local service area plan - denton county mhmrdentonmhmr.org/pdf/lsap.pdflocal service area plan fy...

Denton County MHMR Center

Local Service Area Plan FY 2011 Draft

4 November 2010

________________________________________________________________________________________________________________________ LSAP FY 2011 DSHS Approved 20101104 page 1 of 79 Markham Jones 3/7/2011 3:26:56 PM

Local Service Area Plan FY 2010 - 2011

4 November 2010


2519 Scripture

Denton Texas 76201-2324

940.381.5000

940.383.1804 fax

www.dentonmhmr.org



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TABLE OF CONTENTS Section, Title Page

1) Title Page ..................................................................................................................................................................................................1 2) Table of Contents......................................................................................................................................................................................2 3) Introduction...............................................................................................................................................................................................6

a. Agency Overview .........................................................................................................................................................................6 b. Service Area & Demographics .....................................................................................................................................................7 c. Purpose of the Center....................................................................................................................................................................9

4) Local Planning Process .............................................................................................................................................................................9 a. Origins and Goals of Local Planning............................................................................................................................................9 b. Local Planning Expectations.......................................................................................................................................................11 c. Current Local Planning ...............................................................................................................................................................11 d. Denton County City Population Demographics .........................................................................................................................13 e. Guidelines for Local Service Area Planning ..............................................................................................................................16

5) Agency Vision, Mission, Philosophy Statements ...................................................................................................................................18 6) General Description of the Center ..........................................................................................................................................................19

a. Historical Development ..............................................................................................................................................................19 b. Organizational Overview............................................................................................................................................................22 c. System Oversight ........................................................................................................................................................................23 d. Organizational Mandates ............................................................................................................................................................25

7) Populations Served..................................................................................................................................................................................25 a. Mental Health (MH) – Adult Population...................................................................................................................................26

i. Mental Health (MH) – Adult Priority Population Definition .........................................................................................26 ii. Mental Health (MH) – Adult Target Population Definition ...........................................................................................26

b. Mental Health (MH) - Children and Adolescent Priority Population Definition .....................................................................26 c. Mental Retardation (MR)/ Intellectual & Developmental Disabilities (IDD) Population Definition ........................................26

8) Services and Supports .............................................................................................................................................................................26 a. Mental Health (MH) - General Services .....................................................................................................................................27 b. Mental Health (MH) - Medication Services ...............................................................................................................................27 c. Mental Health (MH) - Rehabilitation Services...........................................................................................................................29 d. Mental Health (MH) - Residential Services................................................................................................................................29 e. Crisis Services.............................................................................................................................................................................30



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f. Mental Health (MH) – Adult Specific Services..........................................................................................................................31 g. Mental Health (MH) - Children and Adolescent Specific Services............................................................................................34 h. Mental Retardation (MR) / Intellectual & Developmental Disabilities (IDD) Services ............................................................36

9) Local Service Area Planning (LSAP) Process........................................................................................................................................41 a. Mental Retardation / Intellectual & Developmental Disabilities................................................................................................41 b. Mental Health Services ...............................................................................................................................................................41 c. Local Planning Process ...............................................................................................................................................................41

i. Plan Objectives ...............................................................................................................................................................42 ii. Assessment of FY 2005 LSAP Information Supplement Objectives .............................................................................42

iii. Center-Wide Goals..........................................................................................................................................................43 iv. Information Review Survey............................................................................................................................................43 v. Additional Data Information...........................................................................................................................................43

vi. Incorporation of other Center Plans................................................................................................................................44 vii. FY 2008 – 2009 LSAP Review and Monitoring ............................................................................................................44

10) Local Planning & Network Planning (LPND) Process ..........................................................................................................................45 a. Planning Process and Participants ..............................................................................................................................................46

i. Stakeholder Input ............................................................................................................................................................46 ii. Stakeholder Education Efforts ........................................................................................................................................46

iii. Mental Health (MH) Survey Results ..............................................................................................................................47 b. SWOT Analysis ..........................................................................................................................................................................51

i. Strengths .........................................................................................................................................................................52 ii. Weaknesses .....................................................................................................................................................................52

iii. Opportunities...................................................................................................................................................................53 iv. Threats.............................................................................................................................................................................53

c. Priorities and Gaps In Services ...................................................................................................................................................54 d. Planned Changes.........................................................................................................................................................................57

i. Crisis Services Redesign.................................................................................................................................................57 11) Provider Network Development .............................................................................................................................................................58

a. Provider Recruitment ..................................................................................................................................................................58 b. Provider Availability...................................................................................................................................................................59 c. Strategies to Protect Critical Infrastructure.................................................................................................................................61 d. Time Needed to Re-Establish Lost Service Capacity................................................................................................................62

12) Procurement and Transition Timelines...................................................................................................................................................62



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a. Structure of Procurements...........................................................................................................................................................62 i. Mode of Procurement .....................................................................................................................................................62

ii. Timing of Procurement ...................................................................................................................................................63 iii. Proposed Timeframe.......................................................................................................................................................63 iv. Rate Structure..................................................................................................................................................................63 v. Labs.................................................................................................................................................................................64

vi. Pharmacy/PAP ................................................................................................................................................................64 b. Fidelity and Continuity of Care ..................................................................................................................................................65

13) Staff Qualifications .................................................................................................................................................................................65 a. Provider Standards ......................................................................................................................................................................66

14) Consumer Choice....................................................................................................................................................................................68 15) Diversity..................................................................................................................................................................................................68

a. Cultural and Linguistic Diversity Issues.....................................................................................................................................69 16) Capacity Development............................................................................................................................................................................69

a. Cost Efficient ..............................................................................................................................................................................69 b. Previous Network Development Efforts.....................................................................................................................................69 c. Barriers........................................................................................................................................................................................71 d. Long Term Planning ...................................................................................................................................................................71

17) Implementation .......................................................................................................................................................................................76 a. Procurement Timeline.................................................................................................................................................................76

18) Stakeholder Comments on Plan & LMHA Response.............................................................................................................................78 19) Tables

a. Table 1, Denton County City Population Data ....................................................................................................14 b. Table 2, Most Important Factors to Choosing a Provider....................................................................................51 c. Table 3, Most Important or Helpful to Consumer ...............................................................................................51 d. Table 4, Service Areas Where Choice of Providers is Desired ...........................................................................53 e. Table 5, Degree of Satisfaction with Center Services .........................................................................................54 f. Table 6, Gaps in Services – Adult Mental Health ...............................................................................................58 g. Table 7, Gaps in Services – Children and Adolescents Mental Health ...............................................................59 h. Table 8, Gaps in Services – Adult Mental Retardation/Intellectual & Developmental Disabilities....................59 i. Table 9, Gaps in Services – Children’s Mental Retardation/Intellectual & Developmental Disabilities............60 j. Table 10, Staff Qualifications ................................................................................................................................68 k. Table 11, Denton County Diversity Population Data ............................................................................................70



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l. Table 12, Procurement Timeline.........................................................................................................................78 m. Table 13, Stakeholder Comments and LMHA Response ...................................................................................78

20) Resources .......................................................................................................................................................................75 21) Appendices

a. Appendix A - Crisis Services Redesign Implementation Plan b. Appendix B - Jail Diversion Plan c. Appendix C - Local Provider Network Development Plan d. Appendix D - Quality Management Plan

i. Appendix D.1 - Plan to Reduce Abuse & Neglect - Confirmed Cases ii. Appendix D.2 - Consumer Benefits Assistance Plan

iii. Appendix D.3 - Utilization Management Plan



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INTRODUCTION

Agency Overview

The Denton County Mental Health and Mental Retardation Center (DCMHMRC or the Center) is a tax-exempt, contract agency of the State of Texas. It is governed by a nine-member volunteer Board of Trustees (BOT) appointed by the Denton County Commissioner’s Court under legislation enacted by the State of Texas in 1965 under the Texas Mental Health and Mental Retardation ACT. This early legislation provided for the establishment of and contracting for, the operation of Community Centers as Local Mental Health and Mental Retardation authorities. Although not a government agency, Texas Community Centers are considered to be units of local government. This distinction as a local governmental entity is established by the sponsoring governmental entity forming a Center through inter-local governmental agreement. This distinction provides for immunity from certain liabilities, and makes possible the Local Mental Health and Mental Retardation authority roles that enable the Center to act on behalf of the State of Texas to deliver services and determine providers of State funded services. The Center’s sponsoring governmental entity is the Denton County Commissioners Court. The Center was originally established as an outreach center in agreement with Terrell State Hospital in 1970 by the Denton County Health Planning Council and offered counseling and medications to individuals discharged from there. The Center eventually developed into a Community Center to provide mental health and mental retardation services to persons most in need of those services. Especially those individuals identified in the designated priority populations; primarily at risk of local hospitalization, State hospital or school placement; or those being discharged from one of these facilities. The driving principal behind this legislation was that a person with Mental Illness or an Intellectual & Developmental Delay (IDD) should be educated, live, work, and play in their home community – nearest to family and friends. The role of the community-based system was to make this possible by providing services that supported and assisted persons from those priority populations. Although these principles remain at the core of the Center’s current Mission, Vision and Values today, as the needs of the local community and those served have changed over the years, so has the Center. Overtime, the Center has expanded services and adopted innovative best practices; created working partnerships with other service agencies to expand and enhance community service opportunities; and accepted the challenges presented by an ever changing service delivery environment. In developing this Local Service Area Plan, the Center will continue to build on its history and experiences; and strive to assure quality services and public understanding of the Center functions and its service delivery through effective leadership and management at all levels.



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Service Area & Demographics

Denton, Texas is a nationally recognized Main Street City located on the north side of the Dallas/ Fort Worth Metroplex. With Dallas 37 miles to the southeast of Denton via Interstate Highway 35 East and Fort Worth 35 miles to the Southwest via Interstate Highway 35 West. These three cities form an area commonly referred to as the Golden Triangle with the Dallas Fort Worth International Airport (DFW) located twenty-eight miles to the South of Denton via Interstate Highway 35 East and Texas State Highway 121 serving as the virtual Center of this large metropolis. The Center itself serves an area of 888.54 square miles located 30 miles to the South of the North Central border between Texas to Oklahoma. In 2000, the population density of Denton County was reported to be 487. This is 6 times the population density noted for the State of Texas of 80. For 2008, the U.S. Census Bureau (2009) estimated the total population for Denton County was 636,557 individuals. This data indicates that since April 2000, Denton County’s population has grown at a faster rate of 47% than the overall State of Texas average growth of 17%. The population of Denton County also represents a culturally diverse population that is further addressed in the section on Diversity, page 68 of this



