaboutmentalillnesstobothincreasepublicawarenessandencourageindividualsthroughoutthecommunitytoseektreatmentandsupports.HousingSystemRecommendationSR-23:StakeholdersintheRGVshouldimmediatelypreparetoformcollaborative(s)andobtainfundingunderthenewHB13grantprogramforexpansionofsupportivehousingmodelstoprovidehousingstabilityforindividualswhoareexperiencing“superutilization”ofemergencydepartments,jails,andinpatientcare.TheASAMlevelsofresidentialcareshouldalsobeconsideredforindividualsinvolvedwiththecriminaljusticesystembecauseofsubstanceuse/sobrietyissues.Theneedforsoberlivinghousingisalsocritical.SystemRecommendationSR-24:AtthecountyBHLTlevel,beginplanningwithcitiesandtownsonthedevelopmentofindependenthousingoptionsforadultsandtransition-ageyouthmovingtoindependentlivingfromfostercareortheirfamilyhome.Atthesametime,considerdevelopingsupportivehousingmodelsthatassistindividualswithbehavioralhealthconditionstoliveindependently.RefertotheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)materialsonPermanentSupportiveHousing,143anevidence-basedpracticethatpromotesindividuals’tenancyrightsintheirownhomes,andtheHousingFirstModel,144whichwaspilotednationallybytheVAand,asalowbarrierapproachtoprovidingindividualswithahome,doesnotrequirethepersontoparticipateintreatment,butstillprovidessupportstomaintaintenancy.

143Thesematerialsareavailablethroughthisweblink:http://store.samhsa.gov/product/Permanent-Supportive-Housing-Evidence-Based-Practices-EBP-KIT/SMA10-4510.144Tsemberis,S.(2010).HousingFirst:Thepathwaysmodeltoendhomelessnessforpeoplewithmentalillnessandaddiction.CenterCity,MN:Hazelden.

TransportationSystemRecommendationSR-25:AspartofcountyBHLTplanning,workwiththeRioGrandeValleyDevelopmentCouncil(LRGVDC)andotherregionalplanningagenciestoimprovetransportationoptions.SystemRecommendationSR-26:AspartofcountyBHLTplanningandeffortstoaddresstransportationgaps,workwiththeMedicaidMCOstodevelopabroaderprovidernetworkinareaswherethereislimitedavailabletransportation.SystemRecommendationSR-26:AspartofcountyBHLTplanning,studythecosteffectivenessofusingvanstopickupclients(similartoTTBH’sprogramfortheirdrop-inservices)versuspayingatransportationcompanytotransportclientstobehavioralhealthservicesprovidersites.Includeallinterestedprovidersintheplanning,includingthosethatserveveterans.WorkforceSystemRecommendationSR-27:Aspartofcounty-levelcollaborativeplanningefforts,developatargetedworkforcedevelopmentplanatthecollegeanduniversityleveltotrainandprovidecertificatesforculturallydiversebehavioralhealthspecialiststoprovideservicesacrossanarrayofevidence-basedpracticesandservices.Thisworkforcedevelopmentplanwouldalsoincludeinformationtechnologytrainingtosupporttheuseofelectronichealthrecords,behavioralhealthinformationsystems,andtelemedicineequipment.OnegoalistoencourageRGVSpanish-speakingandbi-culturalresidentstoobtainadvanceddegreesinbehavioralhealthspecialties.145StartingwithUT-RGV,whichoffersbaccalaureate,master’s,anddoctoraldegreesinavarietyofdisciplines(andopeneditsSchoolofMedicinein2016),reviewopportunitiesforspecializedtrainingandqualityevaluationactivities(andexpandthisreviewtoSouthTexasCollegeinMcAllen,Weslaco,andRioGrandeCity;TexasSouthmostCollegeinBrownsvilleandotherlocations;andTexasStateTechnicalCollege).Createaformalizedstrategiccollaborationwithalluniversitytrainingprogramstoexpandresidencyandinternshipopportunitiesinlocalprograms;alsoexpandtrainingandjobopportunitiesforpeers,recoverycoaches,communityhealthworkers(CHWs),andfamilypartners.Otherworkforcedevelopmentrecommendationsinclude:

• SystemLevelRecommendationSR-27a:Encouragestrategiestoincreaseaccesstolicensedclinicians,whowouldprovidedirectservicesaswellastrainingandsupervisiontofillgapsintheavailabilityofclinicalsupervisionandtraining.

• SystemLevelRecommendationSR-27b:Encouragetrainingandcertificationof

145Seeasaresource:RioGrandeValleyLinkingEconomicandAcademicDevelopment(LEAD).(2015).Targetingthefuture:2015labormarketinformationreport–ananalysisoftheemerginglabormarketintheRioGrandeValley.Retrievedformhttp://techpreprgv.com/pdf/2015.RGV.LEAD.LMI-Report.pdf

substanceusedisordertreatmentprovidersinscreening,assessment,andreferralformentalhealthandprimarycareclientneeds.

• SystemLevelRecommendationSR-27c:ToaddressthegapinoutpatientpsychiatricservicesforpeoplewhoareineligibleforTTBHservices,allinpatientfacilitiesshouldcollaboratewithotherprovidersintheRGVtoinvestinrecruitingpsychiatristsasastrategyforfacilitatingtheexpansionofambulatoryanddiversionservicesforthepopulation.Effortstoincreasephysiciancapacityshouldattempttoincorporatefast-trackoptionsjustestablishedunderSB674.

SystemRecommendationSR-28:ExpandtheworkforcebyusingcertifiedpeersupportspecialistsandfamilypartnersthroughoutRVGservicesforadults,children,andyouth,andinmentalhealth,SUD,andintegratedcareprograms.CountyBHLTscouldreviewoptionstoincorporatepeersupportspecialistsinvariousservicesaspartoftheiroveralleffortstoimprovetheirsystemsofcare.Again,buildingonthelessonslearnedwithintheTTBHpeerandfamilyprograms,developaplanthatfullyintegratesthesestaffascontributingmembersoftreatmentteamsandintheprovisionofbothdirectrehabilitationservices,andpeersupportserviceswhich,withthepassageofHB1486,canbebilledtoMedicaid.UseofTelemedicineSystemRecommendationSR-29.Aspartofcollaborativeplanningefforts,coordinatetheuseand/orimplementationoftelemedicinetoaccesslicensedbehavioralhealthprofessionals.Toaddressthelimitednumberofpsychiatristsandotherlicensedbehavioralhealthprofessionals,explorethepotentialuseoftelemedicineresourcesavailablethroughpublicandprivateresourcesoutsideoftheRGV.Thetelemedicineplanshouldaddressproviderparticipationstandards,clinicaldocumentationrequirements,privacyrequirements,trainingontheuseoftelemedicine,strategiestoprovideroutineaccessthroughouteachcounty,andidentificationof“champions”toassistwithimplementationandguidanceatprovidersites,includingtheuseoftelemedicineequipment.Major State Level Recommendations (STLR)

Theserecommendationsfocusonissuesthatmustberesolvedatthestatelevel.StateLevelRecommendationSTLR-1:WorkwithHHSCtoreviewthemethoditusestorebaseitscapacitytargetsfortheLMHAs,especiallywhentheyexceedtheircapacity.Ratherthanreceivinganadjustmentinfundingtoaccommodatemoreindividuals,beinglimitedtothesamefundingwitharequirementtomaintainthehighercapacityisunsustainableandineffectpunishesLMHAsfortheirinnovationandoutreach.

StateLevelRecommendationSTLR-2:WorkwithHHSCtoreviewtherequirementforLMHAstoprovidedualentryintotheClinicalManagementforBehavioralHealthServices(CMBHS)system,aweb-basedclinicalrecordkeepingsystemforstate-contractedcommunitymentalhealthandsubstanceusedisorderserviceproviders.Thisrequirementresultsinextraworkandcouldbeaddressedwithmoreup-to-dateapproachestohealthdatainformationexchange.Major Behavioral Health Provider Findings and Recommendations Findingsandrecommendationsforeachmajorbehavioralhealthproviderengagedinthebehavioralhealthsystemsperformancereviewareincludedinthissection.

• TropicalTexasBehavioralHealth• BorderRegionBehavioralHealthCenter• BehavioralHealthSolutionsofSouthTexas• DoctorsHospitalatRenaissance• RioGrandeStateCenter• StrategicBehavioralHealth(PalmsBehavioral)• TheVeteransAdministration–TexasValleyCoastalBendHealthCareSystem• ValleyBaptistMedicalCenter• TheWoodGroup

Tropical Texas Behavioral Health (TTBH)

OverviewTropicalTexasBehavioralHealth(TTBH)servesCameron,Hidalgo,andWillacycountiesthroughsitesinHarlingen,Brownsville,Edinburg,andWeslaco.Additionally,TTBHservesWillacyCountyandRaymondvillethroughtheuseofamobileclinic.ThemissionofTTBHistoimprove“thelivesofpeoplewithbehavioralhealthneedsthroughtheefficientandeffectiveprovisionofqualityservicesdeliveredwithrespect,dignity,culturalsensitivity,andafocusonrecovery.”146Asoneoftwostate-designatedlocalmentalhealthauthorities(LMHAs)intheregion(BorderRegionBehavioralHealthCenterservesStarrCounty),TTBHprovidesservicestoindividualswithseverementalillnesses(SMI)andseriousemotionaldisturbances(SED),specificallytheDSHS“prioritypopulations”withdisablingmajordepression,bipolardisorder,andschizophrenia,including7,500adults147and4,200children/youthwithSED.148TTBHoffersawiderangeofcrisis,outpatient,andspecialtyservicesfortheseprioritypopulations.In

146Retrievedfromhttp://www.ttbh.org.147ThenumberofadultsservedistheunduplicatednumberservedbytheLMHAinFY2015.Asmallernumberofadultsisservedinoneoftheongoinglevelsofcare(LOCs1-4).DataobtainedfromTexasDSHS(personalcommunication,April13,2016).148ThenumberofchildrenandyouthservedistheunduplicatednumberservedbytheLMHAinFY2015.Asmallernumberofchildrenandyouthisservedinoneoftheongoinglevelsofcare(LOCs1-4)andintheYESWaiverprogram.DataobtainedfromTexasDSHS(personalcommunication,April13,2016).

addition,pharmaciesandprimarycareclinicsarelocatedatEdinburg,Harlingen,andBrownsvillesites.TTBHemploysover950staffandmaintainsanoperatingbudgetof$84million,ofwhichaboutonefifthsupports1115DeliverySystemReformIncentivePayment(DSRIP)projects.

ServiceNumberServed

(FY2015–12monthperiod)

AdultServices 11,4227,464(ongoingLOC1-LOC4care)

ACT–threeteamsagencywide 105

COPSD149 535

Children 5,9074,234(ongoingLOC1-LOC4,YES)

HighlightedAgencyStrengthsTTBHisanexcellentorganizationthathasgrowntremendouslyoverthepastfiveyears,effectivelyassessingcommunityneedsandimplementinginnovationsandevidence-basedprograms(EBPs)foradultsandyouthwhilesuccessfullyresolvingthehistoricalmanagementchallengesofpreviousadministrations.Below,wehighlightmajoragencystrengthsidentifiedduringoursitevisitanddeskreview.Severalofthesestrengthsarefurtherdiscussedinthefindingsandrecommendationssection.

• ThecurrentadministrationiswidelyrecognizedthroughouttheRioGrandeValley(RGV)asprovidingeffectiveleadershipsince2003,offeringstablemanagementandsizeableprogrammaticgrowth.Notably,TTBHhasreceivedawardsfortheir“excellenceinfinancialreporting.”

• Thecommitmenttoexcellenceandthemissionandgoalsoftheorganizationwereuniformlydiscussedbyawidearrayofstaffandmanagers,includingpeers,duringtheinterviewprocess.

• TheManagementTeamandseniormanagerstargetedthedevelopmentof1115Waiverinitiatives,aggressivelyseekingDSRIPfunds,foundationresources,andgrantsfromtheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)andothersourcesinordertoexpandservicesanddevelopevidence-basedprograms(EBPs).Seventy-fivemanagersandseniorstaffthroughouttheorganizationandinvariouslocationsworkedcollaborativelytoaccomplishprogramexpansionandcapitalimprovements.Manyofthoseinterviewedduringthesitevisitsdiscussedtheirsatisfactionwiththeseinitiativesandtheextensiveprojectmanagementandplanning

149HollyBorel(personalcommunication,April15,2016).

necessarytoimplementtheseprojectssuccessfully.• TTBH’sapproachtoadoptingnationalbestpracticesandEBPsissystemicandinvolvesa

cadreofcurrentandnewstaffdevelopingskillsinvariouspractices.MultiplesupervisorsaredesignatedasleadsfordifferentEBPs.Asaresult,thissystemicapproachtotrainingcreatesastructurefordevelopingandimprovingthedeliveryofEBPsandmitigatesthepotentialimpactofstaffturnoverandlossofexpertise.

• TTBHhasanongoingemphasisandcommitmenttoprofessionaldevelopment,stafftraining,andaccesstoopportunitiesforhighereducation.SeveralmanagersandstaffdiscussedhowtheywereabletoobtaintheirbachelorlevelandadvanceddegreeswhileworkingatTTBH,orleavingforadditionalstudyandreturningoncecompleted.

• Manystaffandmanagersarebi-culturalandbi-lingualinSpanish,resideinlocalcommunities,andweretrainedattheUniversityofTexasRioGrandeValley,whichplacesinternsinsocialwork,counseling,psychology,nursing,and,mostrecentlywiththeopeningofthemedicalschool,residentsinpsychiatryatTTBH.

• Since2008,TTBHhasachievedCARFaccreditationforAssertiveCommunityTreatment(ACT),adultoutpatientmentalhealthtreatment,childandadolescentoutpatientmentalhealthtreatment,integratedmentalhealthtreatmentforadults,mentalhealthcasemanagement,crisisservices,andgovernance.ByAugust2017,TTBHhopestohaveaccreditationinplacefortheirintegratedcareclinic,peer-rundrop-incenters,andsupportedhousing.ManagementTeammembersreportedthatCARFaccreditationhasprovidedusefultoolstoplan,implement,andimprovethequalityofservices.

• TTBHwasrecentlyselectedasademonstrationsitefortheCertifiedCommunityBehavioralHealthClinics(CCBHC)programandwillparticipateinaplanningandreadinessassessmentthroughaSAMHSAgranttothestateofTexastomeetcertificationrequirements.ThisinitiativewillexpandtheprioritypopulationbeyondthecurrentDSHStargetpopulationsandincludechildrenfrombirthtoagethree.Itfocusesonutilizationofprospectivepaymentsystemssimilartothoseinuseforfederallyqualifiedhealthcenters(FQHCs)andwouldprovideenhancedMedicaidfunding.TTBHwascertifiedbytheHealthandHumanServicesCommission(HHSC)forCCBHCinSeptember2016.

• TTBHwasrecentlyawardedaSAMHSAAssistedOutpatientTreatmentgrantawardthatincludedacollaborativeprocesswithsystempartners,includingNAMIandlocallawenforcement.

• TTBHisarecentgrantrecipientoftheTexasVeteran’sInitiative,whichdemonstratestheircollaborationwithotherpartnersandcommitmenttoveterans.

• TTBH’sparticipationwithlocalpartnersandstakeholdersisgenerallyverygood.Duringsitevisits,theMMHPIteamparticipatedinseveralstakeholdersessions.TTBHworkscollaborativelywitharangeofpartnersandappearstobewellrespected.TheManagementTeamhaspositiverelationshipswithandreceivesfundingfromtheKnapp

CommunityCareFoundation(forservicesinWeslaco),ValleyBaptistLegacyFoundation(forservicesinCameronCounty),andMethodistHealthMinistries(forservicesinBrownsville).

• Therearenotableprogramexamplesthatshouldbehighlightedfortheirinnovationandaccomplishments:- TheMentalHealthPeaceOfficer/MobileCrisisOutreachTeaminitiative;- Thereductioninout-of-areainpatientutilizationforadultsthroughcreative

contractingwithlocalhospitals;- DevelopmentofthreeprimarycareclinicswithinTTBH,includingadiabetes

educationandmanagementprogram;- CollaborationwiththeUniversityofTexasSchoolofPublicHealth(UTSPH)to

providebehavioralhealthconsultationtohealthcareoutreachworkers;- Integrationofadultpeersandfamilysupportpeersintotheorganizationaswellas

theoperationofpeer-rundrop-incenters;- Aco-occurringpsychiatricandsubstancedisorders(COPSD)program,expandedin

2013through1115Waiverfunding,thatservedabout1,100individualscenter-widesince2015;

- TheveteransprogramthatworkswiththeVeteransCoalitionandhelpsreturningveteransreadjusttolifeoutsidethemilitarythroughpeergroupsandcognitiveprocessingtherapies;

- Thechild/youthwraparoundplanninginitiative,whichisamodelforthestate;- School-basedprogramsandthearrayofcognitivetherapy,traumainterventions,

andotherevidence-basedpracticesavailabletochildrenandfamilies;and- PlacementofTTBHclinicalstaffwithinprogramsoperatedbylocalschooldistricts,

juvenilejusticedetentioncenters,andjails.TTBHFindingsAdultSystemofCare

TTBHFinding1:Despitegapsinthecrisisservicesarraysystemwide,TTBHoperatesaninnovativecrisisresponsesystemforCameron,Hidalgo,andWillacycounties.TTBHprovidesacrisisline24hoursaday,sevendaysaweek,365daysayearthathandlesanaverageofnearly1,500crisiscallspermonth,anddispatchestheMobileCrisisOutreachTeams(MCOTs)anaverageof675timespermonth.TheMCOTsarelocatedatallfourTTBHsites.InadditiontotheMCOTs,TTBH’scrisisservicesincludethesuccessfulMentalHealthPeaceOfficers(MHOT)program,nine(9)crisisrespiteandtransitionalbeds,andseven(7)assistedlivingbedsavailablethroughTheWoodGroupCrisisCenter(subcontractedbyTTBH)locatedinHarlingen.

• TheMCOTisthefirstresponderforcallsthatcomeintothecrisislineandworkcloselywiththeMHOTwhenpeaceofficerpresenceisdesirable.TheMCOT/MHOTprojectisaninnovativecollaborationwith11(atthetimeofthereview)differentlocalpoliceand

countysherifflawenforcementagencies.Ateamof22peaceofficersworkwiththeMCOTtoimprovethelocalresponsetoindividualsexperiencingamentalhealthcrisis,divertarrests,andreduceunnecessarywaitingtimeinhospitalemergencydepartmentsforlawenforcementofficersonroutinepatrol.Operatinginfoursiteswithseparateentrances,thisprogramprovidespleasant,safespacesforindividualsincrisesandsafelyofferssomestabilizationduringtheinitialhoursofthecrisisaswellastheopportunitytoprovidemedicalclearanceifneededforindividualsbeingreferredtoinpatientcarethroughaccesstoTTBHprimarycareclinics(duringbusinesshours).

• MembersoftheMHOTarewelltrainedinverbalde-escalationtechniquesandcollaboratewithclinicianstostabilizecrises,avoidarrests,andreduceinpatientutilization.FundedthroughDSRIP,localandcountylawenforcementagencies,andtheValleyBaptistLegacyFoundation,theMHOTprogramhasreceivedpositiveacclaim.However,ithasbeenachallengetoprovideaccesstotheMHOTafterbusinesshourswhentheteamisoncall.Iftherearemultiplecalls,theMHOTteammembercannothandleeverycrisisorbeinmultiplelocationsatonce.AnotherkeyissueissustainingthefundingfortheexistingprogramandexpandingitthroughouttheRGVtomeetdemand.

• IfapersonengageswiththeMCOTbutdoesnotrequirehospitalization,theMCOTconnectsthemtocommunityresources,includingpsychopharmacologyservices,andfollowsthepersonfor90daysorcoordinatescarewithexistingservices.ThisserviceisavailableandprovidedtoanyoneneedingassistanceinconnectingwithcommunityresourcesafterengagingwiththeMCOT,includingindigentclientswhoarenotstateprioritypopulationmembers.StakeholdersreportthatthisworkswellforcurrentTTBHclients,butnewclientsandthoseservedbyTTBHwhodonotfitthestate’sprioritypopulationscriteriahavemorechallengesconnectingwithservices.Thisisparticularlyanissuewhennewclientsneedtimelymedicationfollowupafterhospitalization.

• ThecrisisrespitebedsoperatedbyTheWoodGroupofferanalternativeforpeoplewhodonotrequireanintensivelevelofsupportduringcrises.TheWoodGroup’stransitionalbedsareavailableforindividualsforupto90daysuntilsupportedhousingorotherhousingresourcescanbecoordinated.Individualsinassistedlivingbedsmayremainpermanently,iftheydesire.

• TTBHisabletoprovideclientswithcrisisstabilizationthroughpsychiatricemergencyservices(PES)contractswithlocalinpatientfacilities.

TTBHFinding2:ThecrisisservicegapsforTTBHclientsincludeaccessto23-hourcrisisrespite/observationalbedsorotherintensiveshort-termcrisisresidentialandcrisisstabilizationservices.TTBHFinding3:Therehasbeensignificantreductioninout-of-regioninpatientutilizationforadults,includingdecreasesintheutilizationofstatehospitalbeds.TTBHusesboth

legislativelyappropriatedfundingaswellasfundsprovidedbyDSHStopurchaselocalbeds.Lowercostshavebeenachievedthrougheffectivepurchasingstrategiesandlowerinpatientutilizationimplementedbytheirprogressiveclinicalprogram,aswellasthroughassertivefollow-uppostdischargeandeffectivecrisismanagement.Theseoutcomesdemonstrateeffectiveclinicalandadministrativemanagementstrategies.TTBHFinding4:TTBHplaceslicensedcliniciansintheregion’sinpatientfacilitiestofacilitateauthorizationanddischargeplanning,whichisanexcellentstrategytoaddresscontinuityofcare.Theroleofthelicensedcliniciansistoassistwithdischarge/transitionplanningandcoordinationofcare.ThedischargeprocessincludeslinkagetoMCOTstaffdedicatedtoprovidingfollow-upcare,whoconnectindividualstoservicesandprovidefollowupfor90dayspostdischarge.Thecommunityteamsfollowupwithclientsonadailybasis,schedulingappointmentsandassistingwithdischargeplanning.TheyusecrisisrespiteatTheWoodGroupasastep-downservice.Forindividualsdischargedonweekends,followupisprovidedbytheMCOTinsteadofthecommunityteams.TheTTBHProjectsforAssistanceinTransitionfromHomelessness(PATH)programforhomelessindividualsprovidessomeservicesandaccesstoshelters(e.g.,SalvationArmy,LoavesandFishes,OzanamCenter)upondischarge.However,therearelimitedresourcesfortemporaryhousingduringcrisesandupondischargefrominpatientfacilities.TTBHFinding5:TheTTBHintake,authorization,anddischargeplanningprocessworkssmoothlyforexistingprioritypopulationclients,butnotaswellforprioritypopulationclientsnewtoTTBHorfornon-prioritypopulationclients.TTBHschedulesfollow-upappointmentswithinsevendaysforallprioritypopulationclients(includingnewclients)whoaredischargingfrominpatientcare.Additionally,TTBHprovidesvoucherstohospitalstheyarecontractedwithtoobtainupto14daysofmedicationsthroughtheTTBHpharmacytoassistclientsinthetransitionfromdischargetotheirfirstfollow-upappointment.TheMCOTstaffdedicatedtoprovidingfollow-upcaretoclientsandconnectionstocommunityresources(mentionedpreviouslyinFinding3)followthesenewpatientsuntiltheysuccessfullyattendtheirfirstfollow-upappointment.Securingfollow-upservicesfornon-prioritypopulationclientsposesachallenge,asthereisnofundingtosupporttheprovisionofongoingcare.Clientsidentifiedaspartofanon-prioritypopulationareeligibletoreceiveonlyupto90daysoftransitionalservicestolinkthemwithothercommunityresources.TTBHFinding6:TTBHprovidesaccesstoitsnon-emergentservicesthroughregularintakesscheduledbytheTTBHcentralizedtriagecallcenter.IntakesareprovidedatTTBHclinicsinEdinburg,Harlingen,Brownsville,andWeslaco,orthroughmobileclinicsites(twomobilevanclinicsareout-stationedinmultiplecommunitylocationstoconductintakeandprovide

outpatientandrehabilitationservices).Theintakesitesandmobilevanteamsincludelicensedprofessionalsofthehealingarts(LPHAs)andqualifiedmentalhealthprofessionals(QMHPs).Themobilevansworkwithpromotorestoengageindividualsandprovideeducationonmentalhealthservicesandtreatment.TTBHpublishesamonthlyscheduleofaddressesthevanswillvisit,suchasWomen,InfantsandChildren(WIC)officesthatprovidefoodandnutritionservices;theWalmartSupercenter;theFirstMethodistChurch;LaSaraCommunityCenter;andothercommunitylocations.Thesevanstargetpeopleinpovertywhodonothaveaccesstoresources.TheuseofmobileRVclinicsisaninnovativestrategytoprovideaccesstoservices.TTBHFinding7:AccesstoservicesthroughTTBHhadimprovedsignificantlythroughtheuseofstatefundsprovidedtominimizewaitinglists.However,waitinglistshavehadtobereinstated.Thewaitinglistforadultswasreducedby800slotssinceSeptember2015.However,thatsamemonth,TTBHhadtostartawaitinglistforchildren/youthandbyApril2016,anewwaitinglisthadtobeestablishedforadults.Thedemandforservicescontinuestoexceedtheircapacitydue,inparttoinequitiesinfundingLMHAs.TTBHFinding8:Staffresponsibleforobtaininginsuranceauthorization/approvalforcertainservicesperformbestpracticeactivitiesrelatedtoeligibilitydeterminations,workwithinsurerstoobtainanyneededpriorauthorization,andalsocollaboratewithTTBH’sbenefitcoordinatorswhoassistwithbenefitsapplications(SSDI).Pharmaceuticalassistanceprogram(PAP)staffobtainmedicationsforindividualswhoarenotinsuredthroughpharmaceuticalindigentcareprograms.TTBHFinding9:AssertiveCommunityTreatment(ACT)teamsoperateinthreelocations,reportgoodfidelitywiththehighlyregardedToolforMeasuringAssertiveCommunityTreatment(TMACT)standards,andhaveCARFaccreditation.AsofNovember2016,TTBHACTwasserving174individuals.Clientagesrangebetween22to65yearsoldonaverage,withoneindividualage80.Teammembersincludealicensedprofessionalcounselor(LPC);qualifiedmentalhealthprofessionals(QMHPs),whoprovidepsychosocialrehabilitation;registerednurses(RNs);peerproviders;andphysicians.AllACTclientsareprovidedwitheducationonphysicalhealthbyanRN,whocoordinatescarewiththeindividuals’primarycareproviders(PCPs).TheRNalsoprovidesskillsdevelopmentandteachesself-managementofmedications.ThisinitiativewasstartedbecausemanyofthepeoplereceivingACTserviceshaveseriousco-morbidhealthconditions(e.g.,cancer,diabetes)andsubstanceusedisorders(SUDs).TTBHFinding10:TTBHhasacommunity-basedpsychosocialrehabilitation/casemanagementprogramwithastrongemphasisondeployingstaffinthefieldtovisitindividualsintheirhomesettings,abestpracticeapproach.Thecasemanagerswhowereinterviewed,primarily

bachelorlevelQMHPs,150discussedtheimportanceofvisitingthe“person’sworld”tofindoutiftheirclientshaveshelter,areeating,andabletomeettheirbasisneeds,aswellascheckingonmedications,overallmentalhealthstatus,andskilldevelopmentneeds.Supervisorsandcasemanagersdiscussedthecollaborativenote-takingprocesstheyusewithclients:thecasemanagerandclientareencouragedtospendtheirlasttenminutestogetherdiscussinghowtosummarizetheirmeeting,whichhelpsbothpartiestodeterminenextsteps.TTBHFinding11:TTBHhasbyfarthelargestnumberofoutpatientpsychiatristsandpsychopharmacologyprescribersintheregion.Thisisanexcellentachievementinaresource-challengedregionandreflectsthepositiveworkingculturewithinTTBH.TTBHFinding12:TTBHhasbeenabletoimplementbestpracticestrategiesforprovidingmedicationsandtrackingwhetherclientsfillprescriptions.EvolvePharmacySolutions(previouslyknownasUSScripts)isTTBH’scontractedpharmacybeneficiarymanagerandallprescriptionsareprocessedthroughelectronictransmissiontoapharmacyonsiteatTTBHclinicsorachosenpharmacyincommunity.PeoplewhoareindigentcanchooseaTTBHpharmacyoranotherpharmacy.TTBHhasallottedover$12millioninpatientassistanceprograms(PAP)formedications,whichhasfreedupfundingforotherclients.Staffreportthatclientsreallylikehavingaccesstothepharmacyintheirclinics.Casemanagersandotherstaffrelyonthepharmaciestohelpdeterminewhetherclientsarerefillingtheirmedications.TTBHFinding13:TTBHhasimplementedevidence-basedmedication-assistedtreatment(MAT),whichusesacombinationoftraditionalbehavioraltherapiesandprescriptionmedicationsintreatingsubstanceusedisorders.151WhileMATisavailable,thereisaneedtofurtherdevelopprotocolsandtargetexpansionofitsuse.ItisimportanttodevelopoverarchingguidelinesforserviceaccessforindividualswithCOPSDwhomaybeactivelyusingsubstances,andexpandtheTTBHformularytoensureaccesstoanti-cravingagents.TTBHFinding14:PeerleadersatTTBHreportthatpeerleadershipandpeersupportservicesareencouragedandsupported.Therewere23peersupportstaffforadultservicesatthetime

150TexasAdministrativeCode.Title25,Part1,Chapter412.6,Division1,Rule412.305.AQMHP-CSorqualifiedmentalhealthprofessional-communityservicesisastaffmemberwhoiscredentialedasaQMHP-CSwhohasdemonstratedanddocumentedcompetencyintheworktobeperformedand:(A)hasabachelor'sdegreefromanaccreditedcollegeoruniversitywithaminimumnumberofhoursthatisequivalenttoamajor(asdeterminedbytheLMHAorMCOinaccordancewith§412.316(d)ofthistitle(relatingtoCompetencyandCredentialing))inpsychology,socialwork,medicine,nursing,rehabilitation,counseling,sociology,humangrowthanddevelopment,physicianassistant,gerontology,specialeducation,educationalpsychology,earlychildhoodeducation,orearlychildhoodintervention;(B)isaregisterednurse;or(C)completesanalternativecredentialingprocessidentifiedbythedepartment.151SubstanceAbuseandMentalHealthServicesAdministration.(2016,November22).Medication-assistedtreatment(MAT).Retrievedfrom:https://www.samhsa.gov/medication-assisted-treatment

ofMMHPI’svisit.Lessonslearnedaboutintegratingpeersintheworkforce,ontreatmentteams,andinrunningprogramswerediscussedbypeersandmanagers.Theleadershiphasreducedproductivitytargetsforpeerstoaccommodatepart-timepositionsandthenatureoftheirwork.PeersparticipateincasestaffingsforLevelofCare(LOC)3services,withAssertiveCommunityTreatmentTeams,andwithpsychiatrists.Physicians,includingoneofthePCPs,reportedtheyhavecometorelyonpeersbecausetheyseetheirclientsimprovewithpeersupport.OneofthepeerleadersranarecoverygroupintheCameronCountyjailthatresultedinchangestojailpoliciesforindividualswithbehavioralhealthconditions.Thissamepeerleader,withsupportfromtheTTBHManagementTeam,obtainedagranttoprovideadditionalpeersupportgroupsforwomeninjails.TTBHFinding15:ItisnotablethatTTBHhasthreepeer-rundrop-inrecoverycenterslocatedattheirEdinburg,Harlingen,andBrownsvillesites.Thesecentershaveseparateentrances,whichencouragesindividualstodropinandparticipateinsupportiveskilldevelopmentactivitieswithouthavingtogothroughtheformalcheck-inattheclinic.Atthedrop-insites,individualscancookameal,participateinrecovery-orientedtraining,usecomputerstoconductjobsearches,andhaveaccesstoshowersandlaundry.Clothing(andclotheswashing)isalsoavailable,whichisespeciallyhelpfulforindividualswhoarehomeless.PeerspecialistsparticipateintrainingthroughViaHope(astate-fundedtrainingandtechnicalassistancecenterthatcertifiespeerspecialistsandfamilypartners).Additionally,ValleyBaptistLegacyFoundationprovidedfundingtotheSanAntonioClubhousetotrainthedrop-incenterstaffinhowtoimplementtheclubhousemodel.TBHFinding16:WhenindividualsservedbyTTBHbecomeinvolvedwiththecriminaljusticesystem,TTBHfollowsthemthroughouttheirinvolvement.Forexample,ifaclientisarrested,TTBHwillfocusonjaildiversion.Jaildiversionandpeerre-entryservicesareprovidedandofferedbyTTBHtoalljailsintheregion.Additionally,contractswithHidalgoandCameroncountiessupporttheprovisionofpsychiatricservicestoindividualsinthejail.Theyprovidemedicationsandclinicalservices,andmayconsultwiththejudgeand/orprobationdepartmenttodevelopdiversionoptions.ReferralsmaycomedirectlyfromthejailforknownTTBHclientsorwhenthejailidentifiesindividualswhoappeartohavebehavioralhealthissues.TTBHhasthecapacitytousetheDSHSClinicalManagementforBehavioralHealthServices(CMBHS)systemtoidentifyandmatchindividualsbookedintothejailsystem,andwillworkwiththeseindividualstoassistwithdiversionand/orre-entryfromthejailintocommunitylife.TTBHFinding17:TheimplementationofthreeprimarycareclinicswithintheEdinburg,Harlingen,andBrownsvillesites(staffedbyprimarycarephysicians[PCPs],advancedpractitionernurses[APRNs]orphysicianassistants[PAs],andlicensedvocationalnurses[LVNs],certifiednurseassistant,chroniccarenurses,dieticians,andrecently-addedcarecoordinators,plusadministrativeandsupportstaff)isanimpressiveaccomplishment.Atthe

timeofthesitevisit,afourthprimarycareclinicwasplannedforWeslaco,butfundinghasnotyetbeenidentified.TheseclinicsprovideprimarycaremostlyforadultclientswithseriousmentalillnesseswhodonotalreadyhaveaPCP,usethesameelectronichealthrecordasbehavioralhealthservicesproviders,andhavejointintegratedstaffingsamongprimarycareandbehavioralhealthclinicians.Theprimarycareclinicsprovidemedicalclearanceduringbusinesshoursforindividualsrequiringinpatientpsychiatriccare,whichreducesemergencydepartmentutilization.TTBHusedDSRIPfundsfortwooftheseclinicsandMethodistHealthMinistriesandValleyBaptistLegacyFoundationsupportstheBrownsvilleclinic.Forindividualsonpsychotropicmedications,prescribersauthorizebaselinelabworkandannualoras-neededupdates.Thisincludeslaboratoryscreeningforthemanagementofdiabetes,cholesterol,thyroid,kidney,andotherfunctions.TTBHtracksbodymassindex(BMI)tohelpclientsmanagetheiroverallhealthandobesity.Routinescreeningisalsoabestpracticeinprimaryandbehaviorhealthintegration(PBHI)forindividualswithseriousmentalillnesses.TTBHisexploringMedicaidfinancingforprimarycareservicesthroughthehealthplanscoveringtheRGV.OnesignificantchallengeisfindingPCPstostafftheoperations,especiallySpanish-speakingphysicians.Atthetimeofthesitevisit,therewasonefull-timephysicianandrelianceon“locumtenens”physicianshiredasneededtofillvacancies.AsofNovember2016,allavailablephysicianpositionswerefilled.TTBHFinding18:ThecollaborationbetweentheUniversityofTexas(UT)SchoolofPublicHealthinBrownsvilleandTTBH,whichteamsabout150communityhealthworkerswithbehavioralhealthconsultantstoconducthealthandbehavioralhealthscreening,shouldbeconsideredforreplicationandexpansion.Themodel,basedonacollaborativeapproach,facilitateshealthscreening,person-centeredconversations,andsubsequentadministrationofthePHQ-9ifthereisanyindicationofpossibledepression,followedbyreferraltochurches,localsupports,and,potentially,professionalcounseling.Throughthisproject,theyhaveservedover4,000individualsandarebeginningtodocumenttheimpactofthisworkthroughaseriesofpublishedarticles.TTBHFinding19:TTBHreportsthereislimitedcoordinationofcareforTTBHclients,exceptonanindividualpatientbasis,betweentheirprimarycareclinicsandFQHCs.Pasteffortstocollaboratedidnotresultinanyactiveformalpoliciesoragreementstocoordinatecare.BothTTBHandoneoftheFQHCsreportedthatworkloadissueswerepartofthechallengeinestablishingworkingagreements.WithimplementationoftheCCBHCrequirements,TTBHexpectstodevelopMOUswithallreferralpartners,includingFQHCs.TTBHFinding20:DSHSrecentlytransitionedtheresponsibilityforOutreach,Screening,AssessmentandReferralCenters(OSARs)substanceusedisorderservicecontractsforCameron,Hidalgo,WillacyandStarrCountiestoTTBH.OSARs,fundedbyDSHS,arethefirstpointofcontactforthoseseekingsubstanceusedisorder(SUD)treatmentservicesinTexas.In

lightofthisnewarrangement,theTTBHManagementTeamisorganizingSUDservicesunderanewpositionandexpandingtrainingonco-occurringpsychiatricandsubstanceusedisorders(COPSD)byusingstage-matchedassessmentsandinterventions,andAmericanSocietyofAddictionMedicine(ASAM)guidelines,forlevelofcaredeterminations;involvingmorepeers;andexpandingco-occurringdisorderservicesforadolescentsandwithinchild/familytreatment.WiththetransferofOSARresponsibilitiestoTTBHonSeptember1,2016,TTBHnowprovidestheOSARservicesfortheregion.Four(4)stafftransitionedfromtheSouthTexasBehavioralHealthSolutionsOSARprogramtobecomeemployeesofTTBH;theadditionalfive(5)positionsarebeingfilledbynewemployees.TTBHisplacingOSARstaffattheotherLMHAsintheregioninordertoimproveaccesstoSUDservicesforindividualswithmentalhealthconditions.TheOSARresponsibilitiesassignedtoTTBHcoverabroadergeographicareathanthementalhealthanddevelopmentaldisabilitiesserviceareaassignedtoTTBH,whichfurthercomplicatesregionalplanningeffortswithintheRGVandrequiresTTBHtocoordinatewithotherLMHAsintheregiontodeliverservicestoseveralothercountiesoutsideofCameron,Hidalgo,andWillacycountiesforSUDandCOPSDservices.152Thereareresidentialservicesavailable,butthereislimitedcapacitytostepadultsandyouthdownfromresidentialservices,whichisasignificantservicegap.Presently,theonlyavailableresidentialservicesarestate-fundedprogramslocatedinCorpusChristiandLaredo.TTBHFinding21:TTBHhasdoneanexceptionaljobofintegratingCOPSDintoitsservicearrayandstandsoutasapositivemodelforLMHAintegrationoftheseservices.InJanuary2016,TTHBhiredaDirectorofSubstanceUseDisordersServicestooverseetheSUDandCOPSDsystemsofcare.Thepositionwasfilledbyanexperiencedlicensedprofessionalcounselor(LPC),whohasexperienceworkingattheVeteransAdministrationandmostrecentlyworkedwithaprivatesubstanceusedisorderproviderintheRGV.Duringthesitevisit,thedirectordescribedthewillingnessoftheManagementTeamandstafftodevelopmoreexpertiseinprovidingSUDservicesthroughoutTTBH,whichcurrentlyhas19COPSDstaffdisseminatedthroughouttheagency,includingonACTandLevelofCare3teams.TheCOPSDprogrambeganin2005andwasexpandedthroughthe1115Waiverin2013;ithasservedabout1,100clientssinceitsexpansion.ThedirectorwillmanagesubcontractswithSUDprovidersaswellascontractswiththeU.S.ProbationOfficersandtheBureauofPrisonstoprovideservicesforindividualswhoareonparoleorprobation,andwilloverseenewSUDoutpatientandintensiveoutpatientprograms

152TTBHactuallycoverscountiesoutsidetheRioGrandeValleyforOSAR.InadditiontoCameron,Hidalgo,WillacyandStarrcounties,theOSARcatchmentareaincludesAransas,Bee,Brooks,Duval,JimHogg,JimWells,Kenedy,Kleberg,LiveOak,McMullen,Nueces,Refugio,SanPatricio,Webb,andZapatacounties.

forbothadultsandadolescents.AsofNovember2016,thelicensingofthenewSUDoutpatientandintensiveoutpatientserviceprogramswasnearingcompletion.TTBHFinding22:TTBHprovidessupportivehousingandisinterestedinaHousingFirstmodel,whichprovideshousingwithouttherequirementtoparticipateintreatment.Currently,TTBHprovidessupportivehousingto264individualsinscatteredsiteandgroupsettingsfundedthroughtheTexasHHSCandHUDTenantBasedRentalAssistance(TBRA).Theseservicesincludecasemanagementandskillstrainingincommunityliving.Similarservicesareavailabletohelpsomeindividualslivinginassistedhousing.Therearenolicensedboardandcarefacilitiesavailablenoraretherestructuredresidentialsettingsfortheirclientswithintensivesupportneeds.TTBHidentifiedthelackofresidentialhousingoptionsasasignificantservicesgapintheRioGrandeValley.Presently,thereisnoexistingfundingsourcetoprovidehousingthatisunrelatedtotreatment,ashousingcurrentlyfundedbyDSHSandPATHfundsaresupportingtransitionalhousingonly.WhileTTBHisinterestedinaHousingFirstmodel,thechallengeofsecuringfundswasidentifiedasabarrierpreventingthemfrommovingforwardwiththeadoptionofsuchamodel.TTBHFinding23:TTBHalsoprovideshomelessservicesthroughthePATHgrant,includingoutreach,engagement,andtreatment,aswellaswelcominghomelessindividualstothepeer-rundrop-incenterslocatedattheirthreelargestsites.Peerstaffwillpickuphomelessindividualsatsheltersandothersitestoencouragetheiruseofthedrop-incenters.TTBHtriestoaddresschallengesduetolimitedshelteroptions;onlythreeshelteroptionsexist,andonerequiressometypeofpersonalidentification,whichisadisincentiveforsomeTTBHclients.TTBHFinding24:TTBHhasaSupervisorofVeteranServiceswhoisaveteranandprovidesservicestoenhanceveterans’copingskillsastheyadjusttocivilianlife.Shealsoofferssupervisiontootherpeerprovidersandisinhighdemand.Thereisaveteran’sdrop-incenterinHarlingenwhereTTBHprovidespeer-to-peersupport,cognitiveprocessingtherapy(anEBP),SeekingSafety(atrauma-focusedEBP),casemanagement,andcommunityresourcecoordination.Thesupervisorprovidessupporttoseveralpeer-ledgroups,whichofferabestpracticeknownasBringEveryoneintheZone(BEITZ),andhasbeeninvolvedintheVeteran’sCountySequentialInterceptMappinginitiative.SheparticipatesinOperationResilientFamilies(ORF),anexperimentallearningprogramthatempowersveteransandtheirfamiliestoaddresspost-deploymentchallenges.Twostaffworkwiththejudge/courttosupportveteranswhobecomeinvolvedwiththecriminaljusticesystemthroughtheVeteransSpecialtyCourt.ThesupervisoralsoworkswithotherstakeholderssuchasNAMIandaveteran’scoalition.

TTBHwasrecentlyawardedtwonewgrantsfortheTexasVeteran+FamilyAlliance(TV+FA)program.OnegrantwillgotowardtheexpansionofservicesattheHarlingenVeteranDrop-InCenter(DIC),andthesecondtowardthedevelopmentofanewveteranDICinHidalgoCounty.Children’sSystemofCareTTBHFinding25:TheMCOTcrisislineoffersoutreachandinterventionforchildren,youth,andtheirfamilies,andtheYouthandFamilyServicesteamsinalllocationsincorporatecrisisresponseintotheiruniqueprograms.Forexample,thewraparoundprogramtracksandrespondstocrisis.TTBHFinding26:TTBHreportsthataccesstocrisisrespiteandlong-terminpatientcareforchildrenandyouthisverylimited,andfamiliesmustfrequentlytraveltoAustinorSanAntoniotoobtainlong-terminpatientcarefortheirchildren.TTBHcontractswiththreelocalinpatienthospitalstoobtaincrisisstabilizationservicesforyouth.However,therearecurrentlynodesignatedstatehospitalbedsintheValleyforchildrenandyouth.Asaresult,familiesseekingextendedandlonger-termcarefortheirchildrenaremostoftentransferredandadmittedtoSanAntonioStateHospital(SASH)orAustinStateHospital(ASH).TTBHFinding27:TTBHmanagementandclinicalstaffwithYouthandFamilyServicesdemonstrateastrongcommitmenttobuildingagencyandcommunitycapacityforthedeliveryofEBPsandbestpracticesforyouthandfamilies.Theycurrentlyserveyouthagesthreeto17yearsandoffernumerousbestpracticesandEBPs:ASSIST(appliedsuicideinterventiontraining),AggressionReplacementTraining(ART),cognitive-behavioraltherapy(CBT),Trauma-FocusedCBT,NurturingParenting,PreparingAdolescentsforYoungAdulthood(PAYA),SeekingSafety,wraparoundplanning,andnaturalcommunitysupports.Mirroringtheadulttrainingapproach,thesupervisorsforyouthservicesusetheTraintheTrainermodel,whichallowsforcontinuoustrainingandthecapacitytomaintainexpertisewhenthereisstaffturnover.Forexample,TTBHengagedthefounderofNurturingParentingtoofferaTraintheTrainerinitiativetobuildinternalcapacityforcoachingstaff.TTBHFinding28:ServicesforchildrenandyouthincludeastrongwraparoundplanningprogramandYESWaiverservicesincorporatingthewraparoundmodelthatserveacombined176familiesacrossthreecountiesandisrecognizedasamodelforthestate.Thewraparoundplanningprogramserved31children(atthetimeofthesitevisit)inwraparoundplanningservices,whichemphasizefamily-led,youth-guidedserviceplanningandsupportsandutilizestheChildAdolescentNeedsandStrengths(CANS)assessmenttool,abestpracticetoolforwraparoundplanningandchildren’ssystemsofcare.Additionally,TTBHserved145childreninYESWaiverservicesthatincorporatethewraparoundmodel.Sixteen(16)staffprovidewraparoundservices,whichlastbetween12and18months.Caseloadsaverage10to12youthandfamilies,whichisconsistentwithnationalstandards.Familypartners(familymembersof

youthwithbehavioralhealthchallengestrainedaspeersupportstaff)alsosupportfamilieswiththewraparoundplanningprocess.Thereareseven(7)childrenonaninquirylistpendingenrollmentintotheYESWavierservicesthatincorporatewraparoundplanning.Asnotedinthebehavioralhealthneedssectionofthisreport,TTBHisthelowestfundedLMHApercapitainthestate.TheneedforwraparoundplanningservicesfaroutstriptheavailabilitythroughoutTexas,butTTBHhasastrongbaseofprogramminguponwhichtobuild.BeforetheYESWaiverwasdeveloped,theManagementTeamusedgrantfundingtobringtheWashingtonStateUniversitywraparoundplanningmodeltoTTBH,duringwhichtimetheTTBHwraparoundteamwentthroughasixtoninemonthlearningprocessandcollecteddataonfidelity.Asaresult,TTBHunderstandsthewraparoundplanningprocessandhowthisdrivestheMedicaidYESWaiverprogramfunding.IfthefamilyhasMedicaid,TTBHisabletocoverthewraparoundcosts.TTBHhasoneoffourcertifiedwraparoundcoachesinthestate(certificationisatwo-yearprocess).TheTexasInstituteforExcellenceinMentalHealthreportedthatTTBH’swraparoundprogramisamodelforthestateandlikelytobeoneofthefirstwraparoundplanningprogramstobecertifiedinnation.TTBHFinding29:Fourteen(14)certifiedfamilypartnersworkacrossallTTBHsites,whichisanimpressivenumber.ViaHopecertifiesthefamilypartners,allofwhomhavelivedexperiencewithmanagingbehavioralhealthchallengeswiththeirownchildrenorotherfamilymembers.153Twofamilypartnersparticipatedinsitevisitinterviewsanddiscussedtheirrolesinfacilitatingaccesstoabroaderarrayofcommunityresourcesforyouthandtheirfamilies.Theyparticipateinthechildandfamilyteamserviceplanningprocessesandareabletohelpidentifyresourcessuchasexerciseprograms,musictherapy,andsimilaractivitiesthatwouldbeusefultosupporttheneedsofyouthandtheirfamilies.ThefamilypartnersexpressedstrongsupportforTTBH’sapproachtoincorporatingpeersintotheagency.TTBHFinding30:TTBHhasbuilteffectiverelationshipswithotherchildservingagencies,whichhavebeenstrengthenedbyTTBH’swillingnesstosharecosts,co-locateservices,andchangetheirproceduresbasedontheneedsofyouthservedacrossagencies.Forexample,TTBHhasapartnershipwiththeCameronCountyJuvenileJusticeDepartmenttosharetwopositionslocatedatthejuveniledetentionfacilitytoprovideskillstrainingandotherservices.Inaddition,theTTBHMCOTprovidescrisisservicestothefacility.Theyhavealsousedtelemedicinetoimproveaccesstopsychiatricservices.InHarlingen,afull-timepositionisco-locatedwithjuvenilejustice.Servicesincludecrisisscreeningandmanagement,completionoftheMassachusettsYouthScreeningInstrument(MAYSI),andprovidingguidancetoprobation

153ViaHopeprovidestrainingandcertificationoffamilypartnersthroughoutthestate.

officersworkingwithyouth.Thisworkhasresultedindevelopingspecializedcaseloadswithdedicatedprobationofficerssupervisingyouthonprobationwhohavebehavioralhealthconditions.In2016,theDepartmentofFamilyProtectiveServices(DFPS)andTTBHdevelopedtheFosteringAccesstoCommunityEngagement(FACES)programtoallowstafffrombothorganizationstocollaborateoncommonissuesandcases.Throughthiscollaboration,accesstobehavioralhealthserviceshasimproved,includingaccesstopsychiatricevaluations.Fivefull-timestaffarededicatedtothisprogramandcurrentlyserve131youthinthefostercaresystem.Staffparticipateincourthearingsandsupportfosterparentswhoexperiencechallengeswithaddressingthementalhealthneedsoftheirfosterchildren(the“NurturingParenting”programwouldbeincludedwithsupportsprovidedbythesestaff).Since2014,TTBHhasorganizedapartnershipwithjuvenilejusticeandtheschoolsystemstodevelopanevidence-basedchildren’ssystemofcare(SOC)fortheRGV,usingwraparoundprinciples.ThiseffortwasinitiatedwithseedfundingfromtheTexasSystemofCareConsortiumundertheauspiceofHHSC,andaddresseschildrenandyouthservedbymultiplesystems.Itemphasizesfamily-led,youth-guidedserviceplansthatsupportyouthintheirhomesandcommunities,minimizingout-of-homeplacementsandpsychiatrichospitalization.Asyet,thesetwoinitiatives(FACESandSOC)havenotyetcoalescedintoaunifiedchildren’ssystemofcaredevelopmenteffortincorporatingwraparoundplanningofferedbyTTBH.TTBHFinding31:TTBHhasco-locatedtwenty(20)staffinschools154toprovideschool-basedservicesandhasprovidedtheMentalHealthFirstAidtrainingtomorethan2,100educatorsandothercommunitymembers,whichisanimpressivenumber.With37independentschooldistrictsacrossthefourcountiesintheRGV,155itisachallengetodevelopschool-basedprograms.TTBHbeganfingerprintingstaffinorderforthemtoworkatschoolsites,anexampleofhowTTBHreducesbarrierstocollaboratingwithsystempartners.Inaddition,TTBHobtainedaSafeSchoolsgranttostarttheco-locationprocess.However,therehavebeensignificantchallengesassociatedwiththenumberofschoolsaswellasthetimeandplanningnecessarytoaddressschooldistricts’concernsabouthaving“outsiders”co-locatedintheschools.AsofNovember2016,TTBHwasprovidingservicesto204childrenintheco-locatedschool-basedservicesprogramatthefollowinglevelsofcare:

154TTBHstaffareco-locatedinseveralschooldistricts,including:BrownsvilleISD,EdinburgCISD,HarlingenCISD,HorizonMontessoriPublicSchools,IdeaPublicSchools,McAllenISD,MidvalleyAcademyCharterDistrict,Pharr-SanJuan-AlamoISD,andRaymondvilleISD.TTBHstaff(personalcommunication,October2017).155RioGrandeValleyLinkingEconomicandAcademicDevelopment(LEAD).(2015).Targetingthefuture:2015labormarketinformationreport–ananalysisoftheemerginglabormarketintheRioGrandeValley.