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document. Educational data from that report reflects an 89% high school graduation rate, as compared to the 76% statewide average. Persons holding a bachelors degree or higher was 37% versus 23% for the State overall. Persons with a disability and age 5 or older were noted as 47, 873 individuals or 7.5% of the County population. This is down from the 11% calculation estimate reported in 2007. The US Census Bureau (2009) report also indicates that the reported median household income for 2007 had increased from 2004 by almost $10,000 to $71,296. This is significantly higher than the State wide median income of $47,563. The Denton County homeownership rate of 64.4% and the per capita money income of $37,780 are also slightly higher than the State averages reported at 63.8% and $35,166. The number of persons living in poverty in Denton County has also decreased since 2004 from the then reported 8% of the area’s population to 7.1% in 2007 compared to a slight State wide rate increase from 16% in 2004 to 16.3% in 2007. In developing this Plan, the Center will celebrate our communities’ diversity. Acknowledge both our strengths and limitations; and strive to create opportunities to discuss and maintain our strengths while working to address any limitations and the challenges they bring. According to Dr Ray Perryman in his 2007 report on The Texas Economy, the current economic growth rates for Texas and the states major metropolitan areas will achieve compound annual growth rates through 2030 despite the current National woes with raising energy costs, unstable housing markets and increased healthcare costs. This expectation follows the historic trend that has been reflected by other forecasters and reports and reflects what has been the experience of Denton County itself. Other factors to consider from Dr Perryman’s report are the effect of two demographic changes in the State. The first is the increases in overall population within the traditional minority populations in particular as noted above. And second, the upward trend in the median age of the overall Texas population. For 2007, the US Census Bureau (2009) reports shows that only 34,308 or 5.6 % of the Denton County population is persons who are 65 years of age or older, but this does not the on coming aging of the population for the Baby Boomer Generation over the next two decades. Another service area that has been gathering recent attention is services for Veterans. A "civilian veteran" is noted to be a person 18 years old or over, who has served (even for a short time), but is not now serving, on active duty in the U.S. Army, Navy, Air Force, Marine Corps, or the Coast Guard, or who served in the U.S. Merchant Marine during World War II. People who served in the National Guard or military Reserves are classified as veterans only if they were ever called or ordered to active duty, not counting the 4-6 months for initial training or yearly summer camps. All other civilians 16 years old and over are classified as non-veterans. In Denton County this represents 8.7% of the population or an estimated 38,732 individuals All of these factors lead to the need for ever increasing service capacity and an expanding service delivery network for the persons who live and will move into Denton County over the next few decades.



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Purpose of the Center

Denton County Mental Health Mental Retardation Center is first and foremost a Community Center. We initially began operations as the local provider of an array of comprehensive services that would be an effective alternative to placement of a person in a larger state facility or private institution. Our purpose remains one of ensuring a continuum of comprehensive services, supports and opportunities that are easily accessed are available to the residents of our single county region and its local communities. Today those services are those deemed most necessary by our local stakeholders for persons who need publicly supported care, treatment or habilitation from within the provisions of our current performance contracts with the Texas Department of Aging and Disability Services (DADS) and the Texas Department of State Health Services (DSHS).

We also continue in our role as administrator and coordinator of these continued local service delivery process. One of our primary tasks is

the continued refinement of this service provider role within the moving targets and continued changes in state authority and oversight requirements. Another task integral to that process, is that we also strive to identify and maintain appropriate and viable funding streams, as we assimilate the Center into the expanding healthcare fee for services reimbursement environment being developed in the State of Texas and now a federally required mandate under the Health Care Reform act of 2010.

In sum, our local planning efforts are part of an overall strategic process that looks toward our future. Through a process of repeated

assessments of our established long-term goals and change analysis our decision making is based on this information in order to map a path reflective of the current State goals and our shared vision of the future for Denton County. This document serves to communicate those goals, the current Center direction, and the desired outcomes for our local service area as a caring community that includes the persons we serve, their families, our staff members, the general public, local government agencies and other key stakeholders.

The involvement of our stakeholders and coordination with DADS and DSHS under HHS are critical to fulfilling our Center’s mission.

Through these interactions the Center is better equipped to achieve our shared goals to improve those services and supports that enhance the quality of life in Denton County.

LOCAL PLANNING PROCESS

Origins and Goals of Local Planning

In 1992, a statewide vision for the future of Texas was issued that began a cycle of strategic planning and budgeting on a two year schedule.

In 1996, coordinated strategic planning through the Health and Human Services Commission (HHSC) was added to this vision. This Center and other centers across the state under the legacy agency - Texas Department of Mental Health and Mental Retardation (TDMHMR) began developing



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their own local service area plans as a major function of this statewide process that would specify the uniqueness of each service region and reflect their own local concerns. This idea has evolved through the implementation of House Bill 2377, passed by the 74th (1995) Texas Legislature, the subsequent committee report required by House Bill 1734, passed by the 75th (1997) Texas Legislature and passage of House Bill 2292 from the 78th (2003) Regular Legislature Session.

House Bill 2377 articulated the concept of a local mental health and mental retardation authority to which the state authority may delegate

certain aspects of state authority functions. This bill directed local authorities to “consider public input, ultimate cost benefit, and client care issues to ensure consumer choice and best use of public money in the assemble of a network of service providers; and determining whether to become a provider of a service, or to contract that service to another organization.”

House Bill 1734 built upon House Bill 2377 by requiring our legacy agency the Texas Department of Mental Health and Mental Retardation

(TDMHMR) to appoint a committee that would develop a plan for the local mental health and mental retardation authorities system. Consistent with House Bill 2377 local authority functions, the House Bill 1734 committee proposed that the following broad functions become the responsibility of the local authority; planning, policy development, resource allocation, oversight, network development and consumer empowerment.

Through this process, the local authority became responsible for the implementation of a local planning process to identify local needs for

mental health and intellectual & developmental delay services in a manner that reflects the highest level of integrity and stewardship over public resources. The local planning process would also influence local authorities in the assembly and performance management of a provider network that would deliver the best value in service provision and supports for people with a mental illness or intellectual and developmental disabilities.

During FY 2004, our legacy agency the Texas Department of Mental Health and Mental Retardation (TDMHMR) extended the local planning

process from FY 2003 into FY 2004–2005 to assimilate and integrate the radical new legislative action that reshaped the State of Texas’ delivery of human services. House Bill 2292 resulted in the restructuring of all human service delivery agencies into four service areas under the Health and Human Services Commission (HHSC). The planned role out implementation process for this restructuring was to be originally completed by FY 2009; however; this process was initiated and implemented by the State to be fully effected on 1 September 2005. Senate Bill 1182 provided for local community centers to continue to have local planning responsibility with respect to the former mission of the TDMHMR legacy agency at the same time. Another recent influence to the local planning process and delivery of service provision was Article II, Rider 68. This rider called for administrative efficiencies to minimizing overhead and administrative expenses, achieving purchasing efficiencies and restricting the use of funds allocated for mental retardation community waiver services.



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Local Planning Expectations

The primary objective of the local service area plan is to assess local service needs, prioritize them, and to guide resource development and allocation to address those identified needs.

The secondary objective is to contribute information that may influence and direct statewide strategic processes. Our legacy agency, the

Texas Department of Mental Health and Mental Retardation (TDMHMR) and now the Texas Department of Aging and Disability Services (DADS) and the Texas Department of State Health Services (DSHS), has used our acquired information and information from other centers from previously submitted Local Service Areas Plans (LSAP) to guide their own planning activities.

The most extensive use of previous local service area planning information was in the development of the Texas Department of Mental

Health and Mental Retardation’s (TDMHMR) Strategic Plan for FY 2003–2007. This report provided information to share with other state level and human service agencies about mental health and mental retardation priorities. With the reorganization of state health services in September 2005, the Texas Health and Human Services System (HHSC) assimilated TDMHMR into their own Strategic Plan for FY 2005-2009 (2 July 2004). These plans included direct ties to the then TDMHMR FY 2004 legislative appropriations request and subsequent HHSC funding requests and planning. We currently operate under the FY 2007-2011 plan dated 7 July 2006. This process continues to date with the recent publication for comment of the Texas Health and Human Services System’s Draft Strategic Plan for 2011 - 2015 in May 2010.

Current Local Planning

Some of the challenges we continue to face in our local planning process are refinement in the state mental health facility bed day allocation process; the continued and changing impacts of the Texas State Attorney Generals opinion on the application of House Bill 2292’s statutory language to both mental health and mental retardation service as the “provider of last resort”; local capacity issues; and the anticipated implementation of a fee for services reimbursement model.

Other challenges have been found in previous un-funded mandates, which, although potentially beneficial to the person served, incur

additional administrative and direct care efforts and costs to the Center. The continued jail diversion strategy requirements are another example. Other new challenges include the proposed redesign of the Resiliency and Disease Management (RDM) service deliver system for adult and children’s mental health services; which will also require revisions to the service assignment assessment process called the Texas Recommended Assessment Guidelines (TRAG). Other past examples are the narrowed eligibility criteria through revision of the priority population service definitions for all of our service populations, including intellectual and developmental disabilities; and continued compliance with the Co-Occurring Psychiatric and Substance use Disorders (COPSD) provision have all been required in an environment of shrinking fiscal support and coverage.



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A financial imposition first found in the FY 2007 Performance Contracts of increased sanction and penalty events with additional interest accruals on unpaid amounts after 30 days showed some relief from them in FY 2010. But; other state and federally imposed funding reductions due to the recent economic down turn for the Nation are serious matters for considerations through FY 2012. These type of reductions will also continued to have impact on available CHIP coverage and further reductions in statewide transportation services, which impact local planning efforts across the State.

In FY 2008-2009, $4.1 million dollars in new funding was received over the biennium. These funds were a welcome addition for the

expansion of crisis services, but were also limited to improvements in only the deliver of crisis services and follow up to crisis services not continued or on going care.

In FY 2010, the Center found itself to be the recipient of its second major increase in funding from the State to date. These funds made

available under Rider 65, from the 81st Legislature were also directed at Crisis Services Redesign. The Center’s allocations under this provision expanded to $3,916, 986. Service expansion included the provisions of SP 3 & 4 Intensive Ongoing Services and SP 5 Transitional Services. Through FY 2011 the biennium allocation will total $7,841,294.

As we move forward into the second half of this funding biennium for FY 2011 and look towards the FY 2012-2013 biennium, the realization

is that Texas faces a funding shortfall that will effect both Mental Health and Intellectual and Developmental Disabilities service delivery for many years to come. In general, the Center has always reflected the key reduction principles required by the current Legislative Budget Board (LBB) and the Governor’s Offices joint Budget Reduction and Legislative Appropriations Request directives. Those are to –

1) maintain the highest level of services 2) minimize the direct effect on persons served 3) achieve as much administrative savings as possible without jeopardizing oversight and accountability 4) preserve effective prevention programs that help reduce the Center’s costs in the long run, and 5) Preserve community services (safety net)

However; a 5 % fixed base line reduction based on FY 2010 expenditures and the FY 2011 budget with a proposed 10 % further reduction in

GR and GR dedicated funds is more than significant to any community area. As Denton County is the lowest funded per capita Center in the State already these types of reductions will have a dramatic and significant impact upon other County agencies, the public and private enterprises. This becomes even more significant when taken into consideration of the directive to identify services which could be performed by other governmental entities potentially eliminating the need for the State to conduct those services. Historically, this type of logic has resulted in more and more previous State functions being passed into the contracts of the local authorities - without additional funding and in this case reduced funding to perform them.



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Denton County City Population Demographics

Another key driving force behind the local planning process is the growth in both land size and in total population of individual cities within Denton County. This data also correlates with the population grown noted throughout Denton County where the 1 April 2000 Census showed 432,976 persons living in Denton County with an estimated population for 1 July 2005 of 554,642. A corresponding percentage increase is expected for the majority of Denton County as well with an expected population of 643,572 by 2010. The follow table (Table 1, Denton County City Population Data) reflects the current city population estimates made by the North Central Texas Council of Governments for 2010.