TTBHCo-LocatedSchool-BasedServicesbyLevelofCare

LevelofCare(LOC) Number

LOC-2–TargetedServices 155

LOC-3–ComplexServices 25

LOC-4–AfterCare 2

LOC-YC–YoungChildServices 16

LOC-YES–YESWaiver 16

TTBHFinding32:TTBHprovideslimitedprimarycareclinicservicesforyouthbecausemostfamiliesobtainprimarycareservicesfortheirchildrenthroughhealthplans.About80%ofthechildrenandyouthservedbyTTBHarecoveredbyMedicaidortheChildren’sHealthInsuranceProgram(CHIP),whichprovideaccesstopediatricians.Also,familieswithseveralchildrenthatarenotallservedbyTTBHfinditmoreconvenienttotaketheirchildrentoonehealthprovider.Mostchildrenandyouthdonothavethesamechronicillnessesasmanyadultswithmentalhealthissues.Consequently,outsideofvaccinations,emergencycare(forbrokenbones,stitches),andsickchildcare/schoolphysicals,thereislittleneedforpediatriccareoutsideofannualwell-childcheck-ups.TTBHstilloffersprimarycareservicestochildrenandyouthwhodonothaveaccesstotheseserviceselsewhere,buttheorganizationhasencounteredsignificantchallengesinworkingwithhealthplanstocontractforandauthorizetheseservicestopayforthem.TTBHFinding33:TTBHisimplementingafirstepisodepsychosis(FEP)program,aninnovativeevidence-basedpracticethatistargetedtoadolescentsandyoungadultswiththegoalofstartingtreatmentasearlyaftertheinitialepisodeofpsychosisaspossibleandhelpingpeopletoremainontheirdevelopmentaltrajectories.FEPcareisprovidedthroughateamofspecialiststhatincludesapsychiatricAPRN,anemployment/educationspecialist,askillstrainer,apeerspecialist,andalicensedprofessionalcounselor.TheTTBHprogramwillbebasedinEdinburgandprovideateam-basedintervention.Thecaseloadratiowillbe1professionalto10clients.AtthetimeoftheTTBHsitevisit,positionswerepostedandbeingrecruited,withthegoalofstartingtheprograminthefallof2016.TTBHFinding34:TTBHhassubstantiallyincreaseditscapacitytoservechildrenandfamilies,butthereisacrisisinthefostercaresystemstatewideandasignificantgapinprovidingintensivementalhealthservicesforfosterchildren,whichwouldbenefitfromTTBH’sexpertise.ItwasnotedbytheStephenGroup’s2015report(MeetingtheNeedsofHighNeedsChildrenintheTexasChildWelfareSystem)thatthereisasignificantgapinthesupplyof“step-downsettings”acrossTexas.ThisisalsothesituationintheRGV.MMHPIhasalsofoundinitslocalsystemassessmentsthatmostTexascommunitieshavelittletoofferchildrenandfamilies

whoneedmentalhealthservicesthataremoreintensivethanaroutineoutpatientvisit,butlessintensivethanresidentialcare.TTBHhasexcelledintailoringservicestochildrenandforthisreasonisinagoodpositiontoworkwiththestatetoexpandcapacitytoservethesechildren.Currently,TTBHserves131youthinfostercare,whichisasignificantnumberwhencomparedtootherLMHAs.Asfosterchildrenareinthecustodyofthestate,itisthestate’sresponsibilitytofundtheirmentalhealthservices.TTBHFinding35:TTBHhaspartneredwithmanycommunityorganizationstoprovidecommunityeducationandreducestigma,co-hostingandsupportingvariousactivitiesonschoolcampuses,withthefiredepartment,andothers.Familiesarespearheadingtheseactivitiesandfocusingonsharingtheirstories.Theyhaveorganizedanti-suicidecampaigns,providedanimal-assistedtherapy,andworkedwithabikergroupto“ride”againstchildabuse.TheseactivitiesdemonstratepositivecommunityinvolvementandassistTTBHinassessingserviceneeds.Theseinitiativeswouldbeenhancedbyatargetedearlyinterventionandpreventionplantoidentifychildrenandyouthwithbehavioralhealthconditions. GeneralFindings

TTBHFinding36:TheCARFaccreditationprocessandemphasisondeliveringEBPsinfidelitytoprogramstandardsaregoodexamplesofTTBH’scontinuousqualityimprovement(CQI)approach.TTBHdemonstratesagoodunderstandingofthetechnologyofCQIandutilizesbestpractice“plan,do,study,act”(PDSA)changeprocessestoaddressareaswhereimprovementisneededtomeetinternalstandards.TBHFinding37:TTBHreportssignificantchallengesinhiringpsychiatristsandprimarycarephysicians(especiallythosewhospeakSpanish),nurses,andlicensedmentalhealthprofessionals.Asaresult,TTBHisincreasinglyrelyingontelemedicinebecauseoftheshortageofpsychiatrists.Forexample,someinitialevaluationsfollowinghospitaldischargearedoneviatelemedicine.Weeklycasestaffingwiththepsychiatristandthepsychiatricphysicianassistantareconductedthroughtelemedicinewiththegoalofidentifyingtheneedforaclienttohaveatelemedicineappointmentratherthanwaitingforanin-personsession.TTBHRecommendationsTTBHRecommendation1:TTBHisanidealorganizationforinvestmentofphilanthropicfundingandforexpandingitsroleasacountyleaderforthecountiesitserves.Theexcellenceofthemanagementteam,theemphasisondeliveringEBPsandbestpractices(includingcollaboratingwithsystempartnersindeliveringtheseservices),andthestrongstewardshipofcommunityresourcessuggestthatTTBHisaneffectiveorganizationthatshouldcontinueinapositionofcountyBHLTsfocusingonservicedevelopment.OursystemanalysisshowsthatTTBHdoesagoodjobwithinitsdefinedroleasthestate’sLMHAservingthethreecountiesin

theRGV,andinmanywayshasgonebeyondthisrole,demonstratinganunderstandingofpopulationhealthmanagement,implementationofbestpractices,andeffectivepartnerships.ThebiggestchallengeisthattherearemanyindividualswhoneedbehavioralhealthservicesbutdonotfallunderTTBH’sprioritypopulationsasdefinedbythestate.However,thereisnoentityintheRGVthatcanplanservicesforthebroaderpopulationinneedofbehavioralhealthservices.TTBHisthemostlikelysignificantcountyleader,butgivenitsmandates,otherpartnersmustbeinvolvedasdecisionmakersandfunderstodeterminehowtofillthegapsforthetotalpopulationandgeography,astherearemanypeoplethatnoorganizationcurrentlyhasthecapacitytoserve.AdultSystemofCare

TTBHRecommendation2:TTBHshouldtaketheleadtoaddresstheopportunitiesundertheSB292grantprogramtoreducerecidivism,arrest,andincarcerationamongindividualswithmentalillness,andtoreducewaittimeforforensiccommitmentinordertoexpandavailableservicesallowedunderthegrant.ThiseffortshouldbecoordinatedwiththemajorbehavioralhealthprovidersservingtheTTBHcountiesintheRGVtodetermineifanyofthehospitalsystemscanprovidealternativestostatehospitalrestorationtocompetencyservices(eitheronaninpatientoroutpatientbasis),crisisrespiteservices,andotherdiversionservices.TTBHcouldcollaborationdirectlyorinparallelwiththeBRBHC,buttheprioritiesofeachgeographicareashouldbeaddressed,includingcrisisrespite.TTBHRecommendation3:TocapitalizeonTTBH’sstrongapproachinmanagingcrisesforCameron,Hidalgo,andWillacycounties,itisimportantforTTBHtotracktheproportionofcrisisresponsesthataremanagedbytheMCOT,theMHOT,orotherTTBHprogramsaswellascrisesmanageddirectlybylawenforcementorbynoneoftheabove.ThisinformationwillassistTTBHinprovidingarationaleforexpandingtheMCOTandMHOTandsettingthestageforthedevelopmentofacomprehensiveRGV-widecrisisresponseprogramincollaborationwiththeBRBHCforStarrCountyandotherfacilities.TTBHRecommendation4:TTBHshouldcontinuewithitseffortstoadopttheHousingFirstmodelandworkwithlocalhousingauthoritiestodevelopPermanentSupportiveHousingforadultsandolderyouthwhocanliveindependentlywithsomesupport.AdoptionoftheHousingFirstmodel,wherehavingahomeisnotaconditionoftreatment,shouldbeapriorityconsiderationforfundersofbothtransitionalandpermanenthousingandcanbeimplementedinastep-wiseapproach.ThisisalsoaRGVsystemissueandrequirestheinputoflocalhousingauthoritiesandothercommunityresourcesinanyplanningeffort.TTBHRecommendation5:TTBHshoulddevelopprotocolsforinformationsharingbetweenitsprimarycareclinicsandotherprimarycarepractitionerswithwhomtheyarelikelytosharepatients.WiththeimplementationoftheCBHCH,thisisahighpriorityneedduetothescarcity

ofresourcesandtheneedtocoordinatecareasTTBH’sprimarycareclinicsfurtherdevelop.Ataminimum,memorandaofagreementforsharinginformationandcoordinatingcarebetweenTTBHandotherprimarycareprovidersareessentialtoensuringthatsharedclientsareobtainingthehealthcareservicestheyneedandavoidingduplicationoflaboratorytestsandothermedicalservices.TTBHRecommendation6:TTBHshouldcontinueitscollaborationwiththeUTSchoolofPublicHealthbyprovidingcontinuingconsultationtocommunityhealthworkers.Thismodelhasthepotentialtobereplicatedandwouldbeanidealprojectforgrantfunding.Children’sSystemofCare

TTBHRecommendation7:TTBHshouldbuildonitsstrongbasetoexpandaccesstoLevelofCare3andLevelofCare4services,includingintensivementalhealthservicesforhighneedschildreninfostercareandsupportivehousingforfosteryouthtransitioningoutofcare.Thesechildrenoftenhavecomplexneedsandwouldbenefitfromintensivementalhealthserviceswithinthefostercaresettingaswellasservicesandsupportsastheytransitionintoyoungadulthood.Thisisanareaforthestatetoexpanditsfunding.Border Region Behavioral Health Center

OverviewBorderRegionBehavioralHealthCenter(BRBHC)isanon-profitcommunitymentalhealthcenterandstate-designatedlocalmentalhealthauthority(LMHA)headquarteredinLaredo,Texas,withservicelocationsinJimHogg,Starr,Webb,andZapatacounties.Theirmissionis“toprovidecost-effectiveservicesthatimprovethequalityoflifeofthoseweservebypromotingindependenceinthecommunity.”StarrCountyisBRBHC’ssoleserviceareaintheRioGrandeValley.BRBHChasaclinicinRioGrandeCitylocatedneartheStarrCountyMemorialHospitalanditsoutpatientclinics.BRBHCoperateswitha$13.9millionbudgetandhas319staff,including24staffinStarrCountyconsistingof10.5fulltimeequivalent(FTE)stafffortheAdultBehavioralHealthServicesUnit;6.5FTEfortheChild,AdolescentandParenting(CAP)Program;six(6)FTEsfortheIntellectualandDevelopmentalDisabilities(IDD)Program;andaprogrammanager.Intotal,BRBHCserves3,597individualsannually.BRBHCprovidesmentalhealthservicestonearly700individualsinStarrCounty(426adultsand260youth).AdultMentalHealthServicesTheAdultBehavioralHealthServicesUnitservesadultsages18andaboveusingtheTexasResilienceandRecovery(TRR)model.Servicesinclude:screening,intakeandassessment,psychiatricevaluation,medicationtrainingandsupport,pharmacologicalmanagement,peer

support,crisisinterventionservices(hotline,respite,short-termresidentialplacement),casemanagement,AssertiveCommunityTreatment(ACT),psychosocialrehabilitation,counseling,jaildiversion,supportedhousingandemployment,MobileCrisisOutreachTeam(MCOT),veteransservices,TexasCorrectionalOfficeonOffenderswithMedicalorMentalImpairments(TCOOMMI)IntensiveCaseManagement,thePathforAssistanceinTransitionfromHomelessness(PATH),andskillstraining.Children’sMentalHealthServicesTheChild,AdolescentandParentServices(CAPS)Programserveschildrenandadolescentsagesthree(3)to17yearswithadiagnosedmentalillness,emotionaldisturbance,behavioralproblems,priorin-patientpsychiatrichospitalization,orwhoareat-riskofexpulsionfromschool.Servicesinclude:crisishotline,screening,assessment,casemanagement,intensivecasemanagement,medicationtrainingandsupport,MobileCrisisOutreachTeam(MCOT),jaildiversion,rehabilitationskillstraining,flexiblecommunitysupports,familycasemanagement,familytraining,familypartners,parentsupportgroups,andwraparoundservicesthroughtheYESWaiver.HighlightedAgencyStrengths(contributionstoRGVsystemsofcare)

• BRBHChasastrongcommitmenttoStarrCountyandrecentlypurchasedanewbuildingforitsoperationsinRioGrandeCity,whichisthesecondlargestcityinBRBHC’scoveragearea.

• Fivenewinitiativesstemmingfromthe1115Waiverincludeexpansionoftelemedicine,workforceenhancement,crisisstabilizationresources,integrationofprimarycare,andcrisisprevention.

• WhiletheBRBHCCEOrecentlydeparted,theinterimadministrativeleadership(chieffinancialofficerandhumanresourcesdirector)andclinicalleadershiparerespectedwithintheValley.

• TheBRBHCBoardincludesmembersappointedbytheStarrCountyJudge.BRBHCFindingsBRBHCFinding1:BRBHChasinitiatedtheprovisionofintegratedprimaryandbehavioralhealthcarebycontractingwithalocalphysicianforprimarycareservices,andnotedthataccesstoservicesprovidedbytheFamilyHealthCentertoBRBHCclientshasbeenanasset.BRBHCFinding2:StarrCountyresidentsservedbyBRBHCfacechallengesinaccessinginpatientcare,includingdistancesrequiredtotraveltoinpatientfacilitiesandparticularlywhenthestate-operatedRioGrandeStateCenter(RGSC)orSanAntonioStateHospital(SASH)areondiversionandhavenoavailablebeds.Thesechallengesalsoapplytotransportationtoprivatehospitalsinthesurroundingareas.

BRBHCFinding3:Accesstostate-operatedinpatientbedsisoftenlimitedbecausethesefacilitiesareatorovercapacity(largelyasaresultofthenumberofforensiccommitmentsfromotherareas),resultinginBRBHChavingtopayfortheuseofprivatepsychiatrichospitalsoutofexistingfunds.In2016,BRBHCpaid$132,500forprivatepsychiatrichospitalizationsforclientsinStarrCounty.In2015,totalprivatepsychiatrichospitalcostswere$547,000acrossallofBRBHC’scatchmentarea.BRBHCreportsthataccesstotwotothreepsychiatricbedswithinStarrCountywouldalleviatethissituationsomewhat.BRBHCFinding4:BRBHCreportedlyworkswellwiththesheriff’sdepartmentandnotedanoverallincreaseincollaborationwithlocallawenforcement.InJanuary2017,aCITtrainingsessionwasheldinLaredo,whichwasmadeavailabletoallsurroundingcounties.BRBHCnotedlowerparticipationfromlawenforcementinmoreruralcountiesbecauseofthetimecommitmentandageneralshortageofmanpowerintheircommunities.BRBHCFinding5:WhileBRBHCcoordinateswellwiththesheriff’sdepartment,thestatutoryrequirementforlawenforcementtotransportindividualstopsychiatrichospitalsresultsincoordinationchallengesbecauselengthytransporttimespulllawenforcementawayfromtheirotherduties.Inaddition,transportingindividualswithbehavioralhealthconditionstopsychiatrichospitalsrequirescoordinationamonglocalpolicedepartmentsandthesheriff’sdepartment.Sinceresourcesarelimited,therearenootherentitiesthatcanprovidethisservice.BRBHCFinding6:SimilartoallcountiesintheRGV(andmostacrossTexas),thereisasignificantbehavioralhealthcareworkforceshortageinStarrCounty,particularlyforpsychiatrists.BRBHChasthreepsychiatristsintotal,withoneofferingbilingualserviceswhoisavailableonsiteandparttimetoStarrCounty.Additionally,BRBHCcontractswithlocumtenenscompaniesforpsychiatricservicesforbothchildrenandadultsinthecommunity,aswellasinEastTexasfor24hoursaday,sevendaysaweek(24/7)psychiatriccrisisservicescoverage.Despitethesecontractedresources,therearefewoptionsforface-to-facecare.Telemedicine,providedthroughacontractwithlocumtenenscompaniesaswellasSouthTexasBehavioralHealth,isthemainavenuetoaccesspsychiatryservices,butitsusefocusesonexistingBRBHCclientsandisavailableafterhoursorduringcrises.Additionally,BRBHCreportedhavingdifficultywiththeequipmentfromSouthTexasthatisrequiredfortelemedicineservices,andnotedanaveragecurrentwaittimeoftwohours.BRBHCmustrelyontemporaryphysicianstaffingagenciesforpsychiatrists.Accesstobi-culturaland/orbi-lingualpsychiatristsisalsoasignificantgapinStarrCountyandintheRGV.BRBHCFinding7:Thenumberofcrisiscallsisincreasingandasignificantportionofthecallsarefromnewclients(thosenotalreadyenrolledintreatment).Forexample,BRBHChad12crisiscallstheweekpriortoourmeetingandmostwerefromnewclients.Thisisastrainonthe

crisisinterventionprogram,whichisnotadequatelyfunded.BRBHCidentifiedaneedforadditionalMCOTpositionstoserveStarrCounty,and,asaresult,postedtohiretwonewpositionstomeetthisneed.BRBHCFinding8:AccesstothecrisisinterventionprograminStarrCountyisavailableprimarilyduringbusinesshours.AfterhourscrisisinterventionserviceshavelimitedcapacitytoresponddirectlythroughBRBHC.Duringcrises,accesstopsychiatristsistypicallyprovidedthroughtelemedicinebyEastTexas.BRBHCcontractswithAvailSolutionsfor24/7crisisservicesforallpsychiatriccrisisservicesinthesurroundingBorderRegionareaandEastTexas.BRBHCFinding9:Accesstointegratedprimarycareandbehavioralhealthserviceshasbeenachallenge.WhiletheaccessibilityoftheFamilyHealthCenterhasbeenanassettoclients,onceappointmentsaremadefurtherawayfromthecenter,clientstendnottokeepappointments.BRBHCiscontinuingtoworkwithotherprimarycarephysicianofficesinStarrCountyandisconductingoutreachwithNuestraClinicalDelValleforclientsoftheBorderRegion.BRBHCRecommendationsBRBHCRecommendation1:Continueenhancingandintegratingprimarycareandbehavioralhealthcarebyworkingwithlocalphysiciansandfederallyqualifiedhealthcenters(FQHCs).Assessthefeasibilityofimplementingcoreelementsofintegratedcare,suchascollaborativecaremodelsthatemphasizeuniversalscreeningofbehavioralhealthconditionsinprimarycaresettingsandprovisionofbehavioralhealthconsultationtoprimarycareproviders.156ExpansionofthisapproachwithFQHCsorotherprimarycarephysicianofficeswouldincreaseaccesstobehavioralhealthcare.BRBHCRecommendation2:WithStarrCountyandStarrMemorialHospital,takeadvantageofthependingSB292grantprogramtoreducerecidivism,arrest,andincarcerationamongindividualswithmentalillness,andtoreducewaittimeforforensiccommitmenttoenhancethecrisisresponsesysteminStarrCountyandsurroundingcounties.FormacollaborativewithStarrCounty‘sHospitalDistrict/StarrMemorialtobidonthegrantanddevelopcrisisrespitebedsatabroaderarrayofpsychiatriccrisisresponse/diversionsettings,includingthedevelopmentofcrisisandpsychiatricinpatientcapacityatStarrCountyMemorial.ThecollaborativecouldbepartofabroaderRioGrandeValleycollaborative(withTTBH)orfocusedonStarrCountandsurroundingareas.InadditiontoBRBHCandthehospital,thecollaborationshouldincludeallmunicipalpolicedepartmentsinthecounty,thesheriffdepartment’spatrolandjaildivisions,theprobationdepartment,pre-trialproviders,publicdefenders,thedistrict

156TheMeadowsMentalHealthPolicyInstitute.(2016,June).Bestpracticesinintegratedbehavioralhealth:Identifyingandimplementingcorecomponents.Dallas,TX:Author.CommissionedbySt.David’sFoundation.Availableat:http://texasstateofmind.org/wp-content/uploads/2016/09/Meadows_IBHreport_FINAL_9.8.16.pdf.

attorney,thecountyjudge’soffice,thefelonycourtjudge,themisdemeanorcourtjudge,urgentcareclinics,andEMSproviders(ambulanceproviders).DevelopmentofadditionalcapacityatStarrMemorialisahighpriorityforstart-upfundsfromgrantsorthestatebecauseofthehighuseofservicesbyuninsuredindividualsandthelowpercapitastatefundingallottedtotheBorderRegion.ConsiderasolutionwithDSHSsimilartoTTBH,whichhasreceivedstatefundingfromstatefacilitiestopayforinpatientservicesatlocalhospitals.PlanningforabroaderarrayofcrisisandinpatientservicesshouldbeahighpriorityforStarrCounty,especiallyfocusingonabroaderarrayofcrisisandstep-downservices,andforuninsuredindividualsneedingongoingtreatmentfollowingcrisisinterventionorinpatienttreatment.BRBHCRecommendation3:RecognizingStarrCounty’schallengeswithlimitedresourcesandgreatdistancestotraveltoaccessservices(resourcesareanestimated150milesawayinanydirectionoutsideofStarrCounty),ahighpriorityforfundingwouldbetosupportimplementationofamodifiedMentalHealthOfficerTeam(MHOT)modeldevelopedbyTTBHinpartnershipwithvarioussheriffandpolicedepartments.Modificationcouldincludetheincorporationofparamedicsandpara-medicinefirstresponderstoprovideappropriatecaretoindividualsincrisis.Therelianceonlawenforcementtoprovidementalhealthfirstresponsecouldbelimitedtosituationthatinvolvepublicsafety.Thecurrentmodelincludesfinancialcontributionsfromlawenforcementagenciesandothersources,providesassistanceduringpsychiatriccrisisforinsuredanduninsuredindividuals,andrelievesmostotherofficersonroutinedutyfromtransportingclientswhoareexperiencingemergencies.Localpara-medicineorambulanceproviderscouldbeengagedtoparticipateastheprimarymentalhealthcrisisresponseforcriseswithoutaclearpublicsafetyconcern.BecauseresourceswithinStarrCountyanditslawenforcementagenciesareparticularlylimited,grantfundingcouldbeprioritizedfortheestablishmentofaMHOT.Thiswouldincludestart-upcostsandongoingoperationsoftheMHOT.BRBHCRecommendation4:ContinuetoexploreexpansionoftelepsychiatryandotherprofessionalservicestoStarrCountysites,EastTexaspsychiatricservices,andSouthTexasBehavioralHealthCenter,forprovisionofcrisisassessments.BRBHCRecommendation5:WhileBRBHCisworkingtoimplementajaildiversionprograminStarrCountyandisresearchingthepossibilityofaTexasCorrectionalOfficeonOffenderswithMedicalorMentalImpairments(TCOOMMI)program,weencouragethecountyandlocallawenforcement,aswellasmunicipalandcountymedicalfirstresponders(EMS),toassesssystemicresponsesacrosstheSequentialInterceptModel157(SIM)aspartofaValley-wideinitiativetocomplementexistingplans.Therearefivesequentialinterceptpointswithinthe

157Munetz,M.R.,&Griffin,P.A.(2006).UseoftheSequentialInterceptModelasanapproachtodecriminalizationofpeoplewithseriousmentalillness.PsychiatricServices,57,544-549.

modelwherelawenforcement,firstresponders,andmentalhealthproviderscancollaboratetoidentifyopportunitiestodivertindividualswithmentalillnessawayfromthecriminaljusticesystemandintotreatment,andprovideamorecomprehensiveresponsetothosewhoarearrested.RecommendationsforeachInterceptinclude:

• ForIntercept1:CrisisResponse,Pre-ArrestDiversion–Improvethecoordinationofcrisisresponseserviceswithothercommunitycrisisservices.Engageallfirstresponders,includingmedicalfirstresponders,toimplementamultidisciplinaryteamapproachwhichprovidesservicesonthecrisisscene,managesnon-emergencydistresscalls,linkspersonstoservices,andengagesindata-drivenoutreachandpreventativeserviceswhilereducingtheneedforlawenforcementtobethefirstrespondersformentalhealthcare.

• ForIntercept2:Post-bookingDiversion–Whilepost-bookingdiversiondoesoccurinStarrCounty,itfocusesonscreening,assessment,andidentification.Solidifyproceduresformentalhealthscreening,identification,Magistration,andbondingtobeincompliancewithTexasCodeofCriminalProcedure16.22and17.032.

• ForIntercept3:TherapeuticJusticeServiceswithintheCourts–Bringtoscaletheutilizationoftherapeuticjusticeconceptsintoallcourtservices,includingtheutilizationofariskassessmenttooltodetermineprogrameligibilityandtreatmenttract.

• ForIntercept4:ServiceswithintheJailandReentry–Providementalhealthtrainingtocountyjailerstoincreasetherecognitionofandresponsetopersonsinneedofmentalhealthcareinthejail.Engagelocalproviders,faith-basedinstitutions,andareanon-profitstoincreasejailin-reachservicesandplanforreentrythatlinkstocommunitycare.

• ForIntercept5:CommunityCorrections–Ensurecommunitymentalhealthservicesareinformedcriminaljusticeprinciplesandpractices.Incorporatetheuseofrisk/need/responsivitymodelsincommunitymentalhealthforpersonswhohavehadfrequentarrestsorareonprobationorparoleandarenotassignedtoaspecialtycaseload.CollaboratewithlocallawenforcementandEMS/medicalfirstresponderstocompareinformationonindividualswithcomplexneedwhoarehighutilizersofservices.Additionally,continuetoenhancecollaborationswithcommunitycorrections(e.g.,juvenileandadultprobation)tocomparepeoplewhousecrisisserviceswithprobationandparolecaseloads.Forindividualsidentifiedthroughthesecomparisons,provideengagementservices,includingengagingthosewhoarenotyetenrolledinmentalhealthcare.

Behavioral Health Solutions of South Texas158

BehavioralHealthSolutionsofSouthTexas(BHSST),headquarteredinthecityofPharrinHidalgoCounty,serves19counties(includingStarrCounty)inavarietyofcapacities,offeringprevention,intervention,andtreatmentservicesthatprimarilyfocusonsubstanceuseandco-occurringdisorders.BHSSTbeganastheCouncilonAlcoholandDrugAbuseoftheRioGrandeValleyin1991andthenchangednamesfollowingtheTexasCommissiononAlcoholandDrugAbuse(TCADA)merger.ThemissionstatementforBHSSTisasfollows:BehavioralHealthSolutionsofSouthTexas(BHSST)providesamultilevelapproachinclusiveofprevention,intervention,treatmentandresearchtoreducesubstanceabuseandrelatedco-existingconditionsinourcommunities,encouragehealthierlife-stylerelatedtoatriskpublichealthbehaviors,andpromotestrongerfamilies.Ourmulti-levelapproachcentersonageappropriateness,culturalandlanguagerelevancyinanenvironmentthatisresearchandoutcomebased.BHSSTaimstobealeaderinthedevelopmentofresourcesappropriatetoitscommunitiesbystrengtheningcollaborationsandengagingcommunitymemberstoguideourefforts.BHSSTofferspreventionservicesforgeneralpopulationsofyouth(agessixto19years)andtheirfamilies.Theseservicesaddresshealthandwellnessaswellassubstanceuseprevention,andalsotargetchildren/youthathighriskforsubstanceuse.BHSSTpreventionservicesutilizeevidence-basedpracticessuchasthePositiveActioncurriculumandtheProjectTowardsNoDrugAbuse,forexample.Inaddition,BHSSTprovidesParentingAwarenessandDrugRiskEducation(PADRE),acommunity-basedinterventionprogramservingCameronandHidalgocounties,targetingparentingmalesorexpectingfatherswhohavesubstanceusedisorders(SUDs),orthoseatriskforSUDs;thePregnantPost-PartumInterventionprogramforwomenatriskforSUDinHidalgoandCameroncounties;andtheRuralBorderIntervention,whichtargets“Colonias”inStarr,Willacy,Zapata,Brooks,Duval,andJimHoggcountiestoprovideruralbordercommunitieswithaccesstoacontinuumofbehavioralhealthservices.BHSSTalsooffersrecoverysupportservices(RSS),aprogramavailableinHidalgoCountythatmobilizescommunity-basedrecoverysupportsandservicestohelpindividualsinitiateandsustainrecoveryfromsubstanceusedisorders.BHSSTalsoprovidesaYouthRecoveryCommunityServicesprogramforHidalgoCountyyouthbetweentheagesof13and21whohavesubstanceuseand/orco-occurringdisorders.AsaDSHS-licensedoutpatientmentalhealthtreatmentservicesproviderforadults,BHSSTalsooffersservicesinHidalgoCountytoindividualswhoareuninsuredorinsuredthroughMedicaid.Theseservicesareprovidedthroughatwelve(12)weektreatmentprogramthat158Formoreinformationonthisorganization,pleaseseehttp://www.bhsst.org/.

utilizesmotivationalinterviewingandacognitivebehavioraltherapy-basedcurriculumthroughsix(6)individualand24groupsessions.UntilAugust31,2015,BHSSTwastheOutreach,Screening,AssessmentandReferral(OSAR)providerforDSHSRegion11.Thisarrangementwaschangedinthe2015legislativesession,requiringthatOSARservicesbemanagedthroughthelocalmentalhealthauthorities(LMHAs)statewide.Sincethen,TropicalTexasBehavioralHealthhasmanagedOSARservicesforall19countiesinsouthTexas(includingCameron,Hidalgo,StarrandWillacycounties),thoughTTBHcontractedwithBHSSTtocontinueprovidingOSARservicesforFY2016.AsofSeptember1,2016,TropicalTexasBehavioralHealthnolongercontractedwithBHSSTfortheseservicesandbegantoprovidethemdirectly.BHSSTprovideddataonthevolumeofservicesdeliveredthroughOSARinthefourcountiesintheRGVduringtheperiodfromSeptember1,2014throughAugust31,2015.Thedataincludedthenumberofadultsandyouthserved,percounty,andcanbesummarizedasfollows:SummaryofPopulationsServedSeptember1,2014–August31,2015

PopulationServedHidalgoCounty

CameronCounty

WillacyCounty

StarrCounty

Adults 786 274 12 12 1,084

Youth 140 9 0 3 152

Finally,BHSSThasplayedanimportantroleasaconvenerofcommunitycollaborationregardingsubstanceabuseservicesintheRioGrandeValley.BHSSTreportedthatithastakenaleadershiproleinhelpingtoformtheRecoveryOrientedSystemofCareCollaborationfortheRioGrandeValley(ROSC-RGV),withguidance(butnofunding)fromHHSC.Thisentitymetquarterlyduring2014,buthasmetmoreintermittentlysincethen.HighlightedAgencyStrengths(contributionstoRGVsystemsofcare)

• BHSSThasalongstandingroleinprovidinglocalleadershipandadvocacyforsubstanceabusepreventionandtreatmentservicesintheRioGrandeValley.

• BHHSTisoneofthemajorprovidersofpreventionservicesaswellasawillingparticipantinpreventioncoalitionsinlocalcommunities

• BHSSTconductsresearchprojectsaffiliatedwithuniversities.AsthePreventionResourceCenterforSouthTexas,BHSSTisdevelopinganannualregionalneedsassessment

• BHSSTisoneoftheconvenersoftheregionalROSCcollaboration.

BHSSTFindingsBHSSTFinding1:BHSSTprovidesacontinuumofservices,includingprevention,research,andtreatmentthroughouttheRGV.However,thevolumeoftheseservicesissmallcomparedtotheneed.Therearelong-standingandcontinuingresourcelimitationsforsubstanceabusetreatmentaswellasalackofawarenessofandadvocacyfortheavailabilityofservicesinthecommunity.BHSSTFinding2:BHSSTreportsthatthereareverylimitedresourcesforindigent,Medicaid,orMedicarefundedsubstanceabuseservicesintheRGV.Therearenoavailableresidentialordetoxprogramsforthepublicsectoradultpopulation,andonlyafewoutpatientprovidersintheregion;thereareevenfewerservicesforyouth.PeopleinneedarefrequentlyreferredtoprogramsinCorpusChristiandSanAntonio.BHSSTFinding3:TherehavebeensomeeffortstodevelopregionalcollaborationforsubstanceabuseservicesthroughtheROSCaswellasmanylocalpreventioncollaborationsfundedbyDSHS.BHSSTreferencesWillacyCounty’sCASA(CommunitiesAgainstSubstanceAbuse)asaparticularlyeffectivecollaboration.However,substanceabuseserviceplanninghasnotbeenahighpriorityintheRGVandhasnotattractedresourcesorpoliticaltraction.Substanceabuse-relatedprojectproposalssubmittedbyBHSSTwerenotfundedinthe1115Waiver.BHSSTFinding4:BHSSTreportsthatthereisalackofabilitytoroutinelyidentifyandaddresssubstanceusedisordersinprimarycaresettings,andlittlemovementtoaddresstheimportanceofthisissuewithadditionalresources.Further,thereislimitedabilitytoprovideintegratedinterventionsinsomementalhealthsettingsandmostsubstanceabusesettings.TheexceptionsincludetheexistingcapacityinRGVinpatientunitstoaddressco-occurringdisordersduringbriefinpatientstaysandincreasingcapacitytoaddressco-occurringdisorderswithinTTBH’sclinics.Inaddition,thereneedstobemoreprovisionofroutinementalhealthconsultationtoexistingsubstanceabuseprovidersandfewerbarrierstoaccessingpsychotropicmedicationsforindividualswithmentalillnesswhomayalsobeusingsubstances.RecommendationsBHSSTSystemRecommendation1:Thereisasignificantneedforresourcestotrainandcertifysubstanceabuseprovidersinscreening,assessment,andreferralforothermentalhealthandprimarycareclient/patientneeds.Thisshouldbeahighpriorityforfunding.BHSSTSystemRecommendation2:TheneedforpromotingintegratedbehavioralhealthcarewithinprimarycaresettingsthrougheducationofprimaryhealthcarepracticesandMCOsabouttheimprovementsinoutcomesandultimateefficienciesthatcanbegainedthroughcollaborativeandconsultingintegratedcaremodels.

Doctor’s Hospital at Renaissance Health System (DHRHS)

DoctorsHospitalatRenaissanceHealthSystem(DHRHS)isalargehospital-basedhealthandbehavioralhealthdeliverysystemlocatedinEdinburg,Texas.ThebehavioralhealthcomponentincludestheBehavioralHospitalatRenaissance,an87-bedpsychiatricfacilitythatserveschildren,adolescents,adults,andsenioradultsinseparatepods,andarangeofambulatoryservicesthatarebeingdevelopedalongwithambulatoryhealthservicesintheregion.ThemissionofDHRHSis“toimprovethewell-beingofthoseweservewithacommitmenttoexcellence:everypatient,everyencounter,everytime,”whilethephilosophyoftheBehavioralHospitalatRenaissanceisthebelief“inprovidingcarethatisspecifictoaperson’sneedsandfacilitatescontinuityofcarebeforeadmissionandfollowingdischarge.”Psychiatricinpatientservicesincludethe87-bedBehavioralHospital,whichprovidesspecializedunitsforallageranges,aswellasaunitidentifiedasprovidingco-occurringmentalhealthandsubstanceusedisorderservices,includingdetoxification.Specializedunitsinclude:

• TheChild&AdolescentPsychiatricProgram(featuringseparateprogramsforchildrenagesthreeto12yearsandadolescentsages13to17years),

• TheAdultPsychiatricProgram(featuringrapidstabilization,acomprehensiveevaluationandassessmentbyaninterdisciplinaryteam,short-termandsymptom-focusedinterventions,long-termplacementreferrals,andaco-occurringmentalhealth/substanceusedisorderprogram),and

• TheGeriatricPsychiatricProgram(featuringcrisisintervention,evaluation,stabilizationofdeterioratingpsychosocialfunction,medication,andcaregiversupportservices).

Allserviceshaverelativelyshortlengthsofstayandemphasizedischargeplanning,referrals,andcontinuityofcare.Dischargeplanningisfacilitatedbythepresenceofanon-siteutilizationmanagementclinicianfromTropicalTexasBehavioralHealth(TTBH).Thepsychiatricunitdoesnotacceptpatientswhohavehadforensicinvolvement.DHRHSandsomelocalprovidersidentifiedthisasakeyissue;itmayalsohaveanadverseimpactontheunit’scensus.Likeotherfacilitiesintheregion,DHRHSreportschallengesnegotiatingwithMedicaidmanagedcareorganizations(MCOs).Theyhavemaderecenteffortstohaveon-sitemeetingswithMCOcaremanagerstodiscusstheirconcerns.PsychiatricemergencyandcrisisservicesatDHRHSincludeamobileassessmentunit(ateamoflicensedprofessionalcounselorsthatcoversemergencyroomsandmedicalunitsforpsychiatricevaluations).DHRHSdoesnothaveapsychiatricemergencyservice,nordoesitoperateanytypeofcrisisdiversionprogram.Inresponsetocommunityneed,theyareconsideringopeningacrisisstabilizationunitinEdinburgandalsohavebeendiscussingthepossibilityofsuchaunitinStarrCounty.

Ambulatoryandcommunity-basedservicesattheBehavioralHospitalatRenaissanceincludeanintensiveoutpatientprogram(group,family,andindividualtherapyinastructuredtherapeuticenvironmentforindividualswithmentalillnessandtheirfamilies),outpatientgrouptherapy(e.g.,psychoeducation,familysupport,newlydiagnosedchronicconditions,substanceabuse),school-basedhealthclinics(withtheEdinburgConsolidatedIndependentSchoolDistrict,McAllenIndependentSchoolDistrict,andthePharr-SanJuan-AlamoIndependentSchoolDistrict),ambulatorymentalhealthservicesassociatedwithcommunity-basedhealthcenters,andintegratedbehavioralhealthserviceswiththeirdiabetesspecialtyclinicsinWeslaco,Mission,andEdinburg.DHRHSwouldliketodeveloptelepsychiatryservicestopromoteaccesstooutlyingareas.DHRHSalsohasCommunityHealthCouncils,whichworkwithcommunitymembers,includingthesheriff’sdepartment,toassesstheneedsforvarioussupportservices.HighlightedAgencyStrengths(contributionstoRGVsystemsofcare)

• DHRHSisoneofthelargesthealthcaresystemsintheregionandasignificantproviderofbehavioralhealthservices.

• DHRHSprovidesspecialtyinpatientunitsorprogrammingforchildren,adolescents,olderadults,andpeoplewithco-occurringmentalillnessandsubstanceusedisorders.

• DHRHShasastrategiccommitmenttopopulationhealthandhasidentifiedaseniorvicepresidentpositiontooverseeclinicalintegrationforthesystem.Theyareconceptualizingtheimportanceofimprovingintegratedbehavioralhealthcare(IBH)throughouttheirdeliverysystemaswellasattemptingtointegratebehavioralhealthintodevelopingandexpandingservices.

• DHRHSisworkingtodeveloptelemedicineservicestohelpfillthevoidofprovidershortages.

• DHRHSisdevelopingcommunitycounselingcentersthatprovidetraditionaloutpatientcounseling.

• DHRHSisdevelopingoutpatientsubstanceusetreatmentservices.• DHRHSisimplementingtheintegrationofambulatorybehavioralhealthserviceswith

healthcentersthroughoutHidalgoandStarrcountiesinpartnershipwithStarrCountyMemorialHospital.

• DHRHShasinitiatedintegrationofbehavioralhealthservicesintoschool-basedhealthclinics.

• DHRHShasmadeastrongorganizationalcommitmenttobeingatrainingandresearchsitefortheUT-RGVSchoolofMedicineandwouldliketoincludepsychiatryresidencyandpsychologyinternshiptrainingopportunitiesasareasoffocus.IthasspecificcapabilitytoprovidebehavioralhealthpractitionerswithtraininginIBHinthecontextofacommunity-orientedhealthdeliverysystem.

• DHRHSleadershipisinterestedinusingdataforperformanceimprovementandcollaborationwithbothpayersandprovidersacrosstheregiontoaddressgapsinservice.

DHRHSFindingsDHRHSFinding1:DHRHSoperatesalargeinpatientunitwithspecialtyservicesformultipleagegroupsandoperatestheonlyco-occurringdisorderserviceintheRGV.However,theinpatientprogramutilizationisbelowcapacity.Thismayberelatedtothefactthattheunitdoesnotadmitindividualswithpreviousforensicinvolvement.DHRHSFinding2:DHRHSdoesnotoperateapsychiatricemergencyservice,noranycrisisdiversionbeds.Itisconsideringopeningacrisisstabilizationunit,basedoninputfromcommunitystakeholders.DHRHSFinding3:DHRHSreportedasignificantlackofoutpatientservicescapacityforindividualswithbehavioralhealthneeds,particularlyforchildren,bothforinsuredanduninsuredindividuals.DHRHSfurthernotesthatthereisadramaticabsenceofresidentialandambulatorysubstanceabuseservicesintheRioGrandeValley,andthattheirownservicesonlymeetaverysmallcomponentoftheneed.DHRHSFinding4:DHRHShaslaunchedacollaborationwithStarrCountyMemorialHospital,throughwhichtheyareconsideringthedevelopmentofanarrayofbehavioralhealthcrisisandambulatoryservicesalongwithmultispecialtymedicalservices.DHRHSFinding5:DHRHSrecognizestheimportanceofintegratingbehavioralhealthandprimaryhealthservicesandhastakentheinitiativetoachieveintegrationinschool-basedhealthclinics,diabetesclinics,andsomecommunityhealthclinics.DHRHSFinding6:DHRHSisuniqueamongregionalhealthsystemsbypositioningitselftobecomealeaderinsystem-wideIBHdevelopmentthatimprovesengagementofpatientswithcomplexmedical,behavioral,andsocialneeds,andreducespreventablereadmissions.However,itdoesnothaveaspecificframeworkforhowtodothis,norhasitinitiatedspecificintegratedphysicalhealth/behavioralhealthservicesforpeoplewithhighuseofmedicalserviceswhomighthaveunmetbehavioralhealthandsocialneeds.DHRHSFinding7:DHRHSisuniqueamongregionalhealthcentersbyappointingaChiefAcademicOfficerandhavingadeliberatestrategytodevelopthecapacityandexpertisetobecomearegionalcenterofexcellenceinmedicaltrainingandresearch.However,itisnotclearifthiswillresultintheUT-RGVDepartmentofPsychiatryplacingresidentsatDHRHS.

DHRHSRecommendationsDHRHSRecommendation1:DHRHSshouldworktoimproveaccesstoandutilizationofitsexistinginpatientcapacity.Oneapproachmightbetodevelopaformaldata-drivenperformanceimprovementplantoenhancesafemanagementofindividualswithahigheracuityofneeds.DHRHSRecommendation2:DHRHSshouldparticipateincollaborative(s)formedinresponsetotheSB292grantprogramtoreducerecidivism,arrest,andincarcerationofindividualswithmentalillness;reducewaittimeforforensiccommitment;andassessopportunitiestoprovidecrisisdiversion,crisisrespite,andinpatientandoutpatientrestorationtocompetencyservices.Enhancementsofcrisisservicesshouldespeciallyfocusonimplementationofcrisisstabilization,crisisintervention,andotherintensiveambulatorybehavioralhealthservicesinStarrCounty,includingcollaborationwiththeBorderRegionBehavioralHealthCenterand,potentially,inpatientandoutpatientcompetencyrestorationserviceprograms.DHRHSRecommendation3:DHRHSshouldcontinuetotakeeveryopportunitytointegratebehavioralhealthservicesintonewlydevelopedcommunity-basedambulatoryhealthprogramsandtocollectdataontheimpactofsuchintegrationoncostsandoutcomes.DHRHSRecommendation4:DHRHSisinapositiontomodeltheutilizationofnationalbestpracticestrategiesandtools(e.g.,OATI)todevelopasystem-wideimprovementapproachtoIBHacrossallitsservices.DHRHSRecommendation5:TheUT-RGVSchoolofMedicineandDHRHSshouldcontinuecollaborationtotakeadvantageofDHRHS’scapabilitytoprovidebehavioralhealthtrainingexperiencesthatareintegratedintoprimarycareandfamilymedicineinacommunity-basedhealthsystem.Rio Grande State Center (RGSC)

RioGrandeStateCenter(RGSC),locatedinHarlingen,providesresidentsoftheRioGrandeValleywithoutpatientmedicalservices,inpatientmentalhealthservices,andlong-termservicesforindividualswithintellectualanddevelopmentaldisabilities.159ThemissionoftheRioGrandeStateCenteris“toimprovehealthandwell-beinginSouthTexasthroughsafe,innovative,integratedhealthcareandsupportservices.”160Asathree-componentadultfacility,159TexasDepartmentofStateHealthServices,MentalHealth&SubstanceAbuseDivision.(2017,January18).Statementalhealthcenters:RioGrandeStateCenter.Retrievedfromhttp://www.dshs.texas.gov/mhhospitals/RioGrandeSC/default.shtm160TexasDepartmentofStateHealthServices,MentalHealth&SubstanceAbuseDivision.(2017,January18).Statementalhealthcenters:RioGrandeStateCenter(RGSC)MissionandGoals.Retrievedfromhttp://www.dshs.texas.gov/mhhospitals/RioGrandeSC/RGSC_Goals.shtm

RGSChasatotalcapacityof128beds,which,asshowninthetablebelow,areallocatedtomeetthebehavioralhealthneedsofindividualsreceivingservices.Service Capacity(#ofBeds)InpatientPsychiatricTreatment–AcuteServices 40

InpatientPsychiatricTreatment–ForensicServices 15

IntellectualandDevelopmentalDisabilities 73

TOTAL 128

RGSCservesmostlyindigent,uninsuredresidentsofeightcounties:Brooks,Cameron,Duval,Hidalgo,JimWells,Kenedy,Kleberg,andWillacy.Morethanhalfoftheinpatientcapacityisutilizedforindividualswithintellectualanddevelopmentaldisabilities.IndividualsreceivingforensictreatmentcomefromareasthroughoutTexasforcompetencyrestoration.Becauseofthisinfluxofforensicpatientsfromoutsidetheimmediatearea,RGSCisfrequentlyatmaximumcapacity.Staffreportedthattheneedtoservethisforensicpopulationislimitingtheirabilitytoservelocalpatientswhoneedmoreintensiveinpatientservices.Thefacilityservesthemostacutelyillindividualsandhasanaveragelengthofstayofabouttwoweeks,whichislongerthanthelengthofstayfortypicalinpatientacutecare.Individualsintheforensicunitstayanaverageof84days.Approximately25%ofindividualswhoareadmittedhavebeenpreviouslyservedatTTBH.Allpatientsadmittedtoinpatientpsychiatrictreatmentandresidentialintellectualordevelopmentaldisability(IDD)servicesareprovidedgeneralmedicalservicesbyastaffphysician.TheRGSCOutpatientMedicalClinic(OPC),alsolocatedinHarlingen,isaprimarycaremedicalclinicwhichoffersmedicalandoutpatientbehavioralhealthcareservicesthroughpartnershipswithseverallocalorganizations,including:UT-RGVSchoolofMedicine,MethodistHealthcareMinistries,theHHSCRegion11,BorderHealth,ChronicDiseaseHeart&Stroke,UTHealthScienceCenter–SanAntonio,UTHealthScienceCenter–Houston,UTSchoolofPublicHealth,MHPSalud,BehavioralHealthSolutionsofSouthTexas,andGraciasTexas.161TheclinicservesindividualswhoresideinCameron,Hidalgo,Willacy,andStarrcounties,andreportedserving2,836individualsthroughoutfiscalyear2015.162Atthetimeofthesitevisit,theclinicwasbeginningtoimplementintegratedcare(thisisdiscussedinthereportsectiononIntegratedHealthCare).

161Valencia,M.(n.d.).MethodistHealthMinistries:ForoutpatientpsychiatryservicesprovidedattheRGSCoutpatientclinic.162Valencia,M.(n.d.).

SimilartootherproviderorganizationsthroughouttheRGV,RGSCfaceschallengeswithworkforceshortages,bothatitsmaincampusandtheOPC.Asmentionedabove,theOPCcurrentlyrefersindividualstolocalproviderorganizationsforcounselingservices.ThroughcollaborationswiththeUT-RGVSchoolofMedicineInternalMedicineResidencyProgramanditsnewpsychiatryresidencyprogram,theOPCisworkingtowardintegratingin-housebehavioralhealthcareintotheprimarycareservicesitprovidesbycreatingaresidencytrainingopportunityforclinicalrotations.TheRGSCOPCcurrentlyhasresidentsfromtheinternalmedicineprogramandexpectstoreceivepsychiatryresidentsinJuly2017.Psychiatryresidentswillhavetheopportunitytolearnintegratedphysicalhealth/behavioralhealthpracticesandfollowpatientsthroughouttheirresidency.Inanefforttointegratebehavioralhealthintheprimarycaresetting,theOPCusesthePHQ-9toscreenallpatientsfordepressionateachclinicvisit.RGSChopestoplacefuturepsychiatryresidentsintheIDDandinpatientunitsaspartofthedevelopmentofUT-RGV’sCenterofExcellence,whichwillfocusontheoverlapbetweenneurologyandpsychiatry.HighlightedAgencyStrengthsRioGrandeStateCenterprovidesmuchneededbehavioralhealthservicestoprimarilyindigentanduninsuredresidentsoftheRioGrandeValley.Below,wereviewmajorstrengthsofRGSCandtheservicesitprovides.Severalofthesestrengthsarefurtherdiscussedinthefindingsandrecommendationssectionsthatfollow.

• RGSChasbothavisionandphilosophywhichpromotequality,individualizedservicesforTexanslivingintheRioGrandeValleythroughpartnershipswithconsumers,familymembers,andlocalserviceproviders.

• Withathree-componentfacility,theRGSCmaincampushastheabilitytointegratemultipletypesofservicesintoonelocation(IDD,mentalhealth,andmedical),includingintegratedphysicalhealth/behavioralhealthservicesatitsOutpatientMedicalClinic.

• RGSCmaintainswhatitcharacterizesasa“verygood”workingrelationshipwithTropicalTexasBehavioralHealth(TTBH).Withregularoverlapintheindividualsbothorganizationsserve,itisestimatedthat25%ofRGSCpatientshavealreadybeenseenforservicesatTTBH.TTBHalsoregularlyacceptsdischargedpatientsfromRGSCintoitsservices.

• RGSCmaintainsanannualrecidivismrateof17%,reportingthatmostpatientswhoaredischargedfromthefacilitydonotenterbackintoservices,althoughstaffdorecognizethattheyarelikelybroughtintoserviceswithotherlocalproviders.

• RGSCcontinuestofosterstrongpartnershipswithlocalentities,includingproviderorganizations,funders,andinstitutionsofhighereducation.

RGSCFindingsRGSCFinding1:LongerplacementoptionsareanissueforindividualsservedatRGSC.Housingsupports,suchasPermanentSupportiveHousing,andavailablefamilysupportareoftenlimitedforindividualswithmentalhealthneeds,particularlyafterbeingreleasedfromservices.Asaresult,localmentalhealthauthoritiesmustassistsomepeopleinobtaininghousinginlocalhomelesssheltersfollowingdischarge.Staffreportedlonger-termplacementoptionstendtobemorereadilyavailableforindividualswithintellectualordevelopmentaldisabilities(IDD).RGSCFinding2:RGSCisfacedwithworkforceshortagechallenges,bothonitsmaincampusandwithitsOutpatientMedicalClinic.

• TheIDDprogramatRGSChasbeenwithoutapsychiatristforthepastsixyears,whichpresentscontinuingissuesintreatingindividualswhoareduallydiagnosedwithbothamentalhealthconditionandIDD.

• Peersupporthasbeenexploredinthepast,andRGSCcurrentlyhasonepeerspecialistonstaffthroughacontractwithTTBH.

• TheOutpatientMedicalClinichasasignificantneedforstaffphysicians,psychiatrists,andbehavioralhealthspecialists.WhilethepartnershipswiththeUT-RGVMedicalSchoolareexpectedtobringmuchneededcapacitytoserveindividualswithbehavioralhealthneeds,additionalfull-timeRGSCstaffmembersinthesepositionsareneededtomeetthegrowingneedsofindividualsinthecommunity.

RGSCFinding3:RGSCisnotadetoxfacility,althoughprovidersandpatientsinthecommunityoftenassumethisispartofitsregularoperations.RGSCstaffreportedthatco-occurringpsychiatricandsubstanceusedisorderdiagnosesareverycommonfortheindividualstheyserve(estimatedat90%ofindividualsserved).Physicianswillprescribeadetoxschedule,whichnursesmanagewiththepatients;however,thereisnostandardprotocolcurrentlyinplacefordetoxprocedureswithdually-diagnosedindividuals.Medication-assisteddetoxisincludedintheRGSCformulary,butstaffreporttheyarenotprovidingthistypeofdetoxveryoften.RGSCFinding4:RGSCcurrentlyhasnocapacityforinpatientadolescentbeds;mostadolescentsinneedofinpatienttreatmentaresenttoSanAntonioStateHospitalorlocalprivatehospitalsforservices.In1998,RGSCconverted20adultbedsinEdinburgtoa15-bedunitdedicatedtoinpatientservicesforadolescents.163However,becauseofinadequatefunding,theunitwasultimatelyclosedin2001,leavingRGSCwithnocapacityforadolescentbeds.

163TexasDepartmentofStateHealthServices,MentalHealth&SubstanceAbuseDivision.(2014,June20).HistoryofRioGrandeStateCenter(RGSC).Retrievedfromhttp://www.dshs.texas.gov/mhhospitals/RioGrandeSC/RGSC_About.shtm

RGSCFinding5:VariouschallengesexistforindividualsmakingthetransitionfrominpatientservicesatRGSCtooutpatientservicesatTropicalTexasBehavioralHealth.WhileTTBHworksquicklytosecureservicesforpatientsafterdischargefromRGSC,thereiscurrentlynomechanismbywhichtheycanworkcollaborativelytoproactivelyconnectwith–andpreventreadmissionfor–peoplewhomay“fallthroughthecracks.”RGSCRecommendationsRGSCRecommendation1:Prepareforandparticipateincollaborative(s)formedinresponsetoSB292grantopportunitiestoreducerecidivism,arrest,andincarcerationofindividualswithmentalillness,andtoreducewaittimeforforensiccommitment.Inresponsetolimitedresources,collaboratewithsystempartnerstodevelopexpansionprioritiesfortargetpopulationsandimplementarangeofdiversionandtreatmentservicesthataddressthefollowingmajorsystemgaps:1)mentalhealthjaildiversion;2)alternativestocompetencyrestorationinastatehospital,includingoutpatientcompetencyrestoration(OCR)programstoallowjustice-involvedindividualswithmentalillnessandco-occurringpsychiatricandsubstanceusedisorderdiagnosestoreceivecompetencyrestorationserviceswithintheircommunityratherthaninastatementalhealthfacility;1643)additionalAssertiveCommunityTreatmentandForensicAssertiveCommunitytreatmentwithanoutreachcomponent;4)intensivementalhealthservicesandsubstanceusedisordertreatment,includingintensiveoutpatientprograms;5)expansionofaninterdisciplinaryrapidresponseteamstoreducelawenforcement’sinvolvementwithmentalhealthemergencies;and6)provisionoflocalhospital,crisisrespite,orresidentialbeds.RGSCRecommendation2:IdentifyopportunitiestocreateacontinuumofcareontheRGSCcampus,inpartnershipwithotheragenciesintheRGV,basingthecontinuumontheservicesidentifiedinRecommendation1.RGSCRecommendation3:Considerutilizingmorepeersupportandrecovery-orientedservicesascomponentsoftheservicesidentifiedinRecommendation1.RGSCRecommendation4:Improveconsistencyinthetreatmentofco-occurringdisordersandexpandtheuseofmedication-assistedtreatment.RGSCRecommendation5:PartnerwithTTBHtoimplementacontinuousqualityimprovement(CQI)collaborationinordertotrackindividualswhomayget“lost”duringtransferbetweenthe

164TexasDepartmentofStateHealthServices,MentalHealth&SubstanceAbuseDivision.(2014,July17).Outpatientcompetencyrestorationprograms:Anoverview.Retrievedfromhttp://www.dshs.texas.gov/mhsa/awareness/Outpatient-Competency-Restoration-Programs--An-Overview.doc?terms=outpatient%20competency%20restoration

twoagencies.Developstrategiestoproactivelyconnectwith–andpreventreadmissionfor–peoplewhomay“fallthroughthecracks.”

Strategic Behavioral Health – Palms Behavioral Health (PBH)

PalmsBehavioralHealth(PBH)isa94-bedinpatientpsychiatrichospitalcampusinHarlingenoperatedbyStrategicBehavioralHealth,aprivately-ownedpsychiatrichospitalcompanybasedinMemphis,TN.StrategicBehavioralHealthplannedtheopeningofPBH(itssecondfacilityinTexas;thefirstislocatedinCollegeStation)inresponsetoperceivedcommunityneedforinpatientpsychiatricservicesinHarlingen(othermajorinpatientfacilitiesarelocatedsomedistanceawayinHidalgoCounty).PBHreportsthatithasastrongorganizationalfocusonqualityimprovementanddata,includingaprotocolforsix-monthfollow-uptrackingofadmissionstomonitorreadmissionstothesamefacility.Thefacility,locatedclosetoHarlingenMedicalCenter,openedonAugust2,2016,initiallywith94bedsallocatedasdescribedinthetablebelow.Population Capacity(#Beds)

Adult 42

Geriatric 24

Adolescent 18

Children 10

TOTAL 94

Twounitswereaddedinthefallof2016:a10-bedChildren’sUnitandan18-bedAdolescentUnit.Outpatientservices–partialhospitalandintensiveoutpatientprogramming–openedinJanuary2017.PBHhasrecruitedtwolocaloutpatientpsychiatriststoworkonitsinpatientunit.LikeotherinpatientfacilitiesintheTropicalTexasBehavioralHealth(TTBH)servicearea(Cameron,HarlingenandWillacycounties),PBHcontractswithTTBHtoreceivePBH’sreferralsofindigentpatients.Additionally,TTBHplanstoprovidePBHwithanon-siteutilizationmanagementcoordinatortofacilitatedischargeplanning.PalmsBehavioralHealthalsoacceptsreferralsfortreatmentfromemergencyrooms(ERs)throughouttheRGVaswellasdirectadmissionsfrompatientcalls,familycalls,orotherdirectreferrals.Theyhaveawell-designedtelemedicineprogramtofacilitatebasicmedicalclearanceforthesetypesofdirectadmissions(ratherthanrelyingontheemergencyroom),andacceptindividualscoveredunderMedicare,Medicaid,privateinsurance,andthroughtheVeteransAdministration(VA).PBHdirectsindividualswithhighermedicalrisks(e.g.,individualswhoarrivewhileundertheinfluencealcoholorotherdrugs)tolocalERs.

LeadershipatPBHreportedastronginterestincollaboratingwiththelocalcommunityandsharedthattheyhadmadeconsiderableeffortstoestablishpositivecommunitypublicrelationsinadvanceoftheiropeninginAugust2016.HighlightedAgencyStrengths(contributionstoRGVsystemsofcare)

• PalmsBehavioralHealthhasanattractivecampuswithalargenumberofbedsavailabletotreatpopulationsofallages.

• PalmsBehavioralHealthhasrecruitedanexperienceddirectorofclinicalserviceswhoisfamiliarwiththesystemofcareintheRGVandhassoughttoestablishcommunitycollaborationduringthefacility’splanningandimplementationprocess.

• ThegeriatricunitisstronginconceptandmayserveapriorityneedintheSouthValley,wherethereisasignificantgeriatricpopulation.

• PalmsBehavioralHealthisinterestedinmeetinganypotentialneedformorechildandadolescentbeds.

• PalmsBehavioralHealthhasacontractwithTTBH,similartootherareafacilities,whichallowsPBHtoreferindigentindividualstoTTBHforservices.

• PalmsBehavioralHealthleadershipexpressedastrongcommitment,backedupbycurrentdata-drivenprotocols,toimplementhigh-qualityprogramming,includingservicesthataddresstrauma,co-occurringsubstanceusedisorders,andmedicalissues.