Table 1, Denton County City Population Data

% of City

within

Denton

County if

not 100%

Name of City

Name of

County

City

Population

County

Population

City

Population

Density

City

Population

% of Total

Comment

58% Carrollton Denton 122,100 795,485 5768 16%

Denton Denton 110,300 795,485 1794 15%

99% Lewisville Denton 96,450 795,485 2623 13%

99% Flower Mound Denton 62,944 795,485 1540 8%

Denton County Denton 58, 250 795,485 101 8% Non City Resident Total

The Colony Denton 40,100 795,485 2936 5%

18% Frisco Denton 37,252 795,485 2938 5%

2% Dallas Denton 28,109 795,485 4043 4%

Little Elm Denton 24,000 795,485 4948 3% 500% growth in previous decade

Corinth Denton 19,750 795,485 2513 3%

Highland Village Denton 15,250 795,485 2763 2%

Paloma Creek Denton 11,000 795,485 5820 1% New Community



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% of City

within

Denton

County if

not 100%

Name of City

Name of

County

City

Population

County

Population

City

Population

Density

City

Population

% of Total

Comment

99% Trophy Club Denton 8,000 795,485 1963 1%

Roanoke Denton 7,500 795,485 1244 1%

Sanger Denton 7,500 795,485 2389 1%

Lake Dallas Denton 7,300 795,485 3188 1%

Lantana Denton 7,500 795,485 2757 1% New Community

1% Plano Denton 5,380 795,485 6478 1%

Providence Village Denton 5,000 795,485 1% New Community

Savannah Denton 4,900 795,485 1% New Community

Pilot Point Denton 4,100 795,485 1344 1%

Krum Denton 4,000 795,485 2041 1%

Hickory Creek Denton 3,750 795,485 826 < 1%

Argyl Denton 3,400 795,485 305 < 1%

Dish Denton 3,349 795,485 < 1%

Justin Denton 3,150 795,485 1329 < 1%

Oak Point Denton 2,700 795,485 474 < 1%

< 1% Fort Worth Denton 2,678 795,485 2774 < 1%

Double Oak Denton 2,600 795,485 1193 < 1%



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% of City

within

Denton

County if

not 100%

Name of City

Name of

County

City

Population

County

Population

City

Population

Density

City

Population

% of Total

Comment

Aubrey Denton 2,600 795,485 1250 < 1%

Shady Shores Denton 2,450 795,485 845 < 1%

Northlake Denton 2,300 795,485 151 < 1%

Krugerville Denton 1,793 795,485 2490 < 1%

Bartonville Denton 1,400 795,485 232 < 1%

Copper Canyon Denton 1,350 795,485 303 < 1%

Ponder Denton 1,150 795,485 363 < 1%

3% Southlake Denton 813 795,485 1229 < 1%

Cross Roads Denton 702 795,485 102 < 1%

Hackberry Denton 662 795,485 1226 < 1%

Lincoln Park Denton 645 795,485 4300 < 1%

1% Coppell Denton 598 795,485 4013 < 1%

4% Prosper Denton 414 795,485 < 1%

Lakewood Village Denton 398 795,485 545 < 1%

Hebron Denton 271 795,485 67 < 1%

Corral City Denton 142 795,485 3550 < 1%

1% Grapevine Denton 21 795,485 1384 < 1%



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% of City

within

Denton

County if

not 100%

Name of City

Name of

County

City

Population

County

Population

City

Population

Density

City

Population

% of Total

Comment

6% Westlake Denton 15 795,485 < 1%

< 1% Celina Denton 5 795,485 2156 < 1%

< 1% Haslet Denton 3 795,485 211 < 1%

Preparing for the aging of Texas is another factor with significant impact to local planning for service delivery. In 2010, the population of

Texans 60 years and older is projected to be 3.7 million or 14% of the total population. By 2040, the projection is 10 million or 22% of the total population. In order to address this shifting population, the Center will continue to develop and implement initiatives and programs, that build community capacity to serve an aging population, promote overall wellness and increase access to informal care giver services. Over the past decade in Mental Retardation / Intellectual & Developmental Disabilities services there has been a continued shift toward more community services. These services are critical for allowing aging and older Texans and those with disabilities to achieve and maintain independence and community integration. Currently the demand for these services outpaces available funding, despite increases by the Texas legislature over the past three sessions. More than 58,000 individuals are enrolled in various DADS and Star Plus waiver programs across the State, but more 100,400 individuals are on interest lists for these and other services, including more than 1100 persons in Denton County who may be waiting for services as long as 8 to 9 years away.

Guidelines for Local Service Area Planning

Under our current FY 2010-2011 Performance Contract with the Texas Department on Aging and Disability Services (DADS), our requirements as the local mental retardation authority (MRA) are found in Attachment H, on page H-1; and are stipulated to be those found in the

Texas Health and Safety Code (THSC) provision §533.0352 entitled “Local Authority Planning for Local Service Area”.

Under our current performance contract as the local mental health authority (LMHA) with the Texas Department of State Health Services

(DSHS), for FY 2010 -2011, those requirements are found in the Program Attachment 001 A of the Performance Contract Notebook, page 4, and are



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stipulated to be those from the Texas Health and Safety Code (THSC) provision §533.0354 entitled “Local Authority Planning for Local Service

Area” as follows: 1) As the designated Local Mental Health Authority (LMHA) the Local Authorities (LA) shall ensure the development and implementation of a

Local Service Area Plan (LSAP) that is consistent with– a) The DADS/DSHS strategies referenced in the Texas Health and Human Services (HHS) System Strategic Plan

i) FY 2005-2009 (2 July 2004); and ii) FY 2007-2011 (7 July 2006)

b) Adhere to 25 Texas Administrative Code (TAC) Chapter 412, Subchapter P (Provider Network Development) and applicable DSHS directives related to the development and implementation of a LSAP that is inclusive of the Provider Network Development, Diversion Action Plan and Crisis Service Plan.

c) The State’s Guidelines for Local Service Area Planning (February 2005) developed in accordance to THSC §533.0352 and THSC §533.0354; and

d) DSHS’s Jail Diversion Strategies, developed in accordance with THSC §533.0354(d) and THSC §533.108

2) Our current LSAP is posted on the Center’s internet website. 3) In regards to DSHS, update and ensure the LSAP is inclusive of the implementation of jail and detention diversion strategies for adult clients

with serious mental illness and child or adolescent clients with serious emotional disturbances. The strategies must include the following activities:

a) Identification of stakeholders to participate in the development of the Diversion Action Plan. Stakeholders must include mental health providers, clients, family members and child and adult advocates, representatives from law enforcement, probation, and parole departments, and the judiciary.

b) Implementation and oversight of the Diversion Action Plan for adult and juvenile clients c) Train local law enforcement regarding early identification, intervention, and how to access the local mental health system for both

adults and juveniles.

4) Through our local board, appoint, charge and support one or more Planning and Network Advisory Committees (PNACs) as necessary to perform the committee’s advisory functions, as follows:

a) The Center may develop a combined mental health and mental retardation PNAC. If the Contractor develops such a PNAC, the 50% client and family member representation must consist of equal numbers of mental health and mental retardation clients and family members.



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b) The PNAC must be composed of at least ten members, 50% of whom shall be clients or family members of clients, including family members of children or adolescents, or another composition approved by both DADS & DSHS as appropriate;

c) The Center as MRA shall fill any vacancy on the PNAC within 3 months of the creation of the vacancy or within the timeframe required by the MRA’s bylaws.

d) PNAC members must be objective and avoid even the appearance of conflicts of interest in performing the responsibilities of the committee;

e) The Contractor shall establish outcomes and reporting requirements for each PNAC f) The Contractor shall ensure all PNAC members receive initial and ongoing training and information necessary to achieve expected

outcomes g) The Contractor shall ensure that the PNAC receives training and information related to 25 TAC 412 P (Provider Network

Development and that the PNAC is actively involved in the development of the LSAP, including the Provider Network Development Plan;

h) The Contractor shall ensure the PNAC has access to all information regarding total funds available through this DSHS Program Attachment for services in each program area and required performance targets and outcomes;

i) The Contractor shall ensure the PNAC receives a written copy of the final annual budget and biannual plan for each program area as approved by the Contractors Board of Trustees, and a written explanation of any variance from the PNAC’s recommendations;

j) The Contractor shall ensure that the PNAC has access to and report to the Contractor’s Board of Trustee’ at least quarterly on issues related to: the needs and priorities of the LSA; implementation of plans and contracts; and the PNAC’s actions that respond to special assignments given to the PNAC by the local board;

k) The Contractor may develop alliances with other Local Mental Health Authorities (LMHAs) to form regional PNACs.

AGENCY, VISION, MISSION, AND PHILOSOPHY STATEMENTS

Input is solicited from the Public & Network Advisory Committee (PNAC), Executive Management Team (EMT), program administrators, departmental directors, direct care staff and administrative staff throughout the planning year regarding the current mission, vision and values statements of the Center. The consensus observation is that the following items continue to reflect the overall direction of the Center and provides guidance to our current service delivery process.

Mission Statement

Denton County Mental Health Mental Retardation Center enhances the quality of life of the individuals served and their family members.



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Vision Statements

We envision a Denton County Mental Health Mental Retardation Center:

• That provides effective, comprehensive, and timely services to any and all persons in need.

• Where a qualified, motivated, and caring staff strive to make a difference in the lives of those they serve.

• That offers state-of-the-art, high-quality facilities to assist individuals in living full and productive lives.

Values Statement

We respect each individual's unique and special concerns by providing assistance to best fit their needs, that enhances their ability to live a full and dignified life, and that celebrates the contributions all individuals make to our community. Our core values are: Choice; Compassion; Community Inclusion; Dignity; Individual Worth; Integrity; Opportunity; and Respect.

GENERAL DESCRIPTION OF THE CENTER

Historical Development

The history of Denton County Mental Health and Mental Retardation Center is part of a long term developmental progress based on local

public needs –

In 1841, the Texas Congress issued land grants to the Texian Emegration and Land Company. In 1846, Denton County was formed. In 1856, 100 acres of land was donated to form a central county seat. In 1857, this donation was established as the City of Denton. In 1866, the City of Denton was incorporated.



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In 1867, the State of Texas began providing health and human services for its citizens, initially serving those who were blind or deaf and hard of hearing and those with mental illness.

In 1970, after several unfortunate incidents involving psychiatric crises, the Denton County Health Planning Council took up mental health

services as a project. Several public meetings were held and a committee was formed to explore alternatives. In 1971, mental health services were first provided as an outreach from Terrell State Hospital offering counseling and medications to individuals

discharged from that facility. Offices were located in the old Denton City Hall. In 1972, services were expanded to include a greater emphasis on out patient services. A crisis telephone hotline system was added. In 1973, the Denton County Mental Health Unit was incorporated. The administrative offices for this unit were initially located on Eagle Drive. In 1978, Denton, Collin, and Hunt counties elected to form the North Central Texas Mental Health Mental Retardation Services regional office of

the Texas Department of Mental Health Mental Retardation. The Denton County Mental Health Unit began contracting services through the North Central Texas MHMR Services regional office. A satellite clinic was opened in Lewisville.

In 1979, Mental Retardation Liaison and Mental Health Emergency services contracts were added. In 1981, Mental Health Residential Services became available through the Rice Treatment Center, a halfway house. In 1985, a Mental Retardation Home and Community Based Services (HCS) program was added. The Denton County program was one of only

five available programs in the state and the first to be certified. In 1986, the Denton County Mental Health Unit became the Denton County Mental Health Mental Retardation Center. The Center operated

under the auspices of the Wichita Falls State Hospital (now know as North Texas State Hospital) and the Denton State School. In 1987, the Center became the Mental Health Authority (MHA) and Mental Retardation Authority (MRA) for Denton County. At this point

services began to be contracted directly with the Texas Department of Mental Health and Mental Retardation (TDMHMR) to provide a continuum of services to individuals with severe and persistent mental illness and developmental disabilities. Several locations in Denton and Lewisville began providing services to these populations.

In 1989, Denton’s Flow Hospital Closed and the Denton County Mental Health Deputy Program started.



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In 1992, a Child and Adolescent Service unit was added to the services array provided by the Center. The Texas Children’s Mental Health Plan

funded this program to provide innovative services for children and adolescents with mental illnesses. In 1993, the Center opened the Denton Out-Patient Clinic (DOPC) located at 2519 Scripture Street. This building was dedicated to the citizens of

Denton County with mental illness or mental retardation and their families through the vision and leadership of the Board of Trustees and staff. In 1995, the Lewisville satellite office (LOPC) moved to a more easily accessible location at Highway 121 and Southwest Parkway in Lewisville.

This service location continued to provide a full array of services. In 1996, continued growth of services led to the opening of a satellite office in Denton on East McKinney Street (MOPC) to serve as the

administrative site for mental retardation services and housing for the majority of the related mental retardation programs. In addition, the New Foundations, Child and Adolescent Mental Health unit, staff development, and volunteer services were also housed at this location.

In 1997, Denton County MHMR Center celebrated its 10-year Anniversary as the Mental Health and Mental Retardation Authority of Denton

County. The Center purchased land in Lewisville anticipating the increased need for services in the southern part of Denton County. In 1998, the Lakes Regional State Operated Community Services program - the Denton branch of a State Operated Community Center, merged

with the Center creating one of the largest HCS program providers in the state. This merger increased the available mental retardation services provided by the Center as well as doubling the staff.

In 2001, the Center’s ICF/MR residential services program was sold to a private-for-profit provider. In 2004, the Lewisville satellite office was relocated to nearby location that maintained easy access at Highway 121 and Corporate Drive in

Lewisville. This service location continues to provide a full array of services. The center also received grant funding from the Texas Infrastructure Fund (TIF Grant), which we used to expand and enhance our information system. The Center also began receiving a grant through the Department of Housing and Urban Development (HUD) to address service needs of homeless persons. Fiscal refinancing of existing Center Bonds was completed.

In 2005, a local private inpatient psychiatric facility opened in Denton. University Behavioral Health of Denton (UBH) opened its doors to the

community in December 2005 as a 104- bed facility serving children, adolescents, adults, and senior adults in need of mental health and chemical dependency care.



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In 2006, a second local private inpatient psychiatric facility also opened in Denton. The Mayhill Hospital opened on 23 January 2006 providing physical rehabilitation, behavioral health and medical/surgical service units.

In 2009, the Center participated in the development of a local Aging and Disability Resource Center (ADRC) to provide a “no wrong door”

approach to service access through a network of local agencies. The ADRC serves to coordinate information and access to public and private services and supports programs and benefits avoiding the complex and fragmented intake, assessment and eligibility functions that made it difficult for individuals and their families to determine which services were available to them and where to obtain them.

Today – The Center continues to offer a diversified array of services to the residents of Denton County through coordination with other

governmental and private entities to minimize duplication of services and provide the best value for the public dollar. We understand the needs of those we serve and will work to meet those needs within the finite system of available resources provided sufficient funding to maintain our current service delivery system and increased funding to improve those systems are made available to us in order to meet the County’s future growth.

Organizational Overview

The overriding goal of the Center is to respond to the needs of persons with mental illness, mental retardation, autism, pervasive development

disorder, or substance abuse, as well as the needs of their families, by developing, administering and coordinating quality diversified services that is a vital local component in the overall State of Texas’ continuum of services.

In keeping with identified community needs and available funding, the Center has and continues to strive to provide the highest quality of care to our clients who need public supported care, treatment or habilitation by providing a wide array of services to children and adults with mental health diagnosis and a similar array of services for people with mental retardation or developmental disability within the community and as an effective alternative to placement in larger or more restrictive state or privately operated facilities. We have and continue to find new ways to partner with other governmental and private agencies and entities to positively impact and meet the needs of our community while minimizing duplication of services and responsible sharing our State fiscal resources consistent with applicable rules and standards for our identified priority populations.

The Center continues to contract directly with the Department of Aging and Disability Services (DADS) and the Department of State Health

Services (DSHS) to provide a continuum of services to persons with severe and persistent mental illness and developmental delays who are most in need of screening and continuing care services for persons entering or leaving a state facility; charging reasonable rates for services provided; and not denying services to persons because of their inability to pay.

Funding for the center has historically been through federal, state, and local grants such as the –



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• Adult Mental Health Block Grants;

• Child and Adolescent Mental Health Block Grant funds;

• City of Denton;

• City of Lewisville;

• Denton County;

• General Revenue contracts;

• Home & Community-Based Services contracts;

• Housing and Urban Development Grants;

• In Home & Family Services;

• Medicaid;

• Medicare;

• Omnibus Budget Reconciliation Act 1987;

• Texas Commission on Alcohol and Drug Abuse;

• Texas Department of Criminal Justice

The Center currently employs nearly 350 - professional, paraprofessional, and support staff and has a broad network of 170 independent contract providers throughout the local service area. Each staff person attends mandatory training appropriate for their position and annual refresher classes to keep their training current to all state and regulatory guidelines. The Center continues to offer an attractive compensation and benefits package to its employees. The benefits committee consistently reviews this package under the direction of the Board of Trustees and Human Resource staff.

System Oversight The Center is organized along the divisional lines listed below. These system oversight positions works together to provide support and direction to Center departments in refining service delivery, streamlining operations, and facilitating cross-department innovation. The oversight positions are responsible for Center programs and administrative functions.

• Administrator of Human Resources

• Chief Financial Officer

• Chief Operations Officer

• Director of Mental Retardation Services

• Director of Quality Management & Rights Protection



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The Board of Trustees is comprised of a nine-member committee appointed by the County Commissioners. It is an active committee placing emphasis on quality care, fiscal soundness, and staff recognition. Membership includes professional leaders from within our community and each brings a wealth of knowledge to the Center. The Board’s role, as well as that of our Executive Director, is to provide leadership and direction to the Center and its overall operations. Their management style has been flexible and supportive, as the Center has struggled with the changing environment that continues leading to dramatic changes in how the Center operates.

Reorganization to meet changing legislative and performance contract requirements continues to be the primary activity of the Center’s administrative management staff and is reflected in their supervisory functions. Refinement in the implementation of Resiliency & Disease Management (RDM) and its related performance contract service measures and outcome targets has been a major undertaking for mental health services since June 2004. Transitioning of case coordination, skills training and service coordination into routine case management and mental health rehabilitation services required a complete re-training and restructure of staff. The development and implementation of a service delivery/referral system to address Co-Occurring Psychiatric and Substance use Disorders (COPSD) and preparation for the anticipated fee for services payment reimbursement system have been continued areas of focus since January 2004.

We have also been positioning the Center to work with the two State-over sight bodies under two separate contracts due the reorganization of

the State’s health care delivery system under House Bill 2292 (78th Legislative Regular Session) during FY 2006. Fee for service payment reimbursement is closely aligned with submission of required encounter data and the Cost Accounting Methodology (CAM) requirements of the State. The Center is in the process of developing a functional capacity tool model to monitor the Center’s service delivery system, capacity of same, staffing ratios, cost expenses and fiscal viability.

The Center continues to be part of an alliance of Community Centers from the North Central Texas region who have joined-together in an inter-local affiliation as the North Central Texas Coalition (NCTC). Current community center members include Denton County MHMR Center, Helen Farabee in Witchita Falls, LifePath Systems in McKinney, Tarrant County Mental Health and Mental Retardation Center, Pecan Valley Mental Health and Mental Retardation Center, and Mental Health & Mental Retardation Services of Texoma. The primary goal of the coalition is to collaboratively implement an accountable and outcomes oriented service delivery system.

Central to this effort are three tightly integrated objectives:

1) Demonstrate the efficiencies and economies of scale that can be realized through self-determined collaboration; 2) Developing the management and administrative capabilities necessary for competing in a managed care environment, and; 3) Building an attractive, well integrated preferred provider network.

Activities collaborated on within the Coalition by the Center were environmental and financial process support to the coalition, medical

director consultation and oversight, and an after hours crisis hotline service. The Center has also participated in strategic planning sessions with



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Technical Assistance Collaborative, Inc, (TAC, Inc.) on legislative issues key to –

• Mental health and mental retardation service issues during the 78th and 79th Texas Legislative sessions;

• Implementation and refinement of Resiliency and Disease Management Service Delivery system;

• Implementation a fee for service reimbursement funding system;

• Application for HRSA grant for rural behavioral healthcare development, and

• Mental Health residential service alternatives to psychiatric hospitalization

In response to these changing authority/provider roles, and the increased administrative and service delivery requirements under the reduced or eliminated funding, the Center has also vigilantly reorganized its organizational structure dramatically. In the past few years, the Executive Management Team has expanded to include representation of fiscal services, management information systems, quality management, utilization management, authority administrative services, authority essential services, provider services, and human resources.

Organizational Mandates

The Center is legally obligated to be the designated local mental health authority and local mental health retardation authority for Denton County. As such we are charged with the authority and responsibility for planning; policy development; administration and coordination of services, including coordination with criminal justice entities; resource development and allocation for and oversight of mental health and mental retardation services, in the most appropriate and available setting to meet individual needs of the person served in Denton County. The Center is also contractually obligated to expend state general revenue funds for persons under the defined service priority and target populations and to meet established service targets and outcomes in both mental health and mental retardation service delivery.

POPULATIONS SERVED

Since FY 2006, the Texas Department of Health and Human Services (HSSC) has separated the Performance Contract for the Department of Aging and Disability Services (DADS) from the Department of State Health Services (DSHS). In FY 2005, both DADS and DSHS had narrowed their population definitions with DSHS having added an adult mental health target population. This refinement continues in the separated DADS and DSHS FY 2010 – 2011 Performance Contracts as shown below. Denton County Mental Health Mental Retardation Center continues to use our available resources to provide services directly or through contract, to meet the targeted needs for persons in each of our defined priority populations.



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ADULT MENTAL HEALTH POPULATIONS

The Adult Mental Health Priority Population is comprised of adults who have severe and persistent mental illnesses such as schizophrenia, major depression, bipolar disorder, or other severely disabling mental disorders that require crisis resolution or ongoing and long-term support and treatment.

The Adult Mental Health Target Population consists of adults who have a diagnosis of schizophrenia, bipolar disorder, or severe major depression.

CHILD AND ADOLESCENT MENTAL HEALTH PRIORITY POPULATION

The Child and Adolescent Mental Health Priority Population is comprised of children aged 3 through 17 with a diagnosis of mental illness

(excluding a single diagnosis of substance abuse, mental retardation, autism or pervasive development disorder) who exhibit serious emotional, behavioral or mental disorders and who have a serious functional impairment; or are at risk of disruption of a preferred living or child care environment due to psychiatric symptoms; or are enrolled in a school systems special education program because of serious emotional disturbance.