PBHFindingsPBHFinding1:PBHdoesnotoperateapsychiatricemergencyservice,nordotheyplantooperateanycrisisdiversionbeds;thisremainsasignificantgapinservicesintheRGV.PBHFinding2:PBHhascreatedcapacityfortelemedicinemedicalclearancetofacilitateadmissions.However,italsohasapolicytorequireallindividualsundertheinfluenceofsubstancestogotoemergencyroomsforclearance,whichmaycreatebarrierstotimelyandappropriateaccesstocare.PBHFinding3:PBHisestablishingastate-of-the-artgeriatricunitthatcouldbecomeavaluableadditiontotheservicearrayinCameronCounty.PBHFinding4:PBHisdevelopingtrauma-informedandco-occurringprogrammingbyemployingSeekingSafetyandotherstandardizedmodels.PBHFinding5:PBHhasdevelopedapromisingcollaborationwithTTBHforworkingwithuninsuredpeopleandfacilitatingtheirtransitionplanningpostdischarge.

PBHFinding6:PBHisveryinterestedinbeinganengagedpartnerintheRGVsystemofcareaswellasinexploringhowbesttosupportanexpansionofambulatoryservicesinordertoreducehospitalizations.Currently,however,thereisnoorganizedmechanismbywhichthatparticipationcanformallyoccur.PBHFinding7:PBH’sparentcompany,StrategicBehavioralHealth–newtoTexas–iscommittedtoqualityimprovementprogramming.WhileStrategicBehavioralHealthhasastrongfocusonqualityimprovement(QI)anddatacollection,itisnotyetclearwhatQIcapabilityPBHwillimplementforimprovingcontinuityofcareandreducingreadmissions.PBHRecommendationsPBHRecommendation1:PBHshouldcollaboratewithotherinpatientfacilitiestoassesswhetherthereiscontinuedneedfor94inpatientbeds.Ifavailablebedsareunderutilizedandnotneeded,PBHmayconsiderrepurposingitsresourcesforcrisisdiversion,transitionalresidential,andambulatoryservices.PBHRecommendation2:PBHshouldplantoparticipateincollaborativesformedtobidonfundingthatwillbeavailableundertheSB292grantprogramforthediversionofindividualsfrominpatientcareandjails,includingfundingfortheprovisionofcrisisdiversion,crisisrespite,residentialcare,andintensiveoutpatientservices.TheoptiontoprovideinpatientoroutpatientrestorationtocompetencymayalsobeavailablethroughSB292.PBHRecommendation3:PBHshoulddevelopaQIprocesstotrackandimprovecontinuityofcareandrecidivism,ideallyincollaborationwithTTBHandotherproviders.PBHRecommendation4:PBHshouldconsiderexpandingitsmodelgeriatricservicecontinuumthroughouttheregionand,throughcollaborationwithgeriatricserviceprovidersintheRGV,considerinvestinginenhancementstothecontinuityofcarefortheindividualstheyserve.PBHRecommendation5:PBHshouldconsiderstrategiesto(1)reducebarrierstodirectadmissionbasedsolelyonuseofsubstances(suchasalcohol),(2)provideguidanceforitstelemedicineclearanceteamonsafeprotocolsfortheseadmissions,and(3)developprocessesinitsadmissionunittofacilitatebothrapidadmissionsforthoseinneedaswellasappropriatediversioninterventionsforthosewhomaybebestservedinotherlevelsofcare.PBHRecommendation6:Topreventduplicationofservices,PBHshouldconsidercoordinatingitsplanningformentalhealthintensiveoutpatientprogrammingwiththeexistingprogramoperatedbyVBMCinHarlingen.

PBHRecommendation7:PBHshouldconsiderexpandingitsarrayoftrauma-informed,recovery-oriented,andintegratedprogrammingtocomprehensivelycoverallofitsunits.Aspartofthiseffort,PBHshouldalsoconsiderrenamingitsadultunitstoavoidthestigmaoflabelingoneunitfor“lowfunctioning”adults.Texas Valley Coastal Bend Health Care System (VA-TVCBHCS)

InOctober2010,theU.S.DepartmentofVeteransAffairs(VA)createdtheTexasValleyCoastalBendHealthCareSystem(VA-TVCBHCS)asanindependenthealthcaresystemtobetteraddressthehealthcareneedsofveteransinthetwentycountiesthatmakeuptheLaredo,McAllen,Harlingen,andCorpusChristiVAserviceareas.ThesecountieswerepreviouslypartoftheVAhealthcaresysteminSanAntonio.VA-TVCBHCS’visionisasfollows:

VATexasValleyCoastalBendHealthCareSystemwillcontinuetobethebenchmarkofexcellenceandvalueinhealthcareandbenefitsbyprovidingexemplaryservicesthatarebothpatientcenteredandevidencebased.Thiscarewillbedeliveredbyengaged,collaborativeteamsinanintegratedenvironmentthatsupportslearning,discoveryandcontinuousimprovement.Itwillemphasizepreventionandpopulationhealthandcontributetothenation'swell-beingthrougheducation,researchandserviceinNationalemergencies.165

AsahealthcaresystemcomprisingacombinationofVAstaffandanextensivenetworkofcontractedproviders,theVA-TVCBHCSprovidessecondaryandtertiaryhealthcareinmedicine,surgery,psychiatry,andrehabilitationmedicine.Itoperatesa100-patientHomeBasedPrimaryCareprogramanda200-patientCareCoordinationHomeTele-HealthProgram.SummaryofRGVVeteranPopulationsServed,September1,2014–August31,2015166

County TotalVeteranPopulation

NumberofUniquePatientsReceiving

PercentofVeteranPopulationServed

Cameron 17,418 6,721 39% $75,718,000

Hidalgo 23,374 8,787 38% $91,733,000

165U.S.DepartmentofVeteransAffairs,TexasValleyCoastalBendHealthCareSystem.(n.d.).AbouttheVATexasValleyCoastalBendHealthCareSystem.RetrievedonFebruary5,2017,fromhttp://www.texasvalley.va.gov/about/index.asp166U.S.DepartmentofVeteransAffairs.(n.d.).Summaryofexpendituresbystateforfiscalyear2015.Retrievedfrom:https://www.va.gov/vetdata/expenditures.asp

SummaryofRGVVeteranPopulationsServed,September1,2014–August31,2015166

County TotalVeteranPopulation

NumberofUniquePatientsReceiving

PercentofVeteranPopulationServed

Starr 890 360 40% $3,735,000

Willacy 867 332 38% $4,583,000

RGVAreaTotal

42,549 16,200 38% $175,769,000

TheVA-TVCBHCSprovideshealthcareservices,includingbehavioralhealthservices,attheVAHealthCareCenterinHarlingenaswellasthroughclinicslocatedinLaredo,McAllen,andHarlingen.167Mentalhealthandsubstanceusedisorderservicesinclude:

• Outpatientmentalhealththerapiesandmedicationmanagement;• Asuicidepreventionprogram,whichisactiveatallclinicsandprovidesamoreintensive

levelofcareforthosewhoarehighrisk;• Outreachteams,includingissue-specificspecialtyteams(e.g.,substanceusedisorders)

thatprovideintensive,aftercare,andfamilycare,asappropriate;• Traumaservicesofferedatallsites;• Intensivecasemanagementformentalhealthrecovery;• Services,includinghome-andcommunity-basedservices,forthosewithseriousmental

illness;• Intensiveoutpatientprograming(IOP)forindividualswithco-occurringmentalhealth

andsubstanceusedisorders;• VeteransJusticeOutreachProgram;• Integratedbehavioralhealthcareservicesinprimarycareclinics;• Alargertele-mentalhealthprogram(includingtele-psychiatryandtele-psychology)that

utilizesanetworkofVA-TVCBHCSstaff;• Vocationalrehabilitation;• Peersupportembeddedintoprograms;• Expandedtransportationservicestoassistveteranswithtravelingtoclinics;• Homelessservices.

HighlightedAgencyStrengths(contributionstoRGVsystemsofcare)

• TheaveragementalhealthwaittimefortheVA-TVCBHCSis2.81daysaccordingtothe

167U.S.DepartmentofVeteransAffairs,TexasValleyCoastalBendHealthCareSystem.(n.d.).AbouttheVATexasValleyCoastalBendHealthCareSystem.RetrievedonFebruary5,2017,fromhttp://www.texasvalley.va.gov/about/index.asp

mostrecentVAnumbers.168• VA-TVCBHCS’emphasisonprimarycareandmentalhealthintegrationgivesveterans

immediateaccesstoprovidersofmentalhealthservices,particularlyforindividualswithmildtomoderatementalhealthneeds.

• VA-TVCBHCSisalsousingtele-mentalhealthtodelivermentalhealthservices,includingauniquerelationshipwithTheUniversityofTexasRioGrandeValley(UT-RGV)inEdinburgtoservecollegestudentswithbusyschedules.

• VA-TVCBHCSalsoworkswithjustice-involvedveteransthroughitsVeteransJusticeOutreachProgram.

• VA-TVCBHCSoffersextensivevocationalrehabilitationservices.• AsVA-TVCBHCShasexpandedservices,staffinghasincreasedfrom25in2006toover

200atthistime.VA-TVCBHCShirespeoplewhowanttoserveveteransandcreateahealthcareenvironmenttheirownfamilieswouldwanttovisit.

• ThereisgoodcollaborationbetweenVA-TVCBHCSandTTBH;TTBHoperatesaveteran’sdrop-inprograminCameronCountyandisexpandingservicesinHidalgoCountythroughtheTexasVeterans+FamilyAlliance.

• TheVAisalsoworkingwiththeDepartmentofPsychiatryatUT-RGVtosupportaresidencyprogram,whichwillhaveitsfirstclassin2017,hopefullyresultinginmoreprovidersstayinginthearea.

• VA-TVCBHCSisalsostartingjointclinicswiththeUT-RGVDepartmentofPsychiatryfacultytodevelopservicesthatarenotprovidedinthearea(e.g.,electroconvulsivetherapy).

• VA-TVCBHCSstartedavanrouteusingvolunteerdriverstoprovidetransportationforveteranstoandfromappointments.

VA-TVCBHCSFindingsVA-TVCBHCSFinding1:Thestigmaofhavingamentalillnessorsubstanceusedisorderisabarrierforveteransinaccessingservicesbecausethepersonalorsocietalperceptionofweaknessisanathematothemilitarymaximofaccomplishingthemissionregardlessofpersonaldiscomfort.Mentalhealthorsubstanceuseconditionscanalsobemisunderstoodbyveteransandtheirfamiliesasweaknessorself-pityratherthantreatableillnesses.Inaddition,thelackofreadilyavailableoutreachandtreatmentthatistrauma-informedandcompetentinworkingwiththemilitaryculturecontributestobarriersveteransfaceinaccessingservices.

168U.S.DepartmentofVeteransAffairs,VeteransHealthAdministration.(n.d.).Patientaccessdata:October2016datareleases–pendingappointments(asof15October2016).Retrievedfromhttps://www.va.gov/HEALTH/docs/DR56_102016_Pending_and_EWL_Biweekly_Desired_Date_Division.pdf

VA-TVCBHCSFinding2:Accesstomentalhealthtreatmentwithawaittimeof2.81daysisexcellent.Collaborationwithpsychiatryunitsatlocalhospitalstoquicklyadmitveteransandsupportdischargeplanninghasbeensuccessful.VA-TVCBHCSFinding3:Limitedaccesstopublictransportationmakesitverychallengingforveteransandtheirfamiliestoaccessservices.However,volunteerdriversuseaVAvanandhaveestablishedaroutetoassistveterans.VA-TVCBHCSFinding4:WhileinpatientpsychiatricbedsarelargelyavailableintheValley,theprocessofcompletinganinvoluntarycommitmentacrosscountylinesishinderedbythelackofastandardapprovalform.EachcountyutilizesadifferentversionoftheformprovidedbytheStateStatute,withsomecompletedelectronicallyandotherscompletedusingcarboncopypaper.Thiscreateschallengesincompletingrequiredformsfortransferringindividualstoservices,andoftenrequiresextensivetimefromadministratorsandproviderstocompletetheprocess.VA-TVCBHCSRecommendationsVA-TVCBHCSRecommendation1:Continuestrongcollaborativeeffortswithlocalhospitalsystemsandemergencydepartmentstoaddresspsychiatricemergenciesandtheprovisionofinpatientcare,includingeffectivedischargeplanning.Considerparticipationinthenewly-formedcrisisservicescollaborativemeeting.VA-TVCBHCSRecommendation2:ContinuestrongcollaborativeeffortswithTTBH,whichhasoperatedtheCameronCountyVeteransDrop-InCenterfortwoyears.TTBHrecentlyexpandedservicesattheCameronCountyVeteransDrop-InCenterandisopeningtheHidalgoCountyVeteransDrop-InCenterthroughtheTexasVeterans+FamilyAlliance,theinnovativegrantprogramcreatedbytheTexasLegislaturepursuanttoSenateBill55(84thLegislature)thatsupportscommunitymentalhealthprogramsinprovidingandcoordinatingservicesandtreatmentforTexasveteransandtheirfamilies.VA-TVCBHCSRecommendation3:Continuepursuingthedeliveryofintegratedbehavioralhealthcarewithinprimarycaresettingsthrougheducationofprimaryhealthcarepracticesabouttheimprovementsinoutcomesandultimateefficienciesthatcanbegainedthroughcollaborativeandconsultingintegratedcaremodels.VA-TVCBHCSRecommendation4:AsastrategytoaddressgapsintransportationservicesthatcouldaugmenttheexistingVA-TVCBHCSvanprogram,considerexpandingtheprovidernetworktoofferaccesstoprovidersincommunitiesclosertoveterans.

Valley Baptist Medical Center

ValleyBaptistMedicalCenter(VBMC)isalargefor-profithospital,nowownedandoperatedbyTenet,whichhasinpatient,emergency,andoutpatientservicesintwolocations,oneinBrownsvilleandoneinHarlingen.BehavioralhealthissupportedstrategicallyfollowingthetransitiontoownershipbyTenetandfor-profitstatus.VBMC“helpspeopleachievehealthforlifethroughcompassionateserviceinspiredbyfaith,andarededicatedtocontinuingourstrongtraditionofprovidingquality,compassionatehealthcarethatputspeoplefirst.”169VBMC-Brownsvilleoperatesanadultintensiveoutpatientprogram(IOP)anduntilAugust20,2017,operateda37-bedadultpsychiatricinpatientunit.170UpontheclosingofVBMC-Brownsville’sinpatientunit,VBMC-Harlingenopeneda12-bedinpatientGeriatricBehavioralHealthUnit.171Inaddition,theHarlingencampusprovidesanIOPservice,alongwithsomeprovisionforcoverageoftheemergencyroom,locatedinamedicalofficebuildingnexttothehospital.Abreakdownofadmissions,averagelengthofstay,andpayermixfortheVBMC-Brownsvilleinpatientunit(priortoitsclosing)isoutlinedinthetablebelow.AdultInpatientPsychiatricUnit

Admissionspermonth 130-180

Averagelengthofstay 5-7days

PayerMix

Medicare 35%

Medicaid 30%

Privateinsurance 5%

TTBHcontractedbeds($550/day)

VAcontractedbeds 5-10%

Other 10%

169ValleyBaptistHealthSystem.(2017).Aboutus.Retrievedfromhttps://www.valleybaptist.net/about-us170Asthisreportwasgoingtopress,ValleyBaptistMedicalCenter-Brownsvilleannouncedtheywillbeclosingthehospital’sinpatientuniteffectiveAugust20,2017,withnonewpatientsacceptedafterJuly31,2017.VBMC-Brownsvillenotedtheclosingwasdueto“achallengingreimbursementenvironment,increasingoperatingcostsandtheadditionofavailabletreatmentresourceswithinourcounty…”.TheletternotedVBMC-BrownsvillewillcontinueoperatingitsOutpatientIntensiveProgram.171Retrievedfrom:http://www.valleymorningstar.com/life/health_wellness/article_ea1f315c-8df6-11e7-b5f4-c7c305fd70c5.html

WhiletheVBMC-Brownsvilleinpatientunitwasoperational,itprideditselfonbeingmoreaccessibletopatientswithacuteandcomplexneedsthanotherinpatientprogramsintheRGV.TheBehavioralHealthDirectorwasroutinelyoncall24hoursaday,seven(7)daysaweekforadmissions.VBMChadastableteamofpsychiatristswhohadexpertiseinaddictionpsychiatryandworkedwithateamofon-siteprimarycarephysicianstoprovidemedicalcapacityontheunit.Additionally,therewasaphysician’sassistantwithpsychiatricspecializationwhoprovidedservicesontheinpatientunit,aswellasthreesocialworkers(plusinterns)whoprovidedservicestofamilies,dischargeplanning,andsomegrouptherapy.Atthetimeofthisassessment,VBMChadjusthiredalicensedcounselor(andwasrecruitingasecondclinician)tocreatea“mobileassessmentteam”toprovidelimitedcrisiscoverageoftheiremergencyrooms(ERs)andphysicianpractices.In2016,ValleyBaptistMedicalCenteratBrownsvillereportedreceiving2,687individualsintheERwhopresentedwithsometypeofpsychiatricconcern.172VBMCoperatestwointensiveoutpatientprograms,oneateachcampus.Eachprogramprovidesthreehoursofgroupprogrammingthreetimesperweek,coveredbythesameteamoffoursocialworkers,alongwiththetwoinpatientpsychiatrists.Althoughthecapacityoftheprogramisover20,andthehighestcensusinonelocationhasbeen23,thecurrentprogramoperatesatacensusofaround10ateachsite.TheprogrambillsMedicareandMedicaid,andcharges(butdoesnotcollect)$800perday.VBMCmakesastrongefforttoattractreferralsandengagepatientsintheIOPprogram.Theyprovidefreeinitialassessmentsandaccesstotransportation.TheprogramacceptsreferralsfromtheERandinpatientunitsandprovidesoutreachtoindividualphysicianpracticesintheVBMCcommunityaswellastootherhumanserviceproviders.Theprogramhasacognitive-behavioralfocusandusesmeasurementtoolstotracksymptomsandoutcomes(e.g.,PHQ-9;GeneralAnxietyDisorder[GAD]screening).Ofnote,thereisasignificant20%“bump”inserviceutilizationduringthewinter,duetotheuseofservicesby“WinterTexans.”HighlightedAgencyStrengths(contributionstoRGVsystemsofcare)

• Untilitsclosing,VBMCmaintainedawell-runadultpsychiatricinpatientfacilityinBrownsvillethatmadeanefforttofacilitateadmissionforpatientswithcomplexchallengesfromacrosstheregion,andusuallyhadcapacityandavailability.

• VBMCofferstwosmallIOPprogramsthatprovidelimitedcapacitytoprovideshort-term,community-basedservicesforindividualswithhigherlevelsofneed.

172DatareceivedfromBeckyTresnickyofValleyBaptistMedicalCenter(personalcommunication,February2017).

• VBMChason-sitecapacityinaddictionpsychiatryaswellason-sitephysicianstomanageco-occurringmedicalneeds.

• Thereisahospital-widesuicideprotocolinitiatedbyTenet.• VBMCalsoreportedithasaprocessforcollectingERdataforbothcampuseson

individualswithbehavioralhealthneeds.• VBMCismakingaconcertedefforttoexpanditsarrayofoutpatientservices,including

mobileassessmentintheER.• VBMChasaplantoopenanadolescentinpatientunitin2017.• VBMChasconsiderablespaceavailableatitsBrownsvillecampuswhereitcoulddevelop

anarrayofcrisisdiversionservices.• TheIOPDirectorparticipatesontheHarlingencampuscommitteeforplanningaLevel3

TraumaCenterinordertointegratetheprovisionofcommunitycrisisdebriefingservices.

• VBMCleadershiphaspositiveconnectionswithintheregion,includingTTBH,theCameronCountyMentalHealthTaskForce,andparticipatesonthestateMedicaidBehavioralHealthMedicalDirector’sCommittee.

VBMCFindingsVBMCFinding1:TheVBMCpsychiatricinpatientunitatBrownsvilleprovidedqualityacutecareforindividualswithpsychiatricdisorders,includingthosewithco-occurringsubstanceuseandhealthconditions.Theunithadcapacityforallpayersandwasnotatfulloccupancy,raisingthequestionaboutfurtherinvestingtheregion’srelativelyscarceresourcesindevelopinginpatientbedsinsteadofdevelopingcrisisdiversionandoutpatientcapacity.VBMCFinding2:TheVBMCpsychiatricinpatientunithadchallengesindischargeandcontinuityofcareplanningforallpopulations.Someofthesechallengesrelateddirectlytoalackofoutpatientcapacityintheregion,reportedpolicyandprocedurebarriersinaccessingcommunityservices,adramaticlackofsubstanceabusetreatmentcapacityintheRGV,andinternalbarrierstodevelopingafullarrayoutpatientservicesatVBMC.VBMCFinding3:ThereispotentialtodevelopafullarrayofcrisisservicesattheVBMC-Brownsvillecampus,providedthatasuccessfulfinancialmodelforthoseservicescanbedevelopedincollaborationwithawiderangeofpayers.VBMCFinding4:VBMCreportstheneedforhighlevelcollaborationwithMedicaidMCOsintheregiontoaddressbothpaymentchallengesandcontinuityofcareissues.

VBMCFinding5:TheVBMCIOPservicesarewelldesignedandhighquality,butbecausetheprogramrequiresparticipationingrouptreatmentthreedaysaweek,theydonothavetheresourcestomeettherangeofotheroutpatientneedsinthecommunity.VBMCFinding6:Thereisnocapacitytoofferindividualizedoutpatientservices(whethercrisisinterventionorroutine)beyondtheinitialassessment.Also,thelimitedavailabilityofbilingualandtranslationservicesisanotherbarriertoaccessingservices.VBMCFinding7:VBMCreportsthatthereisnoorganizedregionalcollaborationthatsharesresponsibilityforindividualsmovingthroughtheacutecaresystem,nortracksthoseindividualsforthepurposeofcontinuousimprovement.VBMCFinding8:VBMChasparticipatedindevelopingtheCameronCountyMentalHealthTaskForceandreportsthatthistaskforcehaspotentialforincreasingitseffectivenessinaddressingcommunityneeds,butwillrequiresignificanttechnicalassistanceinordertoachievethatpotential.VBMCandSystemRecommendationsVBMCRecommendation1:EstablishamechanismatVBMC,onbothcampuses,forprovidingandbillingoutpatientbehavioralhealthservices,withanemphasisoncrisisinterventionandcontinuityofcare.Participateincollaborative(s)formedinresponsetotheSB292grantprogramtoreducerecidivism,arrest,andincarcerationofindividualswithmentalillness;reducewaittimeforforensiccommitment;andassessopportunitiestoprovidecrisisdiversion,crisisrespite,andinpatientandoutpatientrestorationtocompetencyservices.VBMCRecommendation2:WorkotherCameronCountyMentalHealthTaskForceleaderstodevelopaplantorevitalizethetaskforceasaneffectiveforumforcollaborationtoimprovethebehavioralhealthsysteminCameronCounty.The Wood Group Crisis Respite Program

TheWoodGroupCrisisCenterisa16-bedresidentialcrisisrespiteprograminHarlingen,Texas,operatedbyTheWoodGroup,undercontractwithTropicalTexasBehavioralHealth(TTBH).ThemissionofTheWoodGroupistoprovidequalitybehavioralhealthservicesthatassistindividualswithmentalillnessorotherspecialneedstolivehealthyandproductivelifestyleswithintheircommunities.AprivatecompanybasedinWichitaFalls,TheWoodGrouphas

providedserviceswithintheTexaspublicbehavioralhealthsystemfor29yearsandoperatescrisisservicesinthirtysitesacrossTexas.173TheprograminHarlingen,oneofTheWoodGroup’s“older”programs,hasbeenoperatingforabout10yearsandistheonlycrisisdiversionprogramintheRioGrandeValley.AsofSeptember1,2016,theprogramtransitionedtoamixofninebedsspecificallyforcrisisrespiteservices(previouslyseven)andseven(previouslynine)bedsforlong-termtransitionalresidentialservicesforindividualswithseriouspsychiatricdisabilities.Staffingincludesasiteadministrator(anexperiencedcasemanagerandrehabilitationservicesprovider)andcasemanagers.Program Capacity AverageLOS Costs

CrisisRespite 9Beds 3Days $70.56/Day

TransitionalResidential 7Beds 2–6Years $730/Month

Thecrisisrespiteprogramacceptsadmissions24hoursaday,sevendaysaweek,primarilyfromtheTropicalTexasBehavioralHealthMobileCrisisOutreachTeam,buthaslimitedabilitytomanagehigherlevelsofacuitybecauseoflimitedstaffingandalackofmedicalsupervisionorsecurity.Theadmissioncriteriasupportawelcomingapproachandfacilitateengagementwithindividualswithchallengingissues(e.g.,undertheinfluenceofsubstances,needingre-stabilizationofmedications,homelessandreferredfromemergencyrooms,experiencingdomesticissuesorothershort-termcrises).Thetypicalstayinacrisisrespitebedisaroundthreedays.Theinterventionfocusesoncreatingasafespace;providingshelter,food,andclothing;andconnectingwithcasemanagementfromTTBH.TheprogramalsocoordinateswithTTBHformedicationservices.TheWoodGroupdoesnotbillthirdpartypayers,includingMedicaid,foritscrisisbedservices,viewingMedicaidbillingasachallengingadministrativeburden.TheWoodGroupacknowledgesthattheprogramisunderutilized(duringthesitevisit,onlytwoofthecrisisbedswereoccupied)andleadershipreportsthatfeedbackfromcrisisworkersindicatesthattheprogram’sabilitytomanageindividualsincrisisfallsshortofwhatTheWoodGroupbelievesitcanmanage,sotheyreferforinpatientadmissioninstead.TheWoodGroupisawarethataninebedcapacityfallsshortoftheregionalneedforcrisisbedsandwouldwelcomedevelopingahigherlevelofdiversioncare.However,therehasnotbeenastronginterestintheRGVinallocatingresourcesforthatpurpose.173InadditiontoRGV,theWoodGroupoperatescrisisservicesinAbilene,Amarillo,Austin,Beaumont,BigSpring,Denton,EaglePass,Gatesville,Georgetown,Harlingen,Kenedy,Lytle,SanAntonio,TexasCity,Tyler,Waco,andWichitaFalls.

HighlightedAgencyStrengths(contributionstoRGVsystemsofcare)• TheWoodGrouphasagreatdealofexperiencethroughoutTexasinoperatingarange

ofcrisisdiversionlevelsofcare.TheyarecommittedtothepublicsectorandwelcometheopportunitytoparticipatewithLMHAsandotherpartnerstoidentifyandrespondtocommunityneeds.

• TheCrisisRespiteProgramistheonlycrisisdiversionprograminRGV.• Theprogramiscurrentlywellmanaged,operateswithahighlevelofefficiency,andis

shiftingtowardmoreofarehabilitativefocus.• TheWoodGroupisveryopentoparticipationincrisissystemplanningfortheregion

anddevelopmentofamorecomprehensiveservicearray.Other Organizations Findings and Recommendations Catholic Charities of the Rio Grande Valley

CatholicCharitiesoftheRioGrandeValley(CCRGV)isaregionalsocialserviceagencycoveringCameron,Hidalgo,Starr,andWillacycounties,withofficesinSanJuanandBrownsville.ThemissionofCCRGVis“toprovidefortheneedsofourcommunitythroughselflessserviceandunderthesignoflove.”Thismissioniscarriedoutby15staffunderthedirectionoftheexecutivedirector.Theprimaryactivityoftheorganizationisbasiceconomicsupportforimpoverishedpopulations,includingimmigrants(ofallkinds)anddisastervictims.Inadditiontoitscounselingprogram,specificservicesprovidedbyCCRGVincludethefollowing:

• EmergencyAssistanceProgramprovidesshort-termutility,housing,andmedicalassistanceforthoseinneed.

• HomelessPreventionservicesincludetemporaryfinancialassistanceandhousingrelocationandstabilizationservicesfocusedonhousingforhomelessandat-riskhouseholds,supportedbyanEmergencySolutionsGrant(ESG).

• DisasterReliefProgramprovideshomeassessmentandcasemanagementforpeoplerecoveringfromafederallydeclareddisaster.

• FoodPrograms,supportedbyUSDAfunding,providesover60,700mealstochildrenat59sites.

• HumanitarianRespiteCenter,locatedinMcAllenandpartoftheHumanitarianCrisisReliefeffort,providesimmigrantswhohadcrossedtheborderwithno-costservicesandbasichumanitariancaresuchas:food,water,showerfacilities,shelter,andeducationonU.S.andimmigrationprocessaswellasawarenessandeducationonhumantrafficking.

• PregnancyCenter,supportedbystatefunding,providescounseling,education,support,andmaterialassistanceforthebenefitofchildren(unbornanduptothefirstyearoflife)andtheirparents.