MENTAL RETARDATION / INTELLECTUAL & DEVELOPMENTAL DISABILITES

PRIORITY POPULATION

The DADS Mental Retardation Priority Population consists of

• persons with Mental Retardation, as defined by Texas Health and Safety Code §591.003;

• individuals with a pervasive developmental disorder, as defined in the current edition of the Diagnostic and Statistical Manual, including autism;

• individuals with a related condition listed in the DADS ICD-9CM Diagnostic Codes Guidelines, who are eligible for services in the ICF/MR Program, Home and Community-based Services (HCS) Program, or Texas Home Living (TxHmL) Program;

• nursing facility residents who are eligible for specialized services for mental retardation or a related condition pursuant to Section 1919(e)(7) of the Social Security Act; and

• children who are eligible for Early Childhood Intervention (ECI) services through the Department of Assistive and Rehabilitative Services (DARS)



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The determination of mental retardation and the diagnosis of pervasive developmental disorder and related condition must be made through the use of assessments and evaluations performed by qualified professionals. Individuals who are members of the DADS mental retardation priority population are eligible to receive mental retardation services identified below under the Service and Supports section of this document, as appropriate for the individual’s level of need, eligibility for a particular service, and the availability of that service.

Since resources are insufficient to meet the service needs of every consumer in the mental retardation priority population, services should be

provided to meet the most intense needs first. Intense needs are determined as follows:

• an individual is in danger or at risk of losing his or her support system, especially the living arrangement or supports needed to maintain self;

• an individual is at risk of abuse or neglect;

• an individual's basic health and safety needs are not being met through current supports;

• an individual is at risk for functional loss without intervention or preventive or maintenance services; or

• an individual demonstrates repeated criminal behavior

In addition to members of the DADS mental retardation priority population as defined above, an MRA may serve individuals who have resided in a state mental retardation facility on a regular admission status, but who may not be in the mental retardation priority population.

SERVICE AND SUPPORTS

MENTAL HEALTH - GENERAL SERVICES

Under the guidelines of the Resiliency and Disease Management (RDM) evidence based service delivery model the Center provides the full array of clinical and support services available to adults, adolescents and children. Services available to children and adolescents are further delineated according to the application of designated internalizing and externalizing type diagnostic disorders.

Outreach services are optional activities provided to reach and link to services individuals who often have difficulty obtaining appropriate

behavioral health services due to factors such as acute behavioral symptoms, economic hardship, homelessness, unfamiliarity with or difficulty in accessing community behavioral health care services and other support services, fear of mental illness, and related factors. This service may be provided in a variety of settings, including homes, schools, jails, streets, shelters, public areas, or wherever the individual or the family member of a child or adolescent is found.



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Hotline is a required service of continuously available staffed telephone service providing information, support, and referrals to callers 24 hours per day, seven days per week

Screenings are required activities performed by a Qualified Mental Health Profession-Community Services (QMHP-CS) to gather triage information to determine the need for in-depth assessment. The QMHP-CS collects this information through face-to-face or telephone interview with the individual, caregiver of a child or adolescent, or collateral.

Extended Observation is an optional service of up to 48 hour emergency and crisis stabilization service that provides emergency stabilization in a secure and protected, clinically staffed (including medical and nursing professionals), psychiatrically supervised treatment environment with immediate access to urgent or emergent medical evaluation and treatment. Individuals are provide appropriate and coordinated transfer to higher level of care when needed.

Psychiatric Diagnostic Interview Examination A licensed professional practicing within the scope of their license must provide this service and document as described in the most current version of Title 25 Texas Administrative Code (TAC), Part I, Chapter 412, Subchapter G, Section 412.315(a)(5) MH Community Services Standards.

The Pre-Admission Assessment: QMHP-CS Assessment is a required face-to-face assessment of the individual conducted by a QMHP-CS for the purposes of determining eligibility for services which includes gathering and documenting the information in accordance with 25 TAC, Part I, Chapter 412, Subchapter G, Section 412.314(d)(2) and Section 412.322(a)(1)-(10), MH Community Services Standards.

Engagement Activity are activities with the client or collaterals (in accordance with confidentiality requirements) in order to develop treatment alliance and rapport with the client and includes activities such as enhancing the individual’s motivation, providing an explanation of services recommended, education on service value, education on adherence to the recommended service package and its importance in recovery, and short term planned activities designed to develop a therapeutic alliance and strengthen rapport. This service shall not be provided in a group.

Routine Case Management are primarily site-based services that assist an adult, child or adolescent, or caregiver in gaining and coordinating access to necessary care and services appropriate to the individual's needs. Routine Case Management activities shall be provided in accordance with 25 TAC, Part 1, Chapter 412, Subchapter I, MH Case Management Services. Contractor shall not subcontract for the delivery of these services.

Respite Services are required services provided for temporary, short-term, periodic relief for primary caregivers. Program-based respite

services are provided at temporary residential placement outside the client’s usual living situation. Community-based respite services are to be



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provided by respite staff at the client’s usual living situation. Respite includes both planned respite and crisis respite to assist in resolving a crisis situation.

MENTAL HEALTH - MEDICATION SERVICES

Supplemental Nursing Services are optional services provided to a client by a licensed nurse or other qualified and properly trained personnel working under the supervision and delegation of a physician or Registered Nurse (RN), as provided by state law, to ensure the direct application of a psychoactive medication to the client’s body by any means (including handing the client a single dose of medication to be taken orally), and to assess target symptoms, side effects and adverse effects, potential toxicity, and the efficacy of psychoactive medication for the client and family in accordance with the client’s treatment plan. This service includes such activities as checking a client’s vital signs during a home visit, refilling pill packs, monitoring self-administration of medications, pill pack counts, and evaluating the severity of side effects during a home visit. This service does not include physician services, nursing services incidental to physician services, case management, or the rehabilitative services of "psychiatric nursing services" or "medication related services." This service may be provided in a clinic setting, client home, or other community setting.

The Provision of Medication is a required service to ensure the provision of psychoactive medication benefits to clients registered in the Client Assignment and Registration system (CARE), who have no source of funds for such, as determined to be medically necessary and as prescribed by an authorized provider/representative of the contractor.

MENTAL HEALTH - REHABILITATIVE SERVICES

Crisis Intervention Services are the required interventions in response to a crisis in order to reduce symptoms of severe and persistent

mental illness or emotional disturbance and to prevent admission of an individual or client to a more restrictive environment. Shall be provided in accordance with 25 TAC, Part 1, Chapter 419, Subchapter L, MH Rehabilitative Services. The provision of Crisis Intervention Services to collaterals is limited to the coordination of emergency care services as defined, and outlined in the provision of crisis services within 25 TAC, Part 1, Chapter 412, Subchapter G, MH Community Standards.

Medication Training and Support is the instruction and guidance based on curricula promulgated by DSHS. The curricula includes the Patient/Family Education Program Guidelines referenced in TAC §419.468(3) (relating to Guidelines), and other materials that have been formally reviewed and approved by DSHS. Shall be provided in accordance with 25 TAC, Part 1, Chapter 419, Subchapter L, MH Rehabilitative Services.

Skills Training and Development Services is the required training provided to a client or the primary caregiver or legally authorized representative (LAR) of a child or adolescent that addresses the severe and persistent mental illness, serious emotional disturbance and symptom-



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related problems that interfere with the individual’s functioning, provides opportunities for the individual to acquire and improve skills needed to function as appropriately and independently as possible in the community, and facilitates the individual’s community integration and increases his or her community tenure. This service may address skill deficits in vocational and housing areas and includes treatment planning to facilitate recovery. These services must be provided in accordance with 25 TAC, Part I, Chapter 419, Subchapter L, Medicaid Mental Health Rehabilitative Services.

MENTAL HEALTH - RESIDENTIAL SERVICES

Inpatient Hospital Services are the required hospital services staffed with medical and nursing professionals who provide 24 hour

professional monitoring, supervision, and assistance in an environment designed to provide safety and security during acute psychiatric crisis. Staff provides intensive interventions designed to relieve acute psychiatric symptomatology and restore patient's ability to function in a less restrictive setting. The hospital shall be contracting with or operated by Contractor.

CRISIS SERVICES

Crisis Flexible Benefits are the non-clinical supports that reduce the crisis situation, reduce symptomatology and enhance an individual’s

ability to remain in the home or community. Benefits in adult mental health services include spot rental, partial rental subsidies, respite, utilities, emergency food, house wares, clothing, transportation assistance, and residential services. Examples in children’s mental health services include home safety modifications, child care to allow the family to participate in treatment activities, and transportation assistance.

Safety Monitoring is the ongoing observation of an individual to ensure the individual’s safety. An appropriate staff person must be

continuously present in the individual’s immediate vicinity, provide ongoing monitoring of the individual’s mental and physical status, and ensure rapid response to indications of a need for assistance or intervention. Safety monitoring includes maintaining continuous visual contact with frequent face-to-face contacts as needed.

Crisis Follow-Up and Relapse Prevention are services provided to or on behalf of individuals who are not in imminent danger of harm to self or others but require additional assistance to avoid recurrence of the crisis event. The service is provided to ameliorate the situation that gave rise to the crisis event, ensure stability, and prevent future crisis events.

Crisis Transportation is the transporting of individuals receiving crisis services or Crisis Follow-up and Relapse Prevention services from

one location to another. Transportation is provided in accordance with state laws and regulations by law enforcement personnel, or, when appropriate, by ambulance or qualified staff.



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ADULT MENTAL HEALTH SPECIFIC SERVICES Under the Resiliency and Disease Management service delivery model system the follow services are specific to adult patients only.

Counseling AMH services are individual, family and group therapy focused on the reduction or elimination of a client’s symptoms of mental illness and increasing the individual’s ability to perform activities of daily living. Cognitive-behavioral therapy is the selected treatment model for adult counseling services. Counseling shall be provided by a Licensed Practitioner of the Healing Arts (LPHA), practicing within the scope of his or her own license or by an individual with a master’s degree in a human services field pursuing licensure under the direct supervision of an LPHA, if not billed to Medicaid. This service includes treatment planning to enhance recovery and resiliency.

Consumer Peer Support are activities provided between and among clients who have common issues and needs that are client-motivated, initiated, and/or managed and that allow a client to live as independently as possible. Contractor may use General Revenue funding to assist in the delivery of services provided under Resiliency and Disease Management, or provide outreach through peer facilitated services, e.g., drop in centers, peer counseling, peer support groups, and peer led education groups. This service does not include Mental Health Rehabilitative Services provided by "Peer Providers."

Medication Services: Pharmacological Management AMH is a required service provided to an adult client by a physician or other prescribing professional, in accordance with the Texas Implementation of Medical Algorithms (TIMA) when applicable to the client to determine symptom remission and the medical regime needed.

Rehabilitative Services: Psychosocial Rehabilitative Services –are the required social, educational, vocational, behavioral, and cognitive

interventions provided by members of a client’s therapeutic team that address deficits in the individual’s ability to develop and maintain social relationships, occupational or educational achievement, independent living skills, and housing, that are a result of a severe and persistent mental illness. This service includes treatment planning to facilitate recovery. These services must be provided in accordance with 25 TAC, Part I, Chapter 419, Subchapter L, Medicaid Mental Health Rehabilitative Services.