CounselingProgramTheCCRGVCounselingProgramprovidesshort-termcounselingservicestoindividuals,couples,andfamilieswhoareexperiencinglifecrises.PeoplewithmoreseverementalhealthissuesarereferredtoTTBH.CCRGValsoprovidescounseling,education,andresourcestowomenlookingforalternativestoabortion,aswellasassistanceandcounselingthroughitsMilitaryFamilyReliefProjecttomilitaryservicemenandwomenwhohadbeendeployedtoIraq.CCRGVdoesnotprovidesubstanceabuseservices.

• CCRGVhastwocounselorsonstaff,oneineachoffice.Theexecutivedirector,alicensedcounselor,alsoprovidescounselingservicesandsupervisescounselinginterns.CCRGVoffersaslidingfeescale($2pervisitper$1,000ofannualincome)anddoesnotbillinsurance.Theyrefertolocalprimarycarephysiciansformedicationservices.

ReferralsforCCRGVcounsellingservicescomedirectlyfromotheragenciesandregionalchurches/dioceses.HighlightedAgencyStrengths(contributionstoRGVsystemsofcare)

• CCRGVplaysanimportantroleintheRioGrandeValleythroughcollaborationsamongnon-profithumanservicesproviders,leadershipwiththeFaithCommunitiesforDisasterRecoveryregionaldisasterresponseeffort,andrelationshipswithmanyofthebehavioralhealthserviceproviderorganizationsintheRGV.

• CCRGVhelpstoaddressthegapinavailabilityofcounselingservicestolowincomepopulations.

• Moreimportant,CCRGV,byvirtueofitsroleinprovidingeconomicsupportservicestoimpoverishedpopulations,includingimmigrants,isdeeplyengagedwiththeneedsofsomeofthemostmarginalizedcommunitiesintheRioGrandeValley.

CCRGVFindingsandRecommendationsCCRGVFinding1:CCRGVisabletoprovidesomementalhealthcounselingservicestoimpoverishedandimmigrantpopulations.However,asreportedbytheirstaff,thiscapacityismuchlessthanthesepopulationsneedanditonlyaddressesasmallfractionofthegapinaccesstomentalhealthcounselingforlowincome,uninsuredindividualsintheRGV.CCRGVFinding2:WhileCCRGVprovidesonlyasmallvolumeofcounselingservice,itisintouchwithmajorpopulationsinneedacrosstheregionthroughitseconomicassistanceactivities.CCRGVRecommendation1:CCRGVshouldbeincludedinregionalcollaborationsonbehavioralhealthbecauseoftheirextensiveknowledgeaboutimpoverishedandimmigrantpopulations.

John Austin Peña Memorial Center

JohnAustinPeñaMemorialCenter(JAPCorPeñaCenter),acollaborationbetweentheUniversityofTexasRioGrandeValleySchoolofMedicine(UTRGV-SOM)andtheHidalgoCountyHealthDepartment,offersprimaryhealthcaretoadolescentsages12to18yearswhoareatriskformedical,mentalhealth(behavioralissues,attention-deficit/hyperactivitydisorder,andangermanagement),andappetite-drivenconditions(alcohol,drugs,tobacco,etc.).JAPCoffersaone-stopshopdescribedas“inter-professionalcareinanintegratedfashion”coveringprimaryhealthcarethatissupportedandsupplementedbyadditionaldisciplinesthataddressholisticneedssuchasbehavioralhealth,exercise,nutrition,andoralhealthcare.JAPCidentifiesthefollowingspecificgoalsforthecenter:

• Advanceaccesstotreatmentforadolescentswithsubstanceuse/appetitive-drivendisorders,psychiatricillness,andhealthconcerns;

• Promoteinclusionandintegrationofbehavioralmedicinetothescopeofprimarycare;• Improveaccesstooralhealthservices;• Improvecollaborationandintegrationofscarcespecialtyresources;• Improveoutreachtobuildcommunitycapacityforcomplex,high-risk,triply-diagnosed

adolescents;and• Integrateservicesinthecommunity(McAllenISD,PharrBoysandGirlsClub,Family

services).LaunchedinApril2015,JAPCwasestablishedonlanddonatedbyHidalgoCounty.Sinceitslaunch,thecenterhasservedover500adolescents.ReferralstotheprogramcomeprimarilyfromtheHidalgoCountyJuvenileJusticeDepartment(40%)andthearea’salternativeschoolsandotherreferralsources(60%).ServicesTheIntegratedCareCollaborativeUnit(ICCU)atthePeñaCenterisacommunity-basedclinicofferedthroughtheUTRVGMedicalSchoolwithcollaborationfromtheCollegeofEducation,P-16StudentEducationalOutreachandtheCollegeofHealthAffairs.Thisunitbringstogether12professionalsfromarangeofdisciplines(psychiatry,pharmacy,vocationalrehabilitation,nutrition,nursing,aphysicianassistant,socialwork,andothers)toprovideandenhanceintegratedcareinordertoimprovethementalhealthoutcomesofchildrenandadolescentsintheRioGrandeValley(RGV)whoareathighriskandhavehigh-acuityneeds.Thiscoregroupofinterdisciplinarystaffprovidesprimaryhealthcareandsupportiveservicesand/orarrangesotherservicesthatyouthneed,eitheratthePeñaCenterorthroughreferralstootherorganizations.TheICCUreferstoTropicalTexasBehavioralHealth(TTBH)foroutpatientbehavioralhealthservices,includingsubstanceusetreatment,andwithDoctorsHospitalatRenaissancefordetoxservices.CounselorsatthePeñaCenterusevariouspsychotherapy

methods,includingcognitivebehavioraltherapy(CBT),dialecticalbehaviortherapy(DBT),andmindfulness.In2016,thePeñaCenterdocumentedover4,000visitsfortheyear.InthelocalISDOptionscampus,theCenteroffersclassesinself-esteem,self-efficacy,resilience,schoolpsychologyservices,andhomeoutreach.TheCenteralsooffersscreeningwiththeSubstanceAbuseSubtleScreeningInventory(SASSI)forsubstanceuse,PHQ-9fordepression,andtheRapidAssessmentforAdolescentPreventiveServices(RAAPS)foradolescentbehaviorscreening.Theclinicoffersfull-serviceprimarycareandintegratedcarewiththeotherprofessions.Clinicoutreachworkin2017willincludealargerschool(NikkiRoweHighSchool),wheretheClinicwillcollaboratewiththeschoolcounselingservices,thefirstoffendersprogram,andschoolhealth.Inadditiontotheservicesdescribedabove,theCenteroffersprogrammingtosupportphysicalfitness,nutrition,education(includingtutoringandGEDservices),careercounseling,artandmusictherapy,mediation,gardening,andpettherapy.Duringschoolholidays,theCenteroffersspecificcampsthatprovideclientswitharttherapy,physicaltherapy,dietandnutrition,grouptherapyandfamilytherapy.Twotelehealthsystemsareavailable,buthavenotbeenfullydeployedduetochallengesinimplementingamemorandumofunderstanding(MOU)withthecounty.ThePeñaCentercurrentlyusestelehealthtoconnectstudentswithpreceptors,andplansonplacingthetelemedicineunitsinthealternativeschooltosupportoutreach.JAPCstaffparticipateinwraparoundplanningwithprobationofficersinHidalgo,aswellasbootcampservicestwiceaweek.Also,aspartoftheirsecondphaseofdevelopment,JAPCwouldliketoprovidemobilestafftocoordinatecarebyvisitingyouthandfamiliesintheirhomes,alternativeschools,otherschools,andjuvenilejusticesiteswithgreaterfrequencythaniscurrentlyavailable.TheyalsointendtoprovideAl-AnonandAlateenmeetings,andhavethegoaloftrainingparentsinMentalHealthFirstAid.HighlightedAgencyStrengths

• TheICCUprovidesavenueformedicalresidents(graduatemedicaleducation)fromdifferentdisciplinestoworktogether.Themedicalschoolisthefirstinitsfieldtoprovidetrainingintheinter-professionaldeliveryofcare,andstudentshavetheopportunitytovolunteerforclinicalexperience.ThisapproachnotonlytrainsprofessionalswhomaystayintheRGV,butalsobuildscommunityservicecapacity.Studentsfromprogramssuchasnutrition,pharmacy,rehabilitation,education,counseling,socialworkandnursing/physicianassistanthavetheopportunitytojoinotherstudentsfortheirclinicalexperience.

• Thestafffocusesonharmreductionratherthantotalabstinenceofsubstances,whichis

apositiveengagementstrategyforyouth.• Staffarepassionateandexcitedaboutwantingtohelpyouthandfamiliesinthe

community.Whentheyidentifyaneed,theytrytofindasolution.Forexample,theuseofsyntheticmarijuanawasasignificantproblemamonghighschoolstudents.Staffprovidedaneducationprogramforall12,000seniorsintheEdinburgIndependentSchoolDistrict(ISD),whichwasfollowedbyadropindruguse.Theteamhasfacilitatedmultipleworkshopsforbi-nationalconferences,internationalconferences,andcommunities.

• TheprogramhassupportfromHidalgoCounty,includingthecounty’sdonationofJAPC’sbuildingandICCU’spartnershipwiththeHidalgoCountyJuvenileJusticeDepartment.

• TheICCUisprovidingsomeservicestoyouthwhomightotherwisenothaveaccesstosuchservices(e.g.,GEDclasses,nutritionclasses,cookingclasses,andlinkagetocommunityresources).

• TheICCUisbroadeningitsreachbygoingintothecommunityandtoColoniastoprovideservicessuchasdentistryandtelemedicine.

• TheICCUhastheabilitytorunallclinicallaboratorytestsin-house.Thiseliminatesanycosttothefamilyandadditionalcoststotheclinic.

• TheICCUacceptswalk-inappointments;parentsandyouthcanshowuptotheclinicandnooneisturnedawayregardlessofincomeorimmigrationstatus.

• TheICCUisplanningthedevelopmentofaPatient-CenteredMedicalHomeco-locatedtoprovideservicestofamilymembersandcommunity.

JAPCFindingsJAPCFinding1:JAPChasaninnovativeapproachtoevaluatingandservingadolescentswithcomplexhealthconditionsthroughdirectandcoordinatedcarewithsystempartners.Thecenterhasgrownveryquickly,ashasitsfunding,includingarecent$1milliondollargrantfromtheMethodistHealthcareMinistriesofSouthTexas,Inc.Thisrapidgrowthhasresultedinpositivestrategiesforprovidingservicestoyouthandfamilies.JAPCFinding2:Thenextphaseofdevelopmentcallsforsignificantexpansionandrefinementofitsadministrativepractices.JAPChasthespaceandisconsideringtheprovisionofinpatientcare,atransitionclinic,and/oradrop-incenter.JAPCFinding3:TreatmentforsubstanceuseisprovidedthroughTTBHanddetoxservicesareofferedthroughDoctorsHospitalatRenaissance.Typically,thebestpracticeisprovisionofintegratedoutpatientSUDtreatmentbyonebehavioralhealthprofessionalratherthansplittingcarebetweenmultipleprofessionals/providers.However,becausetheJAPCisstillintheearly

stagesofdevelopment,andstaffingislimited,theapproachofcoordinatingwithpartnersmaybenecessary.JAPCFinding4:TheICCUreportssuccesswithyouththatinitiallyscorehighondepression(PHQ-9).Withthesupportandservicesprovided,depressionscoresdroppedsignificantlyinatwo-weekperiod.JAPCFinding5:TheICCUhasnotyetbilledMedicaidorotherinsuranceforservices.Presently,allservicesareprovidedthroughgrantfunds.Theirplanistobeginbillingindividuals/familiesusingaslidingscalewithaflatfeeforservice.JAPCFinding6:Atpresent,JAPCmaynotalwaysbethesoleprimarycareprovider,whichrequirescoordinationwithotherproviders.JAPCwouldliketodevelopintoapatient-centeredmedicalhomeandalsoprovidefullfamilyprimarycare,becausemanyfamiliesliketoobtaintheirhealthcareinoneplace.Atpresent,fullfamilycareisnotavailable.JAPCFinding7.JAPChasdeployedtheuseoftheSASSI,whichtheyreporthasgreatlyenhanceddiagnosisandtreatmentabilities.JAPCRecommendationsJAPCRecommendation1:BuildingoninnovationsatJAPC,itwouldbeveryhelpfuliftheleadershipparticipatedinfuturesystem-wideeffortstoplanforbehavioralhealthservicesandintegratedcareapproaches.Forexample,acrosstheRGV,therearehugegapsincrisisandhousingservices,andsomebehavioralhealthinpatientbedsarenotutilized.WithJAPCreadytoexpand,itwouldbeusefultodesignservicesthatnotonlyfittheneedsofyouthintheirprogram,butalsoaddresssomeofthesystemicgapsintheRVG.JAPCRecommendation2:AsJAPCexpands,itwillbeimportanttoassessthespecificbehavioralhealthservicesthatwillbeprovidedwithinitsoperations,includingwhetheritwillofferevidence-basedtreatmentforaddressingsubstanceuseand/orco-occurringpsychiatricandsubstanceuseconditions(COPSD),orcontinuetoreferyouthtootherproviders.JAPCRecommendation3:Itwillbeimportanttoformalizecoordinationofcareagreementswithreferralorganizationsandotherhealthsystems.AsnotedbyJAPC,thelimitedresourcesavailableintheRGVmakeitimperativetocoordinatecareandavoidduplicationofprimarymedicalcareandbehavioralhealthservices.JAPCRecommendation4:BillingMedicaidandotherinsurersforservicestoyouthwhohavecoverageisessentialtothelong-termfinancialhealthoftheJAPC.ItisimportanttoexplorepaymentsfromtheMedicaidmanagedcareorganizationsandotherinsurers.Recognizingthat

manyofJAPC’sclientsmaynothaveinsurance,orthattheservicesmaynotbecoveredbyinsurance(e.g.,educationalservices),itisevenmoreimportanttoobtainreimbursementforprimarycareandbehavioralhealthservicesthatarecovered.TheMeadowsMentalHealthPolicyInstitutecanprovideassistancewithexploringreimbursementoptionsfortheseservices.JAPCRecommendation5:Integratingatthecommunity-level,especiallyintheschoolandathome,iscriticalforlongtermchange.Maximizingresourcesbyengagingstudentsfromtheentireregionaswellasthecommunityandorganizationsistheanswertocommunitycapacitybuildingandworkforcedevelopment.The University of Texas Rio Grande Valley School of Medicine Department of Psychiatry and Neurology

TheUniversityofTexasRioGrandeValleySchoolofMedicine(UTRGV-SOM)openedinthesummerof2016withaninauguralclassof55medicalstudents.TheUTRGV-SOMDepartmentofPsychiatryandNeurologyhasfacultyemployedbyUTRGVaswellascommunity-basedfaculty.Thedepartmentandschoolhasacommunity-basedfocus,emphasizingcollaborativeleadership,culturalawareness,andpatientadvocacy.AccordingtotheSchoolofMedicine’swebsite174:“TheUniversityofTexasRioGrandeValleySchoolofMedicineoffersanexceptionallyinnovativelearningexperiencedesignedtoinstillstudentswithscientific,clinicalandresearchexpertiseofthehighestprofessionalstandards.”HighlightedAgencyStrengths

• Incontrasttothetraditionalmethodsforcreatingresidencies,theUTRGV-SOMdevelopeditsresidencyprogramstobeavailabletostudentsfromothermedicalschools,bothbeforeandalongwiththedevelopmentoftheschoolofmedicine,ratherthanwaitinguntiltheirownstudentsbegangraduating.

• Thepsychiatryresidencyprogram,whichbeganinJuly2017,involvesmultipleinstitutionsbasedinthecommunity.ItsthreecorecommunitypartnerorganizationsareRioGrandeStateCenter,theDepartmentofVeteransAffairs,andTropicalTexasBehavioralHealth(TTBH).AdditionalresidencyplacementsareavailableatValleyBaptistMedicalCenter–HarlingenandOriginsRecoveryCenter.

• Theprogramisdesignedtoprovideresidentswithsixmonthsofexperienceinpsychiatricinpatientcare,withthemajorityoftheirtimespentinoutpatientcare.Residentsarerequiredtocompletearotationinprimarycareduringtheirfirstyearandgainexperienceinpsychiatricassessmentandtreatment,bothmedicationandtherapy,

174Retrievedfrom:http://www.utrgv.edu/school-of-medicine/

throughouttheirresidencytraining.• TheDepartmentofPsychiatryisspearheadingthedevelopmentofapre-doctoral

psychologyinternshipprogramaccreditedthroughtheAmericanPsychologicalAssociation.Astheanchorinstitutionfortheinternship,UTRGV-SOMDepartmentofPsychiatry,togetherwithMMHPI,hasengagedlocalstakeholderstobeginplanningatrainingexperience,withthegoalofenticingearlycareerpsychologiststostayonintheRGV.

UTRGV-SOMFindingsUTRGV-SOMFinding1:IntheshorttimesinceUTRGV-SOMhasopened,thepsychiatryresidencyprogramhasalreadycreatedstrongpartnershipswithstateagenciessuchasTTBHandRioGrandeStateCenter,demonstratingthecommitmentofUTRGV-SOMtoretaingraduatingresidentsincommunitypracticewithintheRGV.UTRGV-SOMFinding2:UTRGV-SOMhasinitiateddiscussionswithotherhospitalsintheareatoexplorethepossibilityofcreatingmoreresidencyprogramsaswellasinvolvingmorecommunityinstitutionsintheexistingprograms.PalmsBehavioralHealthhasshownaninterestinhiringadirectorforresidencyprograms,andhasasufficientmodelofcaretobeinvolvedasatrainingsiteforpsychiatryandotherresidencyprograms.BarrierstocreatingpsychiatryresidencyclinicaltrainingsitesatotherhospitalssuchasSouthTexasBehavioralHealthCenterandDoctorsHospitalatRenaissanceincludelimitationsinpsychiatristsandchild/adolescentpsychiatriststoprovidesupervision,funding,andinterestindevelopingtheirownresidencyprograms.UTRGV-SOMFinding3:UTRGV-SOMDepartmentofPsychiatryreceivedseedfundingfromtheHoggFoundationforMentalHealthtosupporttechnicalassistancetodevelopapre-doctoralpsychologyinternshipprogramaccreditedthroughtheAmericanPsychologicalAssociation.TheyalsoreceivedsignificantfundingfromtheLegacyFoundationtosupporttheoveralldevelopmentandimplementationoftheinternshipprogram,aswellasadditionalfundingtohelpestablishtheUTRGVBrainHealthCenter.UTRGV-SOMFinding4:Asthesoleuniversitydepartmentofpsychiatryintheregion,UTRGV-SOMDepartmentofPsychiatryhastheopportunitytotakealeadershiproleintraininganddevelopingbestpracticesacrossthesystem.Thiswouldincludeengagingpsychiatrypractitionersandmentalhealthcommunityprogramsaspartnersinthisendeavor.UTRGV-SOMFinding5:UTRGV-SOMisinitiatingdevelopmentofaregionalstrategicplantoaddresspopulationhealthneeds.TheplanwillbeintegratedintoastatewideplantobeusedfortheentireUTSystem.

UTRGV-SOMRecommendations175UTRGV-SOMRecommendation1:Continuetopartnerwithotherbehavioralhealthentitiesinsurroundingcommunitiestodeveloptrainingexperiences(e.g.,internshipsandresidencies)andemploymentopportunitiesthatsupportrecruitmentandretentionofgraduatingresidents/providersintheRGV.UTRGV-SOMRecommendation2:Continuetoseekoutopportunitiestoconnectandbuildrelationshipswithotherbehavioralhealthprovidersintheareainadditiontothoseprovidingresidencyplacements.ThismayincludeseekingopportunitiestoassistinanyregionalcollaborationdevelopmentsbyofferingtheexpertiseandsupportoftheDepartmentofPsychiatryforimprovingservicesregionally.UTRGV-SOMRecommendation3:ContinuetodevelopaclosepartnershipwiththeactivitiesoftheUTRGVSchoolofPublicHealth–Brownsville,whichhasaverystrongmodelofcommunityservices,physicalhealth/behavioralhealthintegration,andcollectiveimpactintheareaofpopulationhealth.ThispartnershipisprovidingrichlearningopportunitiesforUTRGV-SOMresidentsandtrainees.UTRGV-SOMRecommendation4:Continuetopromoteintegratedbehavioralhealth(IBH)intheregionandprovideemergingprofessionalswithopportunitiestolearnhowtoprovideintegratedcareinateam-basedsetting.UTRGV-SOMRecommendation5:Throughpsychiatryresidencyandpsychologyinternshipexperiences,UTRGV-SOMstudentswouldbenefitfrombeingexposedtoworkingincommunitymentalhealthsettingswheretheyhavetheopportunitytoworkwithlow-incomeandunderservedcommunities,aswellasindividualswithseriousmentalhealthissues.Inthisway,studentsmayseeworkingintheseenvironmentsasaviablecareeroptionratherthangravitatingsolelytowardprivatepracticesettings.UTRGV-SOMRecommendation6:Thedepartmentofpsychiatrycanbealeaderintheschoolofmedicinebyexposingallmedicalschoolstudentstobehavioralhealthcareearlyintheirmedicaleducationandsupportingitsincorporationthroughoutthecurriculumtothegreatestextentpossible.

175UTRGV-SOMRecommendations7-10arebaseduponrecommendationsprovidedinthefollowingreport:UTSouthwesternMedicalCenter(2017,February).Whitepaper:Asummaryoffindingsandrecommendationsdevelopedbyleadersinpsychiatry,education,policyandtrainingfromacrossthestateofTexas.Dallas,TX.

UTRGV-SOMRecommendation7:Continuetoseekoutandparticipateinopportunitiestoconnectwithotherpsychiatryresidencyprogramsacrossthestatetoshareinformationandbestpracticesintrainingstudentsandresidents.UTRGV-SOMRecommendation8:Continuetoprovideopportunitiesforresidentsandstudentstoengageindiversetrainingopportunitiesinthecommunitytolearnhowtobestmeetthehealthneedsofthecommunity.Thismightincluderotationsandtrainingopportunitiesinavarietyoftreatmentenvironments.UTRGV-SOMRecommendation9:Emphasizetheimportanceofthecontinuedrelationshipbetweenstudents,residents,andtheirpatientsacrossthetreatmentprocess;continuetoprovideandenhanceopportunitiesforexperiencesthatpromotetheserelationships.UTRGV-SOMRecommendation10:Continuetoguidestudentsandresidentsinprovidingtreatmentbasedonmeasuredoutcomes,usingdatatobestunderstandhowtomeettheneedsoftheindividualandthecommunity.The University of Texas Rio Grande Valley - Doctors Hospital at Renaissance Family Medicine Clinic

TheUniversityofTexasRioGrandeValley-DoctorsHospitalatRenaissanceFamilyMedicineClinic(UTRGV-DHRFMC),locatedinEdinburg,istheproductofacollaborationbetweenUTRGVSchoolofMedicineandDoctorsHospitalatRenaissance.TheUTRGV-DHRFMCservesasaphysiciantrainingcenterforresidentsinfamilymedicine,providingteam-based,collaborative,integratededucationandhealthcaretrainingtohelpnewphysiciansbestmeettheneedsofthelocalcommunity.176HighlightedAgencyStrengths

• TheUTRGVFamilyMedicineClinic,locatedatDoctorsHospitalatRenaissance,offersintegratedhealthcareservicesusingthePrimaryCareBehavioralHealth(PCBH)model.Atthetimeofoursitevisit,theclinicwasintheprocessofattestingforcertificationasaPatientCenteredMedicalHome(PCMH).

• UTRGVFamilyMedicineClinicstaffprovideservicesprimarilytoindividualswhoareuninsured,havelittleornoaccesstomedicalcare,andoftenexperiencetheaddedstressofseekingserviceswithoutimmigrationdocumentation.Thisprovidesamuchneededservicetoindividualswithsomeofthegreatestbarrierstoaccessingcare.

• TheFamilyMedicineClinicoffersathree-yearresidencyprograminfamilymedicine.Familymedicineresidentsarecoachedinworkingwithbehavioralhealthprovidersand

176Retrievedfrom:http://www.dhr-rgv.com/Newsroom/DHR-UTRGV-Family-Medicine-Center-Opens

consultantsintheirday-to-dayworkaswellasprovidinginstructionstopatientsonseekingbehavioralhealthcareattheclinic.Sinceproviderswhohavenotbeenexposedtothistypeofteam-basedapproachearlyintheircareersoftenfinditdifficulttoworkinIBHsettings,providingthistrainingtoresidentssupportstheimplementationofIBH.

• TheFamilyMedicineClinicisdevelopingaresidencyprograminPreventiveMedicine.WiththehighrateofdiabetesintheRGV,thisisacriticalservicetooffertheregionandtoincorporateintoresidents’training.Trainingprimarycareproviders,psychiatrists,andpreventativemedicinedoctorstogetherinanIBHmodelisapowerfulandinnovativecombinationthatwillbenefitthecommunitycurrentlyservedbytheclinicandindividualsservedbythesephysiciansinthefuture.

UTRGV-DHRFMCFindingsUTRGV-DHRFMCFinding1:TheUTRGVFamilyMedicineClinic,locatedatDoctorsHospitalatRenaissance,offersintegratedhealthcareservicesusingthePrimaryCareBehavioralHealth(PCBH)model.Atthetimeofthekeyinformantinterviews,theclinicwasintheprocessofattestingforcertificationasaPatientCenteredMedicalHome(PCMH)..UTRGV-DHRFMCFinding2:UTRGVFamilyMedicineClinicstaffprovideservicesprimarilytoindividualswhoareuninsured(about70–80%),havenoaccesstomedicalcare,andoftenexperiencetheaddedstressofseekingserviceswithoutimmigrationdocumentation.UTRGV-DHRFMCFinding3:Theclinicemploystwobehavioralhealthconsultantswhoaimtoseeabout10–15%ofthepatientpopulation.Withapatientpanelofaround3,000,theclinicseesanaverageof15-20patientsinanormalclinicday(aboutthreeduringhalf-days),andcurrentlyhasnowaitlistforservices.Oftheprimarycarepatientsthatareservedintheclinic,theBehavioralHealthConsultantsareavailabletoseethemonasame-daybasisbasedonvariousbehavioralandmentalhealthneedsthatarescreenedfor(e.g.,depression)andmayemergeaspartofthevisit(e.g.,insomnia,medicationadherence,motivationforbehaviorslikeexerciseandhealthyeating).UTRGV-DHRFMCFinding4:TheFamilyMedicineClinicoffersathree-yearresidencyprograminfamilymedicine.Familymedicineresidentsarecoachedinworkingwithbehavioralhealthprovidersandconsultantsintheirday-to-dayworkaswellasprovidinginstructionstopatientsonseekingbehavioralhealthcareattheclinic.Psychiatryresidentsandpreventativemedicineresidentsarelikelytoparticipateinthistrainingexperiencewhentheirresidencyprogramsbegin.Currently,theclinicdoesnothaveanybehavioralhealthtrainees,withtheexceptionofafewsocialworkinterns.

UTRGV-DHRFMCFinding5:WithaSíTexasgrantfromMethodistHealthcareMinistriesandtheValleyBaptistLegacyFoundation,theUTRGVFamilyMedicineClinicisabletoprovidea“one-stopshop”forpatientstoreceivebehavioralhealthcareservicesatthesametimetheycometotheclinicforprimarycareservices.EachpatientisscreenedforbehavioralhealthneedsusingthePHQ-9andGAD-7;somehaveco-occurringsubstanceusedisorders.Whiletheclinicdoesnothaveexclusionarycriteriafortheirservices,patientscannotreceiveongoingtraditionalpsychotherapyattheclinic.Leadershipoftheclinicaimtodefinebehavioralhealthmorebroadlyinthefuturetoencompasssuchissuesassmokingcessationandsleephygiene.Suchsystem-widebuy-intobroadenbehavioralhealthbeyondmentalhealthandsubstanceusetoincludepatientactivation,motivation,andcommitmenttobehavioralchangesintheirlifeallowsforapopulationhealthinformedapproachtoprimarycaredelivery.UTRGV-DHRFMCFinding6:AsignificantchallengefortheUTRGVFamilyMedicineClinictoaddressisthehighfacilityfeesthatarechargedtopatients.Theultimatecostforservicesoftendiscouragespatientsfromreturningtotheclinicafteraninitialappointment.UTRGV-DHRFMCRecommendationsUTRGV-DHRFMCRecommendation1:ContinuetoprovideinnovativetrainingexperiencesforFamilyMedicineresidents.Thetrainingprogramforfamilymedicineresidentsisanoutstandingexampleofredefiningthewaythatphysicians-in-trainingareencouragedtotakeaholisticapproachtopatientcare.UTRGV-DHRFMCRecommendation2:Exploreadditionalfundingstreamsandgrantopportunitiestosustaintheclinic’sIBHwork.Becausetheclinicservessuchalargenumberofuninsuredindividuals,itwillbechallengingtosustainitswork.Theclinicmayconsidergettingconsultationortechnicalassistancefordevelopingstrategiestomaximizepartnershipsandaccessnewfundingstreams.UTRGV-DHRFMCRecommendation3:ContinuetoparticipatewiththeUnidosContraDiabetescollectiveimpactgroup.ContinuingactivesupportoftheMedicalIntegrationWorkgroup’seffortswillprovideanopportunitytoensurethatintegratedcareandbehavioralhealthareincludedinastrategytobestaddresshighratesofdiabetesintheregion.UTRGV-DHRFMCRecommendation4:PositiontheFamilyMedicineClinicasaleaderinIBHintheRGVregion.TheclinicmightconsiderofferingtrainingsintheirsuccessfulimplementationofthePCBHmodelandtheIBHtrainingofferedtofamilymedicineresidents.