Rehabilitative Services: Day Programs for Acute Needs provide short-term, intensive treatment to an individual who requires multidisciplinary treatment in order to stabilize acute psychiatric symptoms or prevent admission to a more restrictive setting. Shall be provided in accordance with 25 TAC, Part 1, Chapter 419, Subchapter L, MH Rehabilitative Services

Residential Services: Crisis Stabilization Units are short-term residential treatments designed to reduce acute symptoms of mental illness

provided in a secure and protected clinically staffed, psychiatrically supervised, treatment environment that is licensed under and complies with a



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crisis stabilization unit licensed under Chapter 577 of the Texas Health and Safety Code and Title 25, TAC, Part 1, Chapter 411, Subchapter M (relating to Standards of Care and Treatment in Crisis Stabilization Units).

Residential Services: Crisis Residential Treatment is the short-term, community-based residential treatment to persons with some risk of

harm or who may have fairly severe functional impairment who requires direct supervision and care but do not require hospitalization. Residential Services: Residential Treatment is provided in a twenty-four hour specialized living environment. Services provided include

administration of medications, room and board, and all daily living needs. Adult Foster Care, Personal Care Homes, and Assisted Living Facilities are included in this category.

Specialized Services: Flexible Funds are funds utilized for clinical or non-clinical supports, justified in the treatment plan, to assist clients in developing and maintaining healthy community integration. These supports must also be directly related to the individual's mental illness and recovery process.

• Non-Clinical Supports - Services for assisting individuals to facilitate and support independent living, which are directly related to the individual’s mental illness and recovery process. Services include, but are not limited to: assistance with rent and utility deposits, initial rent/utilities or temporary rental/utilities assistance, house wares, or other necessities.

• Clinical Supports - An array of specialized services in the community that the Local Mental Health Authority does not provide which would assist the individual in his/her treatment. Examples include, but are not limited to: residential COPS-D or detoxification services, or medical/dental assistance related to the individual's behavioral health disorder. Specialized Services: Supported Employment is an array of intensive required services designed to result in employment stability and to

provide individualized assistance to clients in choosing and obtaining employment in integrated work sites in regular community jobs. Includes activities such as - assisting the individual in finding a job, helping the individual complete job applications, advocating with potential employers, assisting with learning job-specific skills, and employer negotiations. This service includes treatment planning to facilitate recovery. Concurrent rehabilitative training should be identified as a separate encounter with the appropriate rehabilitative service code.

Specialized Services: Supported Housing – is an array of activities to assist clients in choosing, obtaining, and maintaining regular, integrated housing. Services consist of individualized assistance in finding and moving into regular, integrated (i.e., no more than 50% of the units may be occupied by clients with serious mental illness), and affordable housing. This service includes:

• Housing assistance in the form of funds for rental assistance (unless the contractor has and documents evidence that housing is affordable for



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people on SSI or that rental assistance funds are guaranteed from another source). To receive rental assistance, clients must be willing to make application for Section 8- Public Housing or have a plan to increase personal income so housing will become affordable without assistance. Housing assistance without services and supports cannot be counted as supported housing.

• Services and supports – are assistance in locating, moving into and maintaining regular integrated housing. This service includes treatment planning to facilitate recovery. While activities that fall under “services and supports” cannot be billed as rehabilitative services, concurrent rehabilitative training should be identified as a separate encounter with the appropriate rehabilitative service code.

Specialized Services: Assertive Community Treatment (ACT) is a team-based program that provides treatment, rehabilitation and support services to clients who have a history of multiple hospitalizations (two or more in 180 days or four or more in two years). Clients identified as needing ACT services shall be prioritized for supported housing, supported employment, and co-occurring psychiatric and substance use disorder (COPSD) services as needed. ACT uses an integrated services approach merging clinical and rehabilitation staff expertise (e.g., psychiatric, substance abuse, vocational/employment, supported housing) within one mobile service delivery system. Accordingly, there will be minimal referral of clients to other programs for treatment, rehabilitation, and support services. Limited use of group activities designed to reduce social isolation, or address substance use/abuse issues is also acceptable as part of ACT. ACT includes an Urban ACT program and Rural ACT program serving clients with an LOC-R = 4. The Urban ACT team serves a client base of 60 or more within a local service area or has a population density of 300 or more persons per square mile in the local service area. The Rural ACT team serves a client base of less than 60 within a local service area. The Urban ACT and Rural ACT programs shall follow the program description, Fidelity Measures, rules and guidelines for Urban ACT and Rural

ACT.

• The Urban ACT team shall maintain a small client-to-staff ratio of 10:1. Urban ACT is a self-contained program with staff members dedicated to the ACT team. The client-to-staff ratio shall take into consideration evening and weekend hours, needs of special populations, and geographical areas to be covered. Flexibility, accessibility, and timeliness of service delivery are reflected in the team’s ability to provide needed support and skills training to clients and their natural support system on evenings and weekends as needed. For all the Urban ACT consumers combined the Urban ACT team shall provide an average of 10 service hours per month; and a minimum of four hours of service per client per month. Services are provided away from the office 80% of the time. The Urban ACT team shall maintain 24 hour responsibility and availability for covering and managing psychiatric crises for Urban ACT clients. Urban ACT team staffing shall include 0.15 full time equivalents (FTE) psychiatrist for every 30 consumers (or 0.25 per 50 consumers) who works directly with and is assigned to the ACT team and at least 1.0 dedicated FTE RN providing direct services. Eighty percent of the ACT team members must have at least a bachelor’s degree or be licensed. This service includes treatment planning to facilitate recovery.



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• The Rural ACT team must maintain a small caseload to include no more than eight ACT consumers (client-to-staff ratio of 8:1) in addition to consumers served in other service packages. Total caseload should be lower than caseloads for staff who serve consumers in service packages other than ACT. The client-to-staff ratio shall take into consideration evening and weekend hours, needs of special populations, and geographical areas to be covered; as well as to provide the intensity of services needed based on the clinical severity for consumers in ACT and to meet service requirements for the consumers they serve in any of the service packages. Flexibility, accessibility, and timeliness of service delivery are reflected in the team’s ability to provide needed support and skills training to clients and their natural support system on evenings and weekends as needed. For all the Rural ACT consumers combined the Rural ACT team shall provide an average of 10 service hours per month; and a minimum of four hours of service per client per month. Services are provided away from the office 80 percent of the time. The Rural ACT team shall maintain 24 hour responsibility and availability for covering and managing psychiatric crises for Rural ACT clients. The psychiatrist shall be available to provide services to individuals in ACT services and shall be available for consultation by Rural ACT team staff at all times. An RN shall be a part of the Rural ACT team, although the RN may also have other duties within a community mental health center. Eighty percent of the ACT team members must have at least a bachelor’s degree or be licensed. This service includes treatment planning to facilitate recovery.

CHILDREN AND ADOLESCENT MENTAL HEALTH SPECIFIC SERVICES

Under the Resiliency and Disease Management (RDM) service delivery model the follow services are only available to adolescents or

children. Intensive Case Management is the required activities to assist a client and their caregiver gain and coordinate access to necessary care and

services appropriate to the individual’s needs. Wraparound Planning is used to develop the Case Management Plan. Intensive Case Management activities must be provided in accordance with 25 TAC, Part I, Chapter 412, Subchapter I, Mental Health Case Management Services. The provider must be a community mental health center and cannot be subcontracted.

Counseling CMH is a required therapy service provided to an individual, family or group focused on the reduction or elimination of a

client’s symptoms of emotional disturbance and increasing the individual’s ability to perform activities of daily living. Counseling must be provided by a Licensed Practitioner of the Healing Arts (LPHA), practicing within the scope of their license or by an individual with a master’s degree in a human services field pursuing licensure under the direct supervision of a LPHA. This service includes treatment planning to facilitate recovery.

Medication Services: Pharmacological Management CMH is a required service provided to a client by a physician to determine symptom

remission and the medical regime needed.



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Residential Services: Children’s Crisis Residential Treatment is the Twenty-four hour, usually short-term residential services provided to a client demonstrating a psychiatric crisis that cannot be stabilized in a less restrictive setting. This service may use crisis beds in a residential treatment center or crisis respite beds.

Specialized Services: Family Case Management is a required service consisting of activities to assist the client’s family members in

accessing and coordinating necessary care and services appropriate to the family members’ needs. The need for family case management must be documented in the client’s case management plan.

Specialized Services: Family Training –is a required service providing training to the client’s primary caregivers to assist the caregivers in

coping and managing with the client’s emotional disturbance. This includes instruction on basic parenting skills and other forms of guidance that cannot be considered rehabilitative skills training. Concurrent rehabilitative training should be identified as a separate encounter with the appropriate rehabilitative service code.

Specialized Services: Family Partner services are a required service where the Family Partners are the experienced parents or primary

caregivers of a child or adolescent with a serious emotional disturbance. The Family Partner is an active member of the Intensive Case Management/Wraparound Team process providing peer mentoring and support to other primary caregivers; introducing the family in the treatment process; modeling self-advocacy skills, providing information, referral and non-clinical skills training; maintaining engagement; assisting in the identification of natural/non-traditional and community support systems; and documenting the provision of all family partner services, including both face-to-face and non face-to-face activities.

Specialized Services: A Parent Support Group is a required service of routinely scheduled support and informational meetings for the

clients’ primary caregivers. Specialized Services: Flexible Funds are the funds used for non-clinical supports that augment the service plan to reduce symptomatology,

and maintain the quality of life and family integration for children. Non-clinical supports must be –

1. Included as strategies in the clients case management plan; 2. Based on the preference of the client and family and focus on outcomes they choose; 3. Monitored for effectiveness by the case manager and adjusted based on effectiveness; 4. Available through GR funding, and 5. Not readily available through other sources (e.g., other agencies, volunteers)



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Flexible community supports include but is not limited to: tutors, family aides, specialized camps, therapeutic child-oriented activities, temporary child care, temporary kinship care, initial job development and placement activities, initial independent living support, transportation services, short-term counseling for family members who do not meet the child or adult priority population definitions. If respite services are provided with flexible community supports, they must be identified with CARE Code TC05.

Specialized Services: Multi-Systemic Therapy (MST) – is an optional comprehensive in-home and community based treatment model.

Services are provided on an average of 8 hours per week. Extensive collaboration with juvenile justice professionals is required.

MENTAL RETARDATION / INTELLECTUAL & DEVELOPMENTAL DISABILITIES SERVICES

A Screening is the optional service provision for gathering information to determine a need for services. This service is performed face-to-

face or by telephone contact with persons. Screening includes the process of documenting a consumer’s initial and updated preferences for services and the MRAs annual contact of consumers on the Mental Retardation Services Interest List. The service does not include providing information and referrals.

An Eligibility Determination is the required interview and assessment or an endorsement conducted in accordance with Texas Health and Safety Code, §593.005, and 40 TAC Chapter 5, Subchapter D to determine if an individual has mental retardation or is a member of the mental retardation priority population.

Service coordination is the assistance in accessing medical, social, educational and other appropriate services and supports that will help a

consumer achieve a quality of life and community participation acceptable to the consumer as described in the Plan of Services and Supports. Service coordination functions consists of

• an Assessment to identify a consumer’s needs and the services and supports that address those needs as they relate to the nature of the consumer's presenting problem and disability;

• Service planning and coordination are activities to identify, arrange, advocate, collaborate with other agencies, and link for the delivery of outcome-focused services and supports that address the consumer’s needs and desires;

• Monitoring activities to ensure that the consumer receives needed services, evaluating the effectiveness and adequacy of services, and determining if identified outcomes are meeting the person's needs and desires; and

• Crisis prevention and management activities that link and assist the consumer to secure services and supports that will prevent or manage a crisis



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The plan of services and supports is based on a person-directed process that is consistent with the DADS Person Directed Planning

Guidelines and describes the consumer's desired outcomes; and the services and supports including service coordination services, to be provided to the individual, with specifics concerning frequency and duration. This service category includes the following:

• Basic Service Coordination is performed in accordance with 40 TAC Chapter 2, Subchapter L, for a consumer who has been assessed as having more than one need and who is not residing in an ICF/MR, including a state supported living center SSLC or enrolled in the TxHmL or HCS Program

• Continuity of Services are activities performed in accordance with: o 40 TAC Chapter 2, Subchapter F, for a consumer residing in a SSLC whose movement to the community is being planned or for a

consumer who formerly resided in a state facility and is on community-placement status, or o Article II. B. 6 of the current DADS Contract for a consumer enrolled in the ICF/MR program to maintain the consumer’s placement

or to develop another placement for the consumer.

• Service Authorization and Monitoring are the required services provided to a consumer who is assessed as having a single need (provision of this service counts toward Total Served if the consumer is receiving no other general revenue-funded mental retardation service).

• Service Coordination – HCS or Texas Home Living Program are the required service coordination activities for individuals enrolled in the HCS or Texas Home Living (TxHmL) Program in accordance with 40 TAC Chapter 9, Subchapter D or N

• MR Community Services are services provided to assist an individual to participate in age-appropriate community activities and services. The type, frequency, and duration of support services are specified in the individual’s plan of services and supports. The MRA ensures that an array of support services is available in the LSA. This service category includes:

• Community Support is the optional individualized activities that are consistent with the individual’s person-directed plan and provided in the individual’s home and at community locations, (e.g., libraries and stores). Supports include:

o Habilitation and support activities that foster improvement of, or facilitate, an individual’s ability to perform functional living skills and other daily living activities;

o Activities for the individual’s family that help preserve the family unit and prevent or limit out-of-home placement of the individual; o Transportation for an individual between home and the individual’s community employment site or day habilitation site; and o Transportation to facilitate the individual’s employment opportunities and participation in community activities.

• Respite is the required planned or emergency short-term relief services provided to the individual’s unpaid caregiver when the caregiver is



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temporarily unavailable to provide supports due to non-routine circumstances. This service provides an individual with personal assistance in daily living activities (e.g., grooming, eating, bathing, dressing and personal hygiene) and functional living tasks. The service includes assistance with: planning and preparing meals; transportation or assistance in securing transportation; assistance with ambulating and mobility; reinforcement of behavioral support or specialized therapies activities; assistance with medications and the performance of tasks delegated by an RN in accordance with state law; and supervision of the individual’s safety and security. The service also includes habilitation activities, use of natural supports and typical community services available to all people, social interaction, and participation in leisure activities, and assistance in developing socially valued behaviors, daily and functional living skills.

• Employment Assistance: is an optional service providing assistance to an individual in locating paid, individualized, competitive employment in the community, including helping the individual identify their own employment preferences, job skills, work requirements and conditions, and identifying prospective employers offering employment compatible with the consumer’s identified preferences, skills and work requirements and conditions.

• Supported Employment is an optional service provided to an individual who has paid, individualized, competitive employment in the community (i.e., a setting that includes non-disabled workers) to help the individual sustain that employment. It includes individualized support services consistent with the individual’s person-directed plan as well as supervision and training.

• Behavioral Supports are the optional specialized interventions by professionals with required credentials to assist an individual to increase adaptive behaviors and to replace or modify maladaptive behavior that prevent or interfere with the individual’s inclusion in home and family life or community life. Support includes assessing and analyzing assessment findings so that an appropriate behavior support plan may be designed; developing an individualized behavior support plan consistent with the outcomes identified in the individual’s plan of services and supports; training and consulting with family members or other providers and, as appropriate, the individual; and monitoring and evaluating the success of the behavioral support plan and modifying the plan as necessary.

• Nursing is the optional treatment and monitoring of health care procedures prescribed by physician or medical practitioner or required by standards of professional practice or state law to be performed by licensed nursing personnel.

• Specialized Therapies are the optional assessment and treatment by licensed or certified professionals for social work services, counseling services, occupational therapy, physical therapy, speech and language therapy, audiology services, dietary services, and behavioral health services other than those provided by a local mental health authority pursuant to its contract with the Department of State Health Services (DSHS); and training and consulting with family members or other providers.



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• Vocational Training are optional day training services provided to an individual in an industrial enclave, a work crew, a sheltered workshop, or an affirmative industry, to enable the individual to obtain employment. Contract funds are not used for the cost of production.

• Day Habilitation are optional service activities of assistance with acquiring, retaining, or improving self help, socialization, and adaptive skills necessary to live successfully in the community and to participate in home and community life. Individualized activities are consistent with achieving the outcomes identified in the individual’s person-directed plan and activities are designed to reinforce therapeutic outcomes targeted by other service components, school, or other support providers. Day habilitation is normally furnished in a group setting other than the individual’s residence for up to six (6) hours a day, five days per week on a regularly scheduled basis. The service includes personal assistance for individuals who cannot manage their personal care needs during the day habilitation activity as well as assistance with medications and the performance of tasks delegated by a RN in accordance with state law.

• Residential Services are optional twenty-four hour services provided to an individual who does not live independently or with his/her natural family. These services are provided by an employee or contractor of the MRA who regularly stays overnight in the individual’s home. This included the follow service categories:

• Family Living provides residential services to no more than three individuals living in a single residence that is not a contracted specialized residence.

• Residential Living provides residential services to more than three individuals living in a single residence that is not a contracted specialized residence.

• Contracted Specialized Residences are residential services provided to an individual in a general hospital, a substance abuse program, an autism program, or an AIDS hospice.

• Medicaid Waiver Programs are home and community-based programs providing services and supports to persons with mental retardation who live in their own or their family home or in other home-like settings in the community. They are called "waivers" because certain ICF/MR requirements are "waived." In most situations an individual who is eligible for the ICF/MR Program is also eligible to participate in one of the waiver programs. An important and distinguishing feature of funding provided in the waiver program is the ability to move that funding source with the individual to any part of the state. For example, if an individual enrolled in a waiver program in Houston, then moves to El Paso, they can continue to participate in the waiver program in El Paso. An individual also can change providers within the same city or county. Public or private entities may provide waiver program services and supports. All waiver providers are certified by DADS initially who then reviews each provider at least annually to ensure the provider continues to meet the program certification principles. The two waiver programs are:



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o The Home and Community-based Services (HCS) Program: The HCS Program provides services to individuals with mental

retardation who live with their family, in their own home, in a foster or companion care setting, or in a residence with no more than four individuals who also receive services. The HCS Program provides services to meet an individual's needs so that they can maintain themselves in the community and have opportunities to participate as a citizen to the maximum extent possible. Services consist of case management, adaptive aids, minor home modifications, counseling and therapies, dental treatment, nursing, residential assistance, respite, day habilitation, and supported employment. In the HCS Program, individuals pay for their room and board either with their SSI check or other personal resources. There is a limit to the yearly cost of services provided through the HCS Program.

o The Texas Home Living (TxHmL) Program: The TxHmL Program provides essential services and supports so that individuals with

mental retardation can continue to live with their families or in their own homes in the community. TxHmL services are intended to supplement instead of replace the services and supports an individual may receive from other programs, such as the Texas Health Steps Program, or from natural supports such as his or her family, neighbors, or community organizations. Services consist of community support, nursing, adaptive aids, minor home modifications, specialized therapies, behavioral support, dental treatment, respite, day habilitation, employment assistance, and supported employment. Service coordination is provided to the individual by the MRA. TxHmL Program services are limited to a yearly cost of $10,000 per participant.

o If an individual’s name is on the Interest list for the HCS Program, they may be offered an opportunity to enroll in the TxHmL

Program. If the individual enrolls in TxHmL, their name will remain on the Interest List for the HCS program.

o If an individual is offered an opportunity to enroll in either the HCS or TxHmL Program, the Center will provide information about the applicable timelines for enrollment.

o A review of the Medicaid Estate Recovery Program is provided by the Center’s enrollment staff in accordance with Texas

Administrative Code, Title 1, Part 15, Chapter 373 Medicaid Estate Recovery Program (MERP), to all consumers and their legally authorized representatives, who seek enrollment in a State MR Facility, a community ICF/MR, HCS or TxHmL

The In-Home & Family Support (IHFS) Program – MR is a grant program authorized by the Texas Health and Safety Code, Chapter 535,

administered by the MRA. The program disburses specifically appropriated general-revenue funds as assistance of up to $2500.00 per year to eligible individuals and families to pay for services or items that meet a need that exists solely because of the individual's mental disability or co-occurring physical disability, as defined in 40 TAC Chapter 1, Subchapter I § 1.404 and that 1) directly supports the individual to live in his or her natural home; 2) integrates the individual into the community; or 3) promotes the individuals self-sufficiency. IHFS does not provide assistance for the sole purpose of improving the living conditions of eligible persons or families living at or below the poverty level. Assistance is neither an



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entitlement nor an income supplement. The program is resource of last resort; therefore, assistance may not be used to supplant items available to an eligible individual or family through any other support program (including MRA provided services) or third-party resource. IHFS provides assistance in accordance with 40 TAC Chapter 1, Subchapter I, and to the extent funds are available. Eligibility for IHFS is not limited to consumers who are currently receiving other general-revenue funded services from the MRA

The information in the consumer’s written plan must be consistent with the CARE data entered in Screen 460. The MRA may not use any appropriated IHFS Program – MR funds to pay for indirect cost related to the IHFS Program – MR.

LOCAL SERVICE AREA PLANNING PROCESS

Mental Retardation (MR) / Intellectual & Developmental Disabilities (IDD) The Center is the designated local Mental Retardation Authority (MRA) for the Denton County service area. As the local MRA, the Center has the responsibility to ensure that funds received from the Texas Department of Aging & Disability (DADS), are utilized appropriately and efficiently within Denton County.

Mental Health Services

The Center is also the designated Local Mental Health Authority (LMHA) for the Denton County service area. As the local LMHA, the

Center has the responsibility to ensure that funds received from the Texas Department of State Health Services (DSHS), are utilized appropriately and efficiently within Denton County.

Local Planning Process

The combined DADS & DSHS FY 2010 – 2011, local service area planning process is a continuation of the planning processes that began

during development of the FY 2000 Local Plan; continued into planning for the FY 2004 – 2005 Local Service Area Plan; and the development of the FY 2005 Local Service Area Plan Supplement. The current LSAP review process began in September 2009, with ongoing input and feedback requested from the Planning & Network Advisory Committee (PNAC), Executive Management Team (EMT), other Center staff, input from individuals served and their family and friends, our board members, and the community as a whole to be incorporated into the planning process for this document.