The University of Texas School of Public Health – Brownsville Regional Campus

TheUniversityofTexas,SchoolofPublicHealth–BrownsvilleRegionalCampus(UTSPH-BRC)wasstartedin2001.TheschoolhasfourfacultyandhasusedconsiderableresourcesfromtheNationalInstituteofHealth,earmarkfunds,foundations(MethodistHealthcareMinistries,ValleyBaptistLegacyFoundation),1115Waiverfunds,andotherstateandfederalfundstohire150stafftoprovidedirectservicesinCameron(primarily)andHidalgocountiesinanefforttohaveadirectimpactoncommunityhealth,whileatthesametimegatheringdataforresearchandhealthimprovementactivities.TheinitialfocusforUTSPH-BRCwastodeterminethetruepopulationhealthneedsintheRioGrandeValley,identifyingobesity(51%ofHispanicmenandwomenareobese),diabetes(27.6%ofadultsaged18yearsandolderhavediabetes),andtheirrelatedconditionsasprioritytargets.177AsUTSPH-BRCconductedmoreresearchonthispopulation,theydiscoveredahighassociationofdepressionwithdiabetesanddeterminedthatthosewhowerediagnosedwithbehavioralhealthconditionshadpooreroutcomeswiththeirdiabetesthanthosewhodidnothavethesediagnoses.Theyalsofoundthatthosewhoknowtheyhavediabetesweresignificantlymorelikelytobedepressedthanthosewhohadundiagnoseddiabetes,suggestinganimportantroleforaddressingdepressionatthetimediabetesisdiagnosed.Additionally,theyhavegathereddataoncognitivefunctioningassociatedwithdiabetesandobesityoutofconcernthatdiabeteshasanearlyeffectoncognition.TheirresearchandoutreachprogramminghasnowextendedtoHidalgoCountyandtoLaredoinWebbCounty.Inordertoaddressissuesrelatedtotheinterplaybetweenphysicalandbehavioralhealth,UTSPH-BRChastakenonanactivistapproachtocollaborativeimpactthroughouttheregion.Thedepartmentcreateda“communityadvisoryboard”whichfunctionsasacollaborativesteeringcommitteeforcommunityhealthimprovementplanning,withacurrentfocusonnutritionandphysicalactivity,includingweightreductionandincreasingexercise,aswellasanemphasisonscreeningfordiabetes(43%ofthosewithdiabetesareundiagnosed)andpre-diabetesintheBrownsvillecommunity.ThedepartmentparticipatesinboththeUnidosContraDiabetesandSíTexaseffortsasananchororganization,bothofwhicharefocusedonpreventingDiabetesandcommittedtoincorporatingbehavioralhealth.TheservicesprovidedundertheauspicesofvariousUTSPH-BRCprojectsareextensive.Recognizingthattheirtargetpopulationisnotgoingtoaccesstraditionalhealthandbehavioralhealthservices,theyhavebroughton150staff,manyofwhomarecommunityhealthworkers(CHWs),toprovidein-homeoutreachandengagementatcommunitylocationsandhealthcenters(SaluddeVidaprimarily)throughouttheregion.Theyhavealsoworkedwiththetwo

177Fisher-Hoch,S.P.,Vatcheva,K.P.,Rahbar,M.H.,&McCormick,J.B.(2015).Undiagnoseddiabetesandpre-diabetesinhealthdisparities.PLoSONE,10(7):e0133135.doi:10.1371/journal.pone.0133135

largefederallyqualifiedhealthclinicstocreatepatient-centeredmedicalhomestoprovidemoreeffectiveandefficientservices–includingbehavioralhealthservices–tolargernumbersofpatients.TheCHWs,whocanreceivecontinuingeducationcreditforMentalHealthFirstAidtraining,facilitatehealthscreeningandperson-centeredconversations,andthenadministerscreeningtools(e.g.,thePHQ-9)ifthereisanyindicationofpossibledepression,followedbyreferraltochurches,localsupports,and,potentially,professionalcounseling.UTSPH-BRChascontractedwithTTBHtoprovidebehavioralhealthconsultantstotheseoutreachworkersandhealthcentersinordertoincreasetheirlikelihoodofengagingindividualsincounsellingandmedicationmanagement,andthereforepromotingbetterhealthoutcomes.Throughthisproject,theyhaveservedover4,000individualsandhaveaseriesofpublishedarticlesthatquantifyhealthburdensandriskfactors,anddocumentthesocial,health,andfinancialimpactofthiswork.HighlightedAgencyStrengths

• UTSPH-BRCdemonstratesastrongcapacitytousecollaborativeimpactandcollectiveimpactstrategiestoimprovepublichealthinCameronCounty,withincreasingoutreachtoothercommunitiesintheregionasawhole.

• Further,UTSPH-BRCrecognizesthehighprevalenceandimpactofoverlappingbehavioralhealthandprimaryhealthneedsintheRGVpopulation,particularlyintheareaofchronicdiseasessuchasdiabetes.

• UTSPH-BRChasdemonstratedthecapacitytoimplementpublichealthstrategiesthatinfluencecommunityhealth,andtocollect(andpublish)datathatevaluatethesuccessofthosestrategies,includingtheimportanceofattendingtobehavioralhealthneeds.

• UTSPH-BRChasattractedconsiderableresourcestoprovidepublichealthservices,reachingover4,000individualswithdiabetes(manyofwhomareuninsuredandhaveco-occurringbehavioralhealthissues)andmanymorethroughpatient-centeredmedicalhomeprogramsandcommunity-widecampaignprogramsin10communities.

• UTSPH-BRCisawareofthestrongstigmaagainstbehavioralhealthintheRGVcommunityandisveryinterestedinbeingapotentialpartnerinanti-stigmaeffortssuchasOkaytoSayandMentalHealthFirstAidtraining.

• Finally,UTSPH-BRCiswillingandabletostepforwardtoprovideadditionalleadershipinintegratingbehavioralhealthintoabroad,collaborativepublichealtheffortthataddresseshealthdisparities,costs,andoutcomesintheregion,andtopartnerwithMMHPIandotherparticipantsintheregioninordertohaveabroaderimpactonpolicyandpractice.UTSPH-BRCisparticularlykeentoengageininnovativepublichealth,population-basedapproachestobehavioralhealth,particularlydepression,anxiety,and,tosomeextent,cognitivefunction.

UTSPH-BRCFindingsUTSPH-BRCFinding1:UTSPH-BRCdemonstrateshowintegratedcommunityoutreachservicescanhaveanimpactonco-occurringdiabetesandbehavioralhealthissues(e.g.,depressionandanxiety)intheRioGrandeValley.Theseeffortshavebeenstudiedandshowntoproducepositiveresults.Thousandsofindividualshavebeenserved,buttheneedsacrosstheRioGrandeValleyaremuchgreaterandgobeyondafocusondiabetestoincludeotherchronicdiseases,aswellassocial,environmental,andeconomicconditions.UTSPH-BRCFinding2:UTSPH-BRChasdemonstratedcapabilityasaconvenerofcollaborativeimpactandcollectiveimpactprojectstoaddresshealthimprovementinCameronCountyandbeyond.Atleastoneoftheseprojectshasbeguntointegrateafocusondepression.Theseprojectsfurtherdemonstrateexistingsuccessfulpartnershipswithstateandlocal(foundation)funders.UTSPH-BRCFinding3:UTSPH-BRCunderstandsthescienceofusingcommunityandpublichealthstrategiestoenhancelargescalesystemimprovementsandiswillingtopartnerwithotherentitiestounderstandhowtointegrateattentiontohealthandbehavioralhealthneedsonabroaderscaleintheregion.UTSPH-BRCisalsopreparedtoevaluatetheimpactofsucheffortsoncostsandoutcomes.UTSPH-BRCFinding4:UTSPH-BRChasbegunarelationshipwiththenewUT-RGVDepartmentofPsychiatryandiswellpositionedtotakeonabroadroleasacommunityconveneronpublichealth.UTSPH-BRCFinding5:UTSPH-BRCdoesnothavemuchexperienceinmentalhealthsystempolicyandfundinginTexasandmayneedguidanceonhowbesttosecurepublicorprivatehealthdeliverysysteminvestmentintheiractivities.UTSPH-BRCRecommendationsUTSPH-BRCRecommendation1:Continuetodevelopandexpandcurrenteffortstoprovideintegratedhealthandbehavioralhealthservicesthroughbehavioralhealthconsultationtocommunityhealthworkers,andcontinuetogatherdatademonstratingtheimpactoftheseservicesoncostsandoutcomes.Expandbehavioralhealthtraining(e.g.,MentalHealthFirstAid)forallcommunityhealthworkersintheregion.Thisisanopportunityforcontinuedstrategicinvestmentbylocalfoundations.UTSPH-BRCRecommendation2:Buildonthecurrenteffortsinprimaryhealth/behavioralhealthintegrationtoengagelargeregionalhealthsystemsingatheringdatathatillustratethepotentialimpactofsucheffortsoncostsandoutcomesforthepopulationstheyserve,andto

illustratethevalueofimplementingthosebroadeffortsasthepaymentsystemmovestoamorequality-focused,at-risk,andoutcome-basedmethodology.UTSPH-BRCcanbeavaluablepartnerandconsultantinsuchefforts.UTSPH-BRCRecommendation4:Engageininnovative,population-basedapproachestobehavioralhealthcarethatraiseculturallyawareness,createcommunityactivitiesthatareknowntoaffectbehavioralhealth(suchasphysicalactivity,nutrition,socialandenvironmentalchanges),andthatarerelatedtopolicychangeswithincommunities.UTSPH-BRCRecommendation5:Becomeinvolvedasakeypartnerorconvener–ineitherCameronCountyoracrosstheregion–indevelopingcollaborativeimpactactivitiesthatfocusonintegratedhealthandbehavioralhealth.Engageineffortsthatarespecificallyfocusedonbehavioralhealthsystemimprovement.UTSPH-BRCRecommendation6:ConsidercontinuingcollaborationwithMMHPIandlocalsystemfunders/providerstoincreasefamiliaritywithmentalhealthsystempolicyandfundinginTexas,aswellasdevelopingeffortstocreatestrategiesforsecuringpublicorprivatehealthdeliverysysteminvestmentintheseactivities.Other Organization Findings OtherOrganizationFinding-1:TheRGVhasadditionalagencieswithamissiontosupportcommunitymemberswithminimalresourcesorpovertywiththeirsocialandmentalhealthneeds.Whiletherearesomeeffortstobringtheseagenciestogether,furtherworkcanbedonetobringthemintostrategicplanningaroundcommonissuesinareassuchasworkforcedevelopment,coordinationofcareandCQIinitiatives.Other Organization Recommendations

OtherOrganizationRecommendation-1:UsingtheCountylevelBHLTstructure,includetheseotheragenciesasinitiativesaredevelopmentandwhenitismostrelevanttoeachagency’smission.InvitetheirparticipationtotheregionwideBHLT,onceestablished.

Physical and Behavioral Health Integration in the RGV Inordertoassesstheintegratedbehavioralhealthcare(IBH)178capacityandneedsintheRioGrandeValley,MMHPIinterviewedadministrativeandclinicalleadersfromthesixprovideragencieslistedinthetablebelow.Priortoconductingtheinterviews,MMHPIrequestedthateachagencycompleteasurveyoncoreaspectsofitsIBHprogram.Additionalkeyinformantswereinterviewedaboutintegratedbehavioralhealthandrelatedissues,includingtheCameronCountyMentalHealthTaskForce,officialsattheBorderRegionHealthCenter,andtheDoctorsHospitalatRenaissanceBehavioralHospital.Thetablebelowsummarizestheprovideragenciesincludedintheassessment,identifiestheirlocationandwhattypeoforganizationtheyare,andprovidesabasicdescriptionofeachagency’sIBHprogrammodel.IBHProgramModelsUtilizedbyRioGrandeValleyProviderOrganizations

Location(s)Typeof

OrganizationDescriptionofIntegratedCareProgram

BrownsvilleCommunityHealthCenter

Brownsville FQHC One(1)embeddedbehavioralhealthspecialistinprimarycareclinic.

HopeFamilyHealthCenter179

McAllen PrimaryCareClinic

SíTexas-fundedHOPEprogramimplementstheIntegratedBehavioralHealthCaremodeltoaddressbothprimarycareandbehavioralhealthcareneedsatthesamefacility.

NuestraClínicadelValle

Edinburg,SanJuan,Mercedes

FQHC Two(2)embeddedbehavioralhealthspecialistsinprimarycareclinicsworkingcollaborativelywithproviders;thedirectorofbehavioralhealthtrainsallstaffinbehavioralhealthscreeningandinterventions.

RioGrandeStateCenterOutpatientClinic

Harlingen State-OperatedOutpatientClinic

SíTexas-fundedIMPACTModel180forolderadultswithdepressionandco-occurringdisorders.

178Weareusingintegratedbehavioralhealthtoreferbroadlytointegratedprimarycareandbehavioralhealthservices,regardlessofthesettinginwhichtheyareprovided.179FormoreinformationontheSíTexasHOPEprogram,see:http://www.hopefamilyhealthcenter.org/what-we-do/integrated-behavioral-health-care.html180ForinformationontheIMPACTmodel(nowmorefrequentlyreferredtoasthe“CollaborativeCareModel”)anditseffectivenesssee:http://aims.uw.edu/impact-improving-mood-promoting-access-collaborative-treatment/.

Location(s)Typeof

OrganizationDescriptionofIntegratedCareProgram

SuClínicaFamiliar

Brownsville,Harlingen,Raymondville,SantaRosa

FQHC IBHprograminplacesince2007;embeddedbehavioralhealthspecialists,socialworkers,andaconsultingpsychiatristinprimarycareclinics.

Brownsville,Edinburg,Harlingen

LMHA Primarycarephysician,registerednurses,andsupportstaffprovideco-locatedprimarycare.

TheUniversityofTexas-RioGrandeValleyMedicalSchool

McAllen PrimaryCareClinic

SíTexas-fundedevidence-basedPrimaryCareBehavioralHealth(PCBH)181model;familymedicineresidenttrainingprogram.

TheUniversityofTexasSchoolofPublicHealth-Brownsville182

Brooks,Cameron,Duval,Hidalgo,JimHogg,JimWells,Kenedy,KlebergStarr,Willacy,Zapata,andWebbcounties

PrimaryCareClinics

SíTexas-fundedSaludyVida2.0programfocusedonenhancingtheSaludyVida1.0chroniccaremanagementprogrambyaddingpatient-centered,IBHcomponentssuchasenhancedprimaryandbehavioralhealthcare,medicationtherapymanagement,andcommunity-basedlifestyleprograms.

Core Integrated Behavioral Health Capacity

Whileprecisefigureswerenotalwaysavailable,weobtainedestimatesofthenumberofpeoplereceivingIBHservicesovera12-monthperiod,relativetoanestimatednumberofpeopleinneed.TheBrownsvilleCommunityHealthCenterestimatedneedbyexaminingmentalhealthscreeningdata,butinothercases,whenneedestimateswerenotavailable,weusedaconservativeestimateof29percentamongprimarycarepopulations.183

181Robinson,PJ.&Reiter,JT.(2015).Behavioralconsultationandprimarycare:Aguidetointegratingservices.2ndedition.NY:Springer.182FormoreinformationontheSíTexasSaludyVida2.0program,see:http://www.mhm.org/library?task=document.viewdoc&id=60183Druss,B.G.,&Walker,E.R.(2011,February).Mentaldisordersandmedicalcomorbidity.ResearchReportNo.21.Princeton,NJ:RobertWoodJohnsonFoundation.

NeedforIBHandEstimatedNeedMetOver12Months,AmongRGVAdultswithMentalHealthConditionsLivingat/below200%oftheFederalPovertyLevel184

ProviderAgencyPopulation/PatientPanel

EstimatedNeedforIBH

12-MonthIBHCapacity

PercentageofNeedMet

BrownsvilleCommunityHealthCenter 22,000 11,000185 120 1%

HopeFamilyHealthCenter Nodataavailable

Nodataavailable

NuestraClínicadelValle 28,000 8,120 1,400 20%

RioGrandeStateCenterOutpatientClinic N/A N/A Noneyetserved N/A

SuClínicaFamiliar Nodataavailable

Nodataavailable 4,200186 Nodata

availableTropicalTexasBehavioralHealth 7,464 5,076187 1,500188 Nodata

available

TheUniversityofTexas-RioGrandeValleyMedicalSchool N/A N/A

Attimeofassessment,hadjustbegunIBH

TheUniversityofTexasSchoolofPublicHealth-Brownsville

Nodataavailable

PrimaryCare 471,287 79,270 5,720

SpecialtyCare(SMI)189 34,760 23,636 1,500

AllAdults190 506,047 102,906 7,220

184Wedidnotincludethosereceivingonlymedicationmanagementwithoutintegratedservices.185EstimateisbasedonBrownsville’sowndata,usingmentalhealthscreeningtools.186Thisisaroughestimate.WedidnothavedataonSuClínica’scapacity.WemultipliedtheNuestraClínicacapacitybythree,giventhattheyhadthreetimesasmanybehavioralhealthspecialistsintheirIBHprogramasdidSuClínica.187BasedonDruss&Walker(citedabove),68%ofthe7,464adultswithSMIservedinongoinglevelsofcare(LOCs)byTTBHwereestimatedtoneedintegratedcare.However,weestimatethatthereare33,061adultswithSMIlivingatorbelow200%ofthefederalpovertylevelintheRGVandmorethan20,000ofthemneedIBH.188WedidnothavedatafromTTBHontheactualnumberreceivingIBH.However,inourexperienceinsimilarprograms,onesitecanserveupto500atanygiventime.TTBHhasthreesites.189Weestimatedthereare34,760adultswithSMIlivingat/below200%oftheFPLintheRGV.190CitingtheNationalComorbiditySurveyReplication,Druss&Walker(citedabove)showedthat68%ofadultswithmentaldisordershavemedicalconditionsand29%ofthe58%ofadultswithmedicalconditionshavementaldisorders.WeusedtheformerpercentageinestimatingtheneedforIBHamongadultswithSMIlivingat/below200%ofthefederalpovertylevelandthelatterfiguretoestimateneedforIBHamongallotheradultslivingat/below200%FPL.Weprovidedamuchsmallerestimateforchildren/youth,onlyfocusingonthesub-populationofchildren/youthwithSED,37%ofwhomhavebeenestimatedtohaveaco-occurringchronicmedicalcondition.

Whilewedonothaveprecisefiguresfromproviders,orevenestimatesinthecaseofsomeproviders,wecanestimatethattheneedforintegratedbehavioralhealthservicesfarexceedsthecurrentcapacitytomeetthatneedintheRioGrandeValley.MostprovidersarekeenlyinterestedindevelopingorgreatlyexpandingtheirIBHcapacities,andmanyareimplementingvariouscomponentsofbestpractices.Prevailing IBH Program Models

Theselectionofaspecificmodelishelpfulinprovidingaframeworkthatisevidence-basedandoffersacommonsetofconceptsandavocabularytowhichallstaffcanrefer.Itcanalsobetterpositionanorganizationforobtaininggrantfundingfromfoundationsandotherentities.TheFourQuadrantModel,outlinedinthefollowingtable,canbeusedtoinplanningwhatIBHmodelismostappropriateforanorganizationbasedupontheclinic’ssub-populations,capacity,andnewprogramsandstaffrequiredtomeettheirIBHneeds.ModifiedFourQuadrantModelforIBHProgramPlanningCareSetting Levels/SeverityofBehavioralHealthandPrimaryHealthConditions

PrimaryCareSetting

QuadrantI(BH:Low,PH:LowtoHigh)

QuadrantIII(BH:Medium,PH:LowtoHigh)

EssentialIntegratedCare–PrimaryCareBehavioralHealthModel

IntensiveIntegratedCare–CollaborativeCareModels

SpecialtyBehavioralHealthSetting

QuadrantII(BH:High,PH:Low/Medium)

QuadrantIV(BH:High,PH:High)

EssentialIntegratedCare–BehavioralHealthPrimaryCareModel

IntensiveIntegratedCare–PersonCenteredHealthcareHome

AbouthalfofprovidersinterviewedforthisreportdonotappeartobeintentionallyimplementingaparticularIBHmodel;theyareembeddingorco-locatingprovidersintheirsettings(behavioralhealthprovidersinprimaryaresettingsandprimarycareprovidersinTropicalTexasBehavioralHealth),referringpeopletothemforcare,andutilizingvaryinglevelsofcoordinationinthosesettings.However,someprovidershavespecificallyadoptedanevidence-basedmodelandinsomecases,theyhavereceivedtrainingfromexpertsinthosemodels.Forexample,theUT-RGVMedicalSchoolclinicinMcAllenspecificallyadoptedandreceivedtraininginthePrimaryCareBehavioralHealth(PCBH)model.TheRioGrandeStateCenterhaschosentoimplementthe

Combs-Orme,T.,etal.(2002).Comorbidityofmentalhealthandchronichealthconditionsinchildren.JournalofEmotional&BehavioralDisorders,10(2),116-125.

evidence-basedIMPACTmodel,avariantoftheCollaborativeCareModel,forolderadultswithdepressionandco-occurringchronichealthconditions.Analysis of IBH Core Components Across Organizations

IncollaborationwiththeSt.David’sFoundation,MMHPIdevelopedareporttitledBestPracticesinIntegratedBehavioralHealth:IdentifyingandImplementingCoreComponents.191Thereport,publishedinAugust2016,identifiedsevencorecomponentsofIBHthatcanbeusedtodeterminetheextenttowhichphysicalhealth(PH)andbehavioralhealth(BH)careisintegrated(versussimplyco-located)forpatients.Thereportoffersaroadmapforproviders,funders,advocates,andpolicymakersinterestedinpromotingIBHandworkingsystematicallytowardachievingitspromise.ThefollowingtableprovidesabriefdefinitionofeachIBHcorecomponentincludedintheSt.David’sFoundationreport.IBHCoreComponents

IntegratedOrganizationalCulture

Theimportanceofbothphysicalandmentalhealthishighlightedinyourorganization’svision,mission,andstrategicplanningdocuments.Leadershipactivelysupportsintegratedcarebypromotingitinallorganizationalfunctions(e.g.,staffdevelopment,performanceassessment,andinformationsystems).

PopulationHealthManagement

Patientsareassessedanddifferentiatedbytheirprimaryco-occurringconditionsandutilizationpatterns.Vitalphysicalhealthandbehavioralhealthoutcomesaretracked.Patientregistriesandotherhealthinformationtechnologiesareusedtomanageoutcomesandcostsacrosspopulationstoapplytherightinterventionsattherighttime.

StructuredTeamApproach

Providerscapableofmeetingbothphysicalandbehavioralhealthneedsare,tothefullestpracticalextent,physicallylocatedinthesamespaceandhaveateam-based,sharedworkflow,withteamhuddles,warmhand-offs,andcontinuouscommunication.

IntegratedBehavioralHealthStaffCompetencies

Providershaveskillssuchaseffectivecollaborationwithcolleagues,patientengagement,andmotivationalinterventionsthatmaydiffersomewhatfromthosedevelopedinthespecialtysettingswheremostprovidersaretrained.

191Toaccessthisreport,pleaseusethislink:http://texasstateofmind.org/wp-content/uploads/2016/09/Meadows_IBHreport_FINAL_9.8.16.pdf.

IBHCoreComponents

UniversalScreeningfortheMostPrevalentPhysicalHealthandBehavioralHealthConditions

Inprimarycare,regularanduniversalscreeningisconductedforcommonmentalhealthandsubstanceuseconditions,andonesassociatedwiththecostliestco-occurringillnesses.Likewise,behavioralhealthsettingsincorporatescreensforcommonandcostlyphysicalhealthconditions.

IntegratedTreatmentPlanning

Eachpatienthasoneintegratedtreatmentplanthatincludesphysicalhealthandbehavioralhealthconditions.

Person-CenteredTreatmentPlanning

Treatmentplansareperson-centered,incorporatingthevalues,lifestyles,andsocialcontextsofthepeoplewhoareobtaininghealthcare.Anexampleofthisisstatingtreatmentgoalsinthepatient’sownwords.

SystematicUseofRelevantEvidence

Providersuseasystematicclinicalapproachthattargetsspecificphysicalandbehavioralconditionsprioritizedforcare,withsharedprotocolsandguidelines.Evidence-basedhealthandwellnessprogramming,whichhelpspeoplelearntomanagetheirillnessesandmakelifestyle/behaviorchanges,isreadilyaccessibletopatients.Thisapproachmayincludetheuseofspecificintegratedcaremodels,suchastheCollaborativeCareorPrimaryCareBehavioralHealthmodels.

Below,wereviewtheoverallstatusoftheimplementationofintegratedcareacrosstheRGVprovidersweinterviewed,utilizingthecorecomponentasalensforcommentingonstrengthsandareasforgrowth.OverallRegionalRatingonLeadershipCulture:MostlyImplemented

ManyRGVprovidershaveembracedIBHandhaveattemptedtoimplementitaswidelyascurrentfundingandresourceswillallow.SomehavedirectorsofIBHorembeddedspecialistswhoareattemptingtoimbuetheentireorganizationwithIBHcompetencies.TheUT-RGVtrainingprogramforfamilymedicineresidentsisanespeciallyoutstandingexampleofanorganizationalcommitmenttoIBHatthemostrudimentaryoflevels(healthprofessionaltraining)byadoptinganevidence-basedmodelandframeworkandhiringexpertstafftoimplementit.TheSocialInnovationFund/CollectiveImpactprojectspearheadedbyMethodistHealthcareMinistries,nowembodiedinUnidosContraDiabetesandseveralgrant-fundedIBHeffortsintheregion,ishelpingtheregionasawholetoadoptanIBHperspective,anditishavingapositiveeffectonproviders.However,manyprimarycareproviderswouldbenefitfromamoreformalincorporationofbehavioralhealthintheirmissionandvisionsstatements,theirstrategicplanning,theirefforts

todiversifypayermixes,andtheirhorizontalorganizationalfunctionssuchashiringpracticesandstaffdevelopment,training,andevaluation(andviceversaforbehavioralhealthproviders).OverallRegionalRatingonPopulationHealthManagement:BeginningtoImplement

Someprovidershavedevelopedcarecoordinationmechanismsandthereareisolatedexamplesofprovidersusingrudimentarypopulationhealthmanagementtechniques,suchaselectronichealthrecord-basedalertsandflagstoaidinillnessmanagement.However,thesystematicexaminationofthepopulation’sintegratedcareneeds,andmatchingspecificIBHprogramsorservicestomeetthoseneedsandtrackthehealthandcost-relatedoutcomes,isnotyetevidentintheRGV.OverallRegionalRatingonStructuredUseofaTeamApproach:InconsistentlyImplemented

Providerswhohaveadoptedspecificevidence-basedIBHmodelsareusingstrongerteam-basedapproachestoIBH.Otherprovidersareusingcarecoordinatorsandcarecoordination,moregenerally,tohelpcoordinateandintegratecareforpeoplewithmorecomplexco-occurringconditions.Andsome,likeTTBH,regularlyemploybehavioralhealthandphysicalhealthstaffingsforclinicalcasereviews.Nevertheless,astrongerpopulationhealthmanagementapproachcouldhelpidentifyclinicalsub-populationswhoareinneedofthetypeofteam-basedcareevidentintheCollaborativeCareModel(includingtheIMPACTversionofit)andtoensurethatteam-basedapproachesareusedtomeettheirneeds.Inaddition,thedevelopmentofmoreroutineteam-generatedassessmentsandtreatmentplansattheindividuallevel,andthedisseminationandadoptionofsharedclinicalpathwaysforcommonphysicalhealth/behavioralhealth(PH/BH)co-occurringconditions(suchasdiabetesanddepression),arealsoneeded.OverallRegionalRatingonIBHStaffCompetencies:InconsistentlyImplementedSomeprogramshaveutilizedexperttrainerstohelpIBHstaffdevelopexpertiseinaparticularmodel.(Again,theUT-RGVfamilymedicineresidentstrainingprogramandclinicisaprimeexample.)However,toachievethefullpromiseofIBH,providersneedtoensurethatembeddedphysicalhealthorbehavioralhealthworkers’rolesaremoreroutinelybroadenedtoallowthemtimetotrainotherstaffinIBHcompetencies.TheNuestraClínicaDelValleFQHCisagoodexample,inthatitsdirectorofbehavioralhealthtrainsphysicalhealthstaffonthebasicsofbehavioralhealthscreeningandothertechniques.Ingeneral,however,muchmoreneedstobedonetotrainPHstaffonbasicinterventionssuchasmotivationalinterviewing,andtotrainbehavioralhealthstaffhowtoroutinelyscreenforcommonphysicalhealthconditionsorhealth-relatedbehaviorssuchassmoking.