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Plan Objectives

Our primary goal with this plan is to ensure quality service provision to the residents of Denton County as defined in the DADS & DSHS

contract. The Center has reemphasized the role of its stakeholders, our PNAC and our Board of Trustees (BOT) in assisting the Center in the development and the implementation of a community provider network of service delivery. The objectives of this plan are to reemphasize and ensure a system of service delivery, where, -

• Consumers have choice from among multiple service providers

• The Center’s role is to provide management and oversight

• The needs and preferences of the local community are met

• The Center demonstrates prudent stewardship of public dollars

• The Center has controls in place to ensure the best possible consumer outcomes

• The rights of consumers to exercise control and to make decisions regarding their health are protected, and

• The greatest return on public investment in services is demonstrated

• The Center demonstrates o ultimate cost benefit, o quality client care, and o the best use of public money in assembling a network of service providers with public input

This plan applies to funds allocated to Center by DADS or DSHS as “department federal and department state funds” through the respective DADS or DSHS performance contract. This includes Federal Block Grants and State General Revenue funds.

Assessment of the FY 2005 Local Service Area Plan Information Supplement Objectives

A significant component of our continued planning process involves the review of the goals and objectives developed and carried forward from the FY 2005 LSAP Information Supplement. Staff members, from mental health and mental retardation / intellectual & developmental disabilities service areas provide updated information on the status of these objectives over time. These status reports indicate attainment of the listed objectives or strategies. Those showing only partially attainment, or not yet addressed remain as our continued goals, objectives and strategies for the Center in FY 2010 -2011. Additionally, current staff and PNAC members involved in the planning processes for FY 2000, FY 2002, FY 2003 - 2004 and the FY 2005 Information Supplement provided feedback to newer stakeholders on the development of these goals and objectives. We use this critical transfer of information from previous planning development during our external/internal assessment reviews to help guide the current years planning processes.



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Center-wide Goals

Goal 1: Improve employee retention Goal 2: Increase revenue Goal 3: Maximize existing financial resources Goal 4: Enhance community relations and participation Goal 5: Provide services for all persons in need Goal 6: Maintain continuity of care Goal 7: Improve agency communications Goal 8: Network Development

Information Review Sources

Development of the FY 2010 - 2011 Local Service Area Plan (LSAP) began with a review of how well the Center synthesized information from our previous plans. We also incorporated current knowledge and status information regarding on going community needs, consumer satisfaction information, and service demands. We continue to use this information to develop a meaningful strategic plan for the Center’s future.

The Center also gathered information from staff attending interagency and public meetings, task forces, and other workgroups in the community and throughout the state. As well as information obtained at state sponsored meetings and trainings. We have incorporated each of these information resources into the local planning process during formal and informal strategic planning sessions throughout FY 2010.

Additionally, past survey findings from the Department of State Health Service’s Adult Mental Health Consumer Surveys and Youth and Family Survey have also been used. Unfortunately, this information is now provided as a State wide assessment and information resource and has become less valuable as a local third party information tool for gauging the satisfaction of people served by the Center in Denton County.

Additional Data Information

Additional sources of data/information utilized in the planning process included -

• Jail Diversion Strategies developed with the Denton County Sheriffs Department and Juvenile Justice System of Denton County

• Comments, issues, and suggestions from meetings held with small groups of consumers and families throughout the year

• Discussions of the management information system, including program and service data, financial data, administrative data and short term &



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long term planning

• Discussions with members of other advisory committees such as the HCS Advisory Committee and Business Advisory Committee

• Funding, regulatory, and licensing requirements which include the DADS, DSHS, Texas Rehabilitation Commission (TRC), Texas Department of Health and Human Services Commission (HHSC), Texas Commission on Alcohol and Drug Abuse (TCADA) the Texas Department of Criminal Justice and the Texas Correctional Office on Offenders with Medical or Mental Impairments (TCOOMMI)

• Outcome reports of consumer satisfaction survey data

• Recognition of the general issues raised by external advocacy organizations in the area, including the ARC of Denton County, Denton County Alliance for the Mentally Ill and the Denton County Autism Society

• Reports from executive staff comprising all service areas

• Review of the annual performance contract requirements and service targets from DADS and DSHS

• Interest/Waiting Lists Incorporation of other Center Plans

The Center will continue to include its Local Planning & Network Development Plan, Crisis Services Plan and Diversion Plan as amendments

to this Local Service Area Plan. We also include our Quality Management Plan, Plan to Reduce Abuse and Neglect, Utilization Management Plan and Consumer Benefits and Eligibility Plan as appendices to this document. Additional Center plans already developed and in place will be amended to this Local Plan as they are revised during FY 2011.

FY 2008 –2009 Local Service Area Plan Review and Monitoring Process

An essential component of any planning initiative is its subsequent implementation. The Center views the FY 2008 – 2008 Local Service Area Plan as a management tool. Successful attainment of goal objectives is based on a process that integrates this plan with other management systems. Success thus depends on active leadership that bridges the gap between planning and implementation and translating strategic intent into action. Such leadership can stimulate action within the strategic framework by emphasizing managerial responsibility for strategic development and implementation. The planning philosophy of the Center is simple - the major outcome of the planning process is action.

In order for the Center to properly manage the plan, a mechanism must be in place to monitor and evaluate its progress toward achieving the objectives. The process for review and monitoring of the Center's plan for FY 2008 – 2009 includes the following steps:

1. Integrate the objectives outlined in the plan into the budgeting processes for FY 2010-2011. 2. Each service area will be responsible for implementing the specified strategies within their program areas. The Center has assigned the

achievement of each objective to a specified manager or department.



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3. On a quarterly basis, each service area will submit to the Planning and Network Advisory Committee a summary report that details its progress in implementing its specified strategies. This quarterly summary report will be distributed to all departments, the Center's administration, the Board of Trustees and the Planning and Network Advisory Committee. The report should describe all tasks undertaken as part of implementing the assigned strategy. The report should also provide any information regarding barriers to achieving the objectives, additional resources needed to implement the strategies, and if necessary, a request for modifying its specified objectives and strategies.

4. The Planning and Network Advisory Committee will address each summary report at meetings held each quarter. The Planning and Network Advisory Committee may ask that a particular staff member attend the meeting and provide information about that person's or department's progress on achieving its assigned objectives.

5. Questions, comments or concerns raised by the Center's administration, Board of Trustees, and the Planning and Network Advisory Committee will be documented with follow up actions taken by the appropriate party as soon as possible. The appropriate party will document its follow up actions and submit these to the Center's administration, Board of Trustees, and the Planning and Network Advisory Committee.

6. The Planning and Network Advisory Committee will incorporate raised questions and concerns throughout the Center into the planning and review process for FY 2012 - 2013.

Local Planning & Network Development Process

As above the Center is the designated LMHA for the Denton County service area and has the responsibility to ensure that funds received from the Texas Department of State Health Services (DSHS), are utilized appropriately and efficiently within Denton County. This same requirement applies to DADS service deliver as well. Under both Performance Contracts our primary goal is to ensure quality service provision to the residents of Denton County as defined by DADS & DSHS. The Center has also reemphasized the role of its stakeholders, PNAC and BOT in assisting the Center in the development and maintenance of a community provider network for service delivery. Since FY 2008, the Center has engaged in the development of a separate Local Planning & Network Development Plan focused on mental health services. That plan draws heavily on the Center’s experience as an extensive contractor of services with MR / IDD external providers and is included as an attachment to this plan to outline that process. In the following sections, the Center outlines its on going steps for MR/IDD services and those steps not currently applicable to the current DSHS LPND plan process.



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Planning Process and Participants

Stakeholder Input

The following sections summarize the input received from stakeholders regarding service needs and priorities for children, adolescents and adults and include information on our crisis response system and services based on our recent Crisis Services Redesign Plan. Development efforts on an external provider network and other significant issues and concerns are also included.

Stakeholder Education Efforts

The Center has actively engaged in a Local Service Area Planning process since 2002. Our process identifies and solicits input from local stakeholders and includes efforts to ensure that planning efforts are inclusive and participants represent the diversity of opinion, culture, and ethnicity of the local service area. Also, that stake holders have opportunities to participate effectively in the planning process; and that the Planning and Network Advisory Committee (PNAC) is actively involved in the planning process.

The Center has actively pursued community involvement in its planning processes for many years. Not only does the Center facilitate a Jail Diversion Task Force comprised of representatives form Denton County, it also relies on input from our PNAC and other local stakeholders. Included in these efforts are NAMI, and other Mental Health Consumer groups, the NCTC Regional Planning and Network Advisory workgroup. Additionally for this FY 2010-2011 Local Planning Process, the Center has hosted various publicized meetings, forums and focus groups as noted in our LPND plan.

The previous planning cycle was slightly different than its predecessors in that the Center also educated and trained staff, consumers, family

members, government official and other interested individuals on the new process of Local Planning and Network Development. Our education and training efforts, while time consuming, were beneficial to the process and those we serve. Efforts made regarding consumer and stakeholder education and information gathering included: development of a Center hosted web site; providing a summary of the LPND process; notification of upcoming meetings and events; and a link to the LPND plan during the public comment period and ongoing.

The Center’s PNAC played an active role in obtaining input from the local community by attending these meetings, reviewing and

completing surveys and postings. They were also utilized to review and make suggestions regarding survey tools and questionnaires and to review and make recommendations to the LPND Draft Plan submitted to DSHS on 31 Aug 2010.



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Once the DSHS approval process is complete, the PNAC will also be involved in the ongoing review process and to make suggestions on the tools to be used to evaluate provider submissions from published RFP or RFA (Open Enrollment) processes. The PNAC will also be actively involved in the evaluation of submissions from potential providers and provider recommendations to the Center’s Board. The Centers last planning cycle resulted in the current consolidation of the Local Service Area Plan and Local Provider & Network Development Plan as posted on the Center’s web site. Since that time, the Center has continued its efforts to ensure the needs and priorities of the local community are being addressed as indicated in that plan as well as to address new initiatives developed. One of those new initiatives is the Crisis Redesign Plan and Jail Diversion Plans. Center staff members actively seek information for the development of these plans from consumers, family members, local officials, agencies and others. The stakeholders and organizations targeted to participate in various planning efforts in the crisis services redesign planning process represented local law enforcement, hospitals, emergency care centers, local university and colleges, OSAR, NAMI and probation, parole and juvenile detention services. These two plans are also part of the consolidated FY 2011 Local Service Area Plan as posted on our Center website. On 1 September 2009, the Center continued in its community planning efforts by initiating this FY 2010-2011 Local Planning and Network Development process with the intent of encouraging even more community involvement as a means of meeting the needs and priorities of Denton County. The stake holders and organizations targeted to participate in this planning effort included all the entities listed previously and those that follow. With DSHS approval of this Local Service Area Plan and the plans to be consolidated as noted above the Center will post them to the Center web site.

Mental Health Survey Results Over a three month period between June and Aug 2010 persons scheduled for services were contacted face to face or provided with copies of the current LPND survey. During this time period 100 surveys were distributed to willing persons at our two main MH outpatient facilities. Completed surveys were returned by the person, forwarded after their service delivery or mailed back to the QM office. A total of 21 hand-delivered and returned surveys were received for an overall response rate of 21%. In the graph tables included below are the data analysis of the 4 primary questions asked by the stakeholder survey process. As the responses for FY 2008 reflected the same outcome response as FY 2010 both data sets were combined to increase the statistical significance of the overall response. Therefore N = 205, with an overall response rate of 42%. In Table 3, below “Most Important Factors to Choosing