ManyprogramsalsoneedtospecificallyidentifyIBHcompetenciesthatworkersshouldhaveandupdatestaffdevelopmentandtrainingplanstoaddressthem.OverallRegionalRatingonUniversalScreening:NearlyFullyImplemented

Nearlyallprogramsweinterviewedwereeitherusinguniversalscreeningorweremovingtowardtheuseofuniversalscreening.TTBHhadbegunusingroutinelaboratorytestsforpeoplewhoareprescribedantipsychoticmedicationandotherpsychotropicmedications,forexample,andtheUT-RGVtrainingprogramcitedabovenotonlyroutinelyusesthePHQ-9andtheGAD-7,butittrainsfamilymedicineresidentsinhowtousetheclinicalrelationshiptoskillfullyprobeforbehavioralhealthissues.Theregionisreadytomovetoanewlevelofidentifyingotherscreensthatcanbeusedbytrainedstafftodetectlessroutinementalhealthconditions(e.g.,notonlydepression,suicidalityandanxiety,butalsopsychosisoreatingdisorders),andlessroutinephysicalhealthconditionsinbehavioralhealthsettings(e.g.,gynecologicalproblems).Overall(Provisional)RegionalRatingonIntegrated,Person-CenteredTreatmentPlanning:InconsistentlyImplementedThisisanareathatouruseofkeyinformantinterviewswasnotabletoassessverywell.Ourimpressionisthatmanyprograms(e.g.,TTBH,UT-RGV)haveworkedhardtodeveloponeelectronichealthrecordthatincludesinformationonbothphysicalhealthandbehavioralhealth.However,wealsohavetheimpressionthatfullyintegratedtreatmentplanningthatisperson-centered(whichisdifficulttoachieve)hasnotyetbeenwidelyimplemented.OverallRegionalRatingonUseofEvidence-BasedClinicalModels:InconsistentlyImplemented

Manyprogramseitherhaveadoptedanevidence-basedIBHmodel(asdescribedintheprevioussectionofthisreport),orhaveutilizedevidence-basedorbestpracticeproceduresorpracticeguidelines–forexample,diabetesmanagementprotocolsatTTBH,ormotivationalinterviewingtechniquesinFQHCs.However,inthisearlystageofthedevelopmentofIBHintheregion(whichistrueforhealthcareingeneral)thereisstilltoomuchrelianceonthemereco-locationofprovidersinsomesettings.Thereisalsoaneedtodevelopsharedclinicalpathwaysthatprovideveryspecificguidancetocliniciansonhowtocollaborateinsuchawaythat,forcommonco-occurringconditions,iscompletelyintegratedandnot“siloed”inthepractice.

IBH Findings

IBHFinding1:ThereisastrongcommitmenttoIBHamongmanyprovidersintheregion,withmanyimplementingsimilaroratleastcomplementaryapproachestocare.ThiscommitmentissharedbyMethodistHealthcareMinistries,theValleyBaptistLegacyFoundation,andotherimportanthealthsystemleadersintheregion,andsetsthestageformoreintentionalcollaborationamongprovidersatseveraldifferentlevels.IBHFinding2:AnencouragingarrayofIBHprogrammingandservicedeliveryhasemergedintheRGV,includingevidence-basedIBHmodels,suchastheCollaborativeCareandPCBHmodels.Exquisitelydesignedtrainingprogramsandambitiousintegratedprogrammingaredevelopinginsomelocations.IBHFinding3:Whilenearlyallsitesshowevidenceofrudimentaryaspectsofintegratedcare(including,forexample,universalscreeningandtestingforbehavioralhealthorphysicalhealthconditions),muchmoredevelopmentisneededforthemoreadvancedaspectsofintegratedcare,suchaspopulationhealthmanagementandthedevelopmentofmorepreciseprotocolsandsharedclinicalpathwaysthatcanservetomakecaretrulyintegratedandwell-organized.IBHFinding4:NotallproviderscanmeettheIBHneedsofallpeopleintheirsettingsand,especiallygiventheuniversally-citedshortageofbehavioralhealthproviders,thereisaneedforcross-providercollaborationtoensurethattherightpeoplereceivetherightcareintherightlocation.Asmentionedabove,providersnowknowenoughaboutIBHtosystematicallycollaborateinthisway,yetfewmemorandaofunderstandingexistbetweenprovidersandmostindicatedtousthatcollaborativeeffortshavemostlydiedoutorfailed.IBH Recommendations

IBHRecommendation1:Whileisolatedexamplesofteam-basedmodelsareevident(forexample,thedevelopmentofanIMPACTprogramforolderadultsattheRioGrandeStateCenter,thePH/BHhomeforpeoplewithdiabetesandbehavioralhealthconditionsatSuClínica,andsomestrongelementsofateam-basedapproachatTTBH),allproviderscouldexaminethepossibilityofdevelopingmoreteam-basedcareforpeoplewiththemostchallengingco-occurringconditionsencounteredintheirsettings.IBHRecommendation2:Eachproviderindividually,andtheregioncollectively,needstodevelopapopulationhealthmanagementapproachtoservingpeoplewithco-occurringPH/BHconditions.TheFourQuadrantModel,describedearlierinthisreport,canbeusedasanefficientproblem-solvingmethodtobeginidentifyingthenumberofpeoplefallingintoeachofseveralclinicalsub-populations,thecurrentcapacitytomeettheirneedsthroughtheimplementationofappropriateIBHmodels,andthenumberofnewprograms(andstaff)neededtomeettheirneeds.

• IBHRecommendation2.a:Patientregistriesandother,simple-to-adoptpopulationhealthmanagementtechnologiescouldbeusedmorewidelyintheRGV’sIBHprograms.

• IBHRecommendation2.b:Someprovidershavespecialprogramsorevenwholeclinicsitesdedicatedtospecificclinicalpopulations(e.g.,women’shealthorpediatrics).Thesesitesrepresentexcellentvenuesforthedevelopmentofpopulationhealthapproachesthattargetspecificco-occurringbehavioralhealthandphysicalhealthneeds.SpecificmodelsaredevelopinginTexasforkeyclinicalpopulations,suchastheDallas-areaintegratedcareprogramforfostercarechildrenwithcomplexco-occurringphysicalhealthandbehavioralhealthconditions.

IBHRecommendation3:Screening,assessing,andreferringpeopletotheappropriateIBHprogramoftenwillrequireproviderstocollaborate.Inparticular,itwouldbeusefulforprimarycareproviderstodevelopmemorandaofunderstanding(MOUs)withLMHAs(particularlyTTBH)thatoutlinetargetpopulations;co-locationofstaffarrangements;referralpractices;sharedresources,particularlyrelatedtotelepsychiatry;clinicaldatasharingprotocols;andmanagementofpsychiatriccrises.TheMOUsalsoshouldaddressprimarycareprotocolsforsharedpatientsinordertomaximizecarecoordinationandminimizeduplicationofmedicalcare.IBHRecommendation4:EffortstoimplementRecommendation3,above,couldbefacilitatedbythedevelopmentofanIBHlearningcollaborativeintheRGV.Providersandtrainingprograms,suchastheUT-RGV,couldusetheexistingcollectiveimpactprogram,called“UnidosContraDiabetes,”asavehiclethroughwhichtosharebestpracticesandengageinregion-widepopulationhealthmanagement.UnidosContraDiabetesfocusesheavilyonintegratedcareforpeoplewithdiabetesanddepression,andprovidesanexistingstructurewithinwhichmanyRGVproviderscollaborate.(However,iftheregion’sleadersandexpertsinIBHfindthatthescopeanddepthrequiredforalearningcollaborativeisbetterattendedtoinanewvenuedevotedonlytoIBH,thenitmightbebettertodevelopsuchanentity,whichcouldhaverepresentationintheUnidosContraDiabetesinordertoensurepropercoordinationacrosstheregion.)

• IBHRecommendation4.a:AnIBHsubgroupofUnidosContraDiabetesshouldrigorouslyexaminetheIBHworkforceintheregionandmakeplansforenhancingit.ThisisalreadyhappeningthroughUnidosContraDiabetes,andmanytrainingprogramsareaddressingtheneed.Thegroupcouldalsotrackthenumberofprimarycareproviders–manyofwhomcanbetrainedthroughembeddedbehavioralhealthspecialistsanddirectorsofbehavioralhealth–whoattainabasiclevelofIBHcompetency.Inaddition,goalsfortraining–andretainingintheregion–familyphysicians,nursepractitioners,psychiatrists,psychiatricnursepractitioners,psychologists,socialworkers,licensedprofessionalcounselors,andlicensedsubstanceusedisordercounselorsshouldbesetandformallytrackedbythegroup.

• IBHRecommendation4.b:TheIBHsubgroupshouldalsotracktheprevalenceofneedforIBHinprimarycareandspecialtybehavioralhealthsettings,byagegroup(child/youth,adult,andolderadult),relativetotheregion’scapacitytomeetthatneed.Itshouldsetmulti-yeargoalsforincreasingthepercentageofneedmet,clarifyandperiodicallyupdatethestrategiesthatwillbeemployed(includingworkforcerelatedstrategies–seeabove),andtrackthepercentageofneedmet.

• IBHRecommendation4.c.TheIBHsubgroupshouldalsotrackoutcomesassociatedwithenhancedIBHintheregion,including,forexample,suicideratespercapitaandbyagegroup,potentiallypreventableemergencyroomandhospitalvisitsandreadmissions,andotherindicatorsofwell-beingasmeasuredbytheBehavioralRiskFactorSurveillanceSystem(BRFSS)andotherongoingmeasuresintheregion.

• IBHRecommendation4.d:Becausemanyprovidershave,orsoonwillhave,expertiseintheimplementationofspecificevidence-basedIBHmodels,aswellasintargetedbehavioralhealthandwellnessinterventions,thelearningcollaborativeshouldcompilealistofregionalexpertise,tracktheimplementationofIBHevidence-basedmodelsacrosstheregion,hostanannualIBHconference,anddevelopatrainingandconsultationcalendarorschedulefordisseminatingandadoptingIBHbestpractices.ThegroupshouldeventuallymovebeyondafocusonIBHprogrammodels(e.g.,CollaborativeCareandPrimaryCareBehavioralHealthmodels),andsharebestpracticesinimplementingsharedclinicalpathways,suchasdiabetes-depressioncare,metabolicsyndrome-seriousmentalillnesscare,andintegratedbehavioralmedicineapproachestosuchcommonmaladiesasinsomnia,headaches,andasthma.

Adult Criminal Justice System Findings and Recommendations Adult Criminal Justice (ACJ) Findings

ACJFinding1:TheMentalHealthOfficerprogramisapromisingpracticethatisnotyetbroughttoscaleacrosstheregion.ACJFinding2:Regardingcrisisresponseandpre-arrestdiversion,acrossmunicipalitiesandcountydepartmentsthereisalackofacultureofdiversion,collaborativepolicydevelopment,trainingefforts,andstrategicplanning,leadingtoalackofpre-arrestdiversionoptionsandpost-arrestconnectiontocare.ACJFinding3:Regardingpost-bookingdiversion,acrosstheregion,thereisalackofadequatein-jailmentalhealthscreeningandconnectiontocare.ACJFinding4:Regardingjail-basedandreentryservices,countyjailersacrosstheregiondonotreceivespecializedmentalhealthtraining.Additionally,localprovidersarenotengagedwithallofthecountiestheyservetoprovidein-jailtreatmentlinkageandreentrycoordination.This

resultsinpeoplewithcomplexneedscyclingthroughthesystemwithoutbeinglinkedtocommunitymentalhealthcare.ACJFinding5:Withtheexceptionofspecializedcaseloads,communitymentalhealthservicesarenotinformedbyrisk.Additionally,firstrespondersandmentalhealthprovidersdonotreceiveinformationonindividualswithcomplexneedsandhighlevelsofserviceutilization,whichleadstoaduplicationofserviceswithoutameasurablyeffectiveoutcome.Adult Criminal Justice (ACJ) Recommendations

ACJRecommendation1:ConsiderevolvingthispromisingpracticebyimplementingamodifiedMentalHealthOfficerTeam(MHOT)modelthatwouldbedevelopedbyTTBHinpartnershipwithvarioussheriffsandpolicedepartments.Modificationcouldincludetheincorporationofparamedicsandpara-medicinefirstresponderstoprovideappropriatecaretoindividualsincrisis.Therelianceonlawenforcementtoprovidementalhealthfirstresponsecouldbelimitedtosituationthatinvolvepublicsafety.Thecurrentmodelincludesfinancialcontributionsfromlawenforcementagenciesandothersources,providesassistanceduringpsychiatriccrisisforinsuredanduninsuredindividuals,andrelievesmostotherofficersonroutinedutyfromtransportingclientsexperiencingemergencies.Localpara-medicineorambulanceproviderscouldbeengagedtoparticipateastheprimarymentalhealthcrisisresponseforcriseswithoutaclearpublicsafetyconcern.BecauseresourceswithinStarrCountyanditslawenforcementagenciesareparticularlylimited,grantfundingcouldbeprioritizedfortheestablishmentofaMHOT.Thiswouldincludestart-upcostsandongoingoperationsoftheMHOT.ACJRecommendation2:Improvethecoordinationofcrisisresponseserviceswithothercommunitycrisisservices.Engageallfirstresponders,includingmedicalfirstresponders,toimplementamultidisciplinaryteamapproachthatwouldprovideservicesonthecrisisscene,managenon-emergencydistresscalls,linkpersonstoservices,andengageindata-drivenoutreachandpreventativeserviceswhilereducingtheneedforlawenforcementtobethefirstrespondersformentalhealthcrisiscare.Establishaninter-departmentalleadershipgrouptodeveloparegion-widestrategicplantoaddressfront-enddiversionneeds.ACJRecommendation3:Solidifyproceduresformentalhealthscreening,identification,Magistration,andbondingtobeincompliancewithTexasCodeofCriminalProcedures16.22and17.032.ACJRecommendation4:Providementalhealthtrainingtocountyjailerstoincreasetherecognitionandresponsetopersonsinneedofmentalhealthcareinthejail.Engagelocalproviders,faithbasedinstitutions,andareanon-profitstoincreasejailin-reachservicesandplanforreentrythatlinkstocommunitycare.

ACJRecommendation5:Ensurecommunitymentalhealthservicesareinformedbyjusticesystempractices.Incorporatetheuseofrisk/need/responsivitymodelsincommunitymentalhealthagenciesforpersonswithfrequentarrests,oronprobationorparole,whoarenotassignedtoaspecialtycaseload.CollaboratewithlocallawenforcementandEMS/medicalfirstresponderstoshareinformationaboutindividualswithcomplexhealthneedswhohavehighlevelsofserviceutilization.Additionally,collaboratewithcommunitycorrectionstocomparecasesofcrisisservicesutilizationwithprobationandparolecaseloads.Forpeopleidentifiedthroughthesecollaborations,providethemwithengagementservices,includingthosewhoarenotyetenrolledinmentalhealthcare.

Appendix A: List of Participants in the System Assessment

SiteVisitParticipants

Name TitleOrganizationalorDepartmentalAffiliation

CountyJudges

ErikaVelasquez-Ryma

ChiefAdministratorforJudgeRamonGarcia

HidalgoCounty

ValdeGuerra CountyExecutiveOfficer HidalgoCounty

AurelioGuerra CountyJudge WillacyCounty

EloyVera CountyJudge StarrCounty

TerryCrocker ChiefExecutiveOfficer

HollyBorel AssociateCEO&COO

HildaGarcia ProgramDirector

DanielGutierrez,MD ChiefMedicalOfficer

StevenVega SubstanceAbuseDirector

JuanAnimas DirectorofTCOOMMI

RickGonzales Director WeslacoClinic

MonikaFlores Manager EdinburgClinic

BrandoMireles Manager EdinburgClinic

MonicaRodriguez YES/WraparoundManager EdinburgClinic

BeatrizTrejo ChiefFinancialOfficer EdinburgClinic

CeliaSolis Controller EdinburgClinic

ConiAguirre ChiefAdministrativeOfficer EdinburgClinic

YolandaParedes DropInCenterPeerCoordinator

EdinburgClinic

CynthiaCash FamilyPartner EdinburgClinic

AdamTrejo PeerSupervisor EdinburgClinic

RickGonzales Supervisor,MHOfficerProgram

EdinburgClinic

JohnLung,MD FamilyPractitioner EdinburgClinic

JohnCantu PrimaryCareSupervisor EdinburgClinic

MaiaBaker DirectorofPrimaryCare EdinburgClinic

JimBanks BusinessDevelopmentDirector

EdinburgClinic

DyanaZamora ServiceAreaManager BrownsvilleClinic

NormaLeija PeerSupervisor BrownsvilleClinic

RomyZarate CertifiedPeerSpecialistPeerProvider

BrownsvilleClinic

JosephinaRomera RN BrownsvilleClinic

LauraSoule Manager HarlingenClinic

AnnaCastilo Supervisor,VeteransServices

HarlingenClinic

DanielCastillon ExecutiveDirector

LauraPalomo Director AdultBehavioralHealthUnit

AldaRendon Directorof1115Waiver

SandraMaldonado Manager StarrClinic

RioGrandeStateCenter

SoniaHernandez-Keeble Superintendent

DavidMoran ClinicalDirector

BlasOrtiz,Jr. AssistantSuperintendent

JaimeFlores MentalHealthServicesDirector

MaryValencia OutpatientClinicDirector

TonyZavaletta

MaryPat Nursing

SeleneMares Nursing

ValleyBaptistHealthSystem

ManuelVela PresidentandCEO

BeckyTresnicky Director,BehavioralHealthServices

CeliaSolis Controller

JoePerez VicePresidentofMinistries

DanielListi ChiefOperatingOfficer ValleyBaptistMedicalCenter-Harlingen

DavidAnthonySaenz,LCSW

SocialServicesManager ValleyBaptistMedicalCenter-Brownsville

CarloEscobar,LCSW ManagerofIOPPrograms ValleyBaptistMedicalCenter-Brownsville

AlejandroKudisch,MD Psychiatrist ValleyBaptistMedicalCenter-Brownsville

KenyaWalker PhysicianAssistant ValleyBaptistMedicalCenter-Brownsville

DoctorsHospitalatRenaissance

IsraelRocha CEO

ArmourForse,MD,PhD ChiefAcademicOfficer DoctorsHospitalatRenaissance

DoctorsHospitalatRenaissance–BehavioralHealthCenter

LindaResendez SeniorVicePresident,ClinicalIntegration

KrystleGonzales,BSN,RN ProgramManager

ManuelAmezquita,RN ClinicalDirector

StarrCountyMemorialHospital

ThaliaMunoz CEO

BehavioralHealthSolutionsofSouthTexas

JoseGonzalez CEO

SouthTexasBehavioralHealthCenter

JoeRodriguez ExecutiveDirector/CEO

PalmsBehavioralHealth

MichaelSauceda,LMSW CEO

BobbyMolina,MHA,MBA BusinessDevelopment

RichardGoldberg CEO PalmsBehavioralHealthCorporateTransitionTeam

MiriamChambliss,JD NurseandOperationsLead PalmsBehavioralHealthCorporateTransitionTeam

JohnAustinPeñaMemorialClinic

EronManusov,MD FoundingChair UTRioGrandeValleySchoolofMedicine,Dept.ofFamilyandPreventiveMedicine

LindaNelson SeniorDirectorofClinicalOperations

UTRioGrandeValley

NuestraClinicadelValle

LucyRamirezTorres ChiefExecutiveOfficer

EricaBonura,PhD DirectorofBehavioralHealth

BrownsvilleCommunityHealthCenter

PaulaGomez ExecutiveDirector

EmilyAlpert ClinicalOperationsDirector

SuClinicaFamiliar

ElenaMarin,MD ExecutiveDirector

LauraLozano DirectorforBehavioralWellnessProgram

ChristinaPerez ChiefOperatingOfficer

DaliaTovar HumanResourcesDirector

TheWoodGroup–RespiteProgram

StacyOtto COO

BeatriceGarcia SiteAdministrator

UTRioGrandeValleyMedicalSchool

FranciscoFernandez ProfessorInauguralDean

LeonelVela,MD SeniorAssociateDeanofEducationandAcademicAffairs

ArdenDingle DirectorofResidencyTrainingProgram

GabrieldeErausquin ChairofPsychiatry

BelindaReininger ProfessorofhealthPromotionandBehavioralScience;InterimChairPopulationHealthandBehavioralSciences

UTRioGrandeValleyMedicalSchool;UTSchoolofPublicHealth

UTRGV-DoctorsHospitalatRenaissanceFamilyMedicineClinic

DeepuGeorge,MD AssistantProfessor/Clinical;DepartmentofFamilyandPreventativeMedicine;DirectorofIntegratedCare

CurtisGalke,DO FamilyPhysician

WesleyHarden,MD DirectorofPreventiveMedicine

AlbertoBernal,MD FirstYearResident

LawEnforcement

RubenVillescas ChiefofPolice PharrPoliceDepartment

RobertGarcia CrimeAnalystandGrantAdministrator

PharrPoliceDepartment

TobinLefler Director Cameron/WillacyCountyCSCD

OmarLucio Sheriff CameronCountySheriff’sDepartment

GusReyna,Jr. ChiefDeputy CameronCountySheriff’sDepartment

ArnoldPatrick ExecutiveDirector HidalgoAdultProbation

MichaelKester AssistantChiefofPolice HarlingenPoliceDepartment

J.E."Eddie"Guerra Sheriff HidalgoCountySheriff’sDepartment

ReyRamirez Sergeant HidalgoCountySheriff’sDepartment

SteveHerrera Captain HidalgoCountySheriff’sDepartment

RubenHinojosa Captain,HidalgoCountyJailOperations

HidalgoCountySheriff’sDepartment

MissyCruz LVN,HidalgoCountyJail HidalgoCountySheriff’sDepartment

AnaMoncivias RN,HidalgoCountyJail HidalgoCountySheriff’sDepartment

BettyRodriguez InmateRehabProgramSpecialist

HidalgoCountySheriff’sDepartment

VictorRodriguez PoliceChief McAllenPoliceDepartment

CommandStaff(Patrol,Fiscal,Training,Investigations,andSpecialInvestigations)

LieutenantsandCaptains McAllenPoliceDepartment

Hon.LarrySpence Sheriff WillacyCountyAdditionalIn-PersonandPhoneInterviewParticipants

Name Title OrganizationalorDepartmentalAffiliation

In-PersonMeetings

EddieOlivarez HealthDirector HidalgoCountyPublicHealthDepartment

SisterNormaPimentel ExecutiveDirector CatholicCharitiesoftheRioGrandeValley

PamMagouirk COO AllegianHealthCare(MCO)

MelissaVillafuerte MedicareAdvantageSalesExecutive

AllegianHealthCare

OrlandoJulian RegionalVPofOperations VBLFCentene(MCO)

StephanieContreras President NAMIoftheRioGrandeValley

Name Title OrganizationalorDepartmentalAffiliation

In-PersonMeetings

RoseGowen CountyCommissioner Brownsville/SuClinicaMD

RosalieTristan CASACoalitionCoordinator WillacyCounty

PhoneInterviews

ErikaVelasquez-Ryma

ChiefAdministratorJudgeRamonGarcia

HidalgoCounty

JerryParker CEO TheWoodGroup

JosephMcCormick,MD,MPH

ChairofPublicHealthDepartment

UTSchoolofPublicHealth-Brownsville

JenniferWood,PhD ActingDeputyChiefofStaff,Administrative

VATexasValleyCoastalBendHealthCareSystem

PamMagouirk COO AlleiganHealthCare

MelissaVillafuerte EnrollmentSpecialistforCameron,HidalgoandWillacycounties

AllegianHealthCare

OrlandoJulian RegionalVPofOperations,McAllen

Centene

Appendix B: Glossary of Acronyms ACE:AdverseChildhoodExperienceACT:AssertiveCommunityTreatmentADA:AmericanswithDisabilitiesActADAC:AlcoholandDrugAbuseCounselingBH:behavioralhealthBHLT:behavioralhealthleadershipteamBSN:bachelorofscienceinnursingCARF:CommissiononAccreditationofRehabilitationFacilitiesCHAMPS:Conversation-Help-Activity-Movement-Participation-SuccessCHW:communityhealthworkerCJ:criminaljusticeCJCC:criminaljusticecoordinatingcommitteeCOPSD:co-occurringpsychiatricandsubstanceusedisorderCQI:continuousqualityimprovementCRCG:CommunityResourceCoordinationGroupCRU:CrisisResponseUnitCSCD:CommunitySupervisionandCorrectionsDepartmentDA:DistrictAttorneyDBA:doingbusinessasDFPS:DepartmentofFamilyandProtectiveServicesDSRIP:DeliverySystemReformIncentivePaymentED:emergencydepartmentEHR:electronichealthrecordEMR:electronicmedicalrecordFEP:FirstEpisodePsychosisFFT:FunctionalFamilyTherapyFPL:federalpovertylevelFQHC:federallyqualifiedhealthcenterFTE:full-timeequivalentFY:fiscalyearHHSC:HealthandHumanServicesCommissionHUG:HighUtilizerGroupIBH:IntegratedBehavioralHealthCarewithPrimaryCareICT:IntegratedCommunityTreatmentIOP:intensiveoutpatient(program)ISD:independentschooldistrictLCDC:licensedchemicaldependencycounselorLCSW:licensedclinicalsocialworker

LMHA:localmentalhealthauthorityLOC:levelofcareLPC:licensedprofessionalcounselorMAT:medication-assistedtreatmentMCO:managedcareorganizationMCOT:MobileCrisisOutreachTeamMH:mentalhealthMHA:MentalHealthAmericaMHMR:mentalhealthandmentalretardationMMF:MidlandMemorialFoundationMMHPI:MeadowsMentalHealthPolicyInstituteMRT:MoralReconationTherapyMST:MultisystemicTherapyMVPN:MilitaryVeteransPeerNetworkNAIP:NetworkAdequacyImprovementProgramNAMI:NationalAllianceonMentalIllnessNOMS:NationalOutcomesMeasurementSystemOSAR:Outreach,Screening,AssessmentandReferralPA:physicianassistantPBIS:PositiveBehavioralInterventionsandSupportPCP:primarycarephysicianPD:policedepartmentSRS:SafeandResponsiveSchoolsPTSD:Post-TraumaticStressDisorderQPR:Question,Persuade,Refer(program)ROSC:recovery-orientedsystemofcareRTC:residentialtreatmentcenterSA:substanceabuseSAMHSA:SubstanceAbuseandMentalHealthServicesAdministrationSE:SupportedEmploymentSED:seriousemotionaldisturbanceSH:SupportedHousingSHS:specialtyhealthsystemSMI:seriousmentalillnessSNOP:SpecialNeedsOffenderProgramSOS:SignsofSuicide(program)START:SkillsTrainingAggressionReplacementTherapySUD:substanceusedisorderTBRI:Trust-basedRelationalInterventionsTCOOMMI:TexasCorrectionalOfficeonOffenderswithMedicalorMentalImpairments

TDCJ:TexasDepartmentofCriminalJusticeTJJD:TexasJuvenileJusticeDepartmentTMACT:ToolforMeasurementofAssertiveCommunityTreatmentTRAS:TexasRiskAssessmentSystemTRY:TopRankYouthVA:VeteransAdministrationWRAP:WellnessRecoveryActionPlanningYES:YouthEmpowermentServices(Waiver)

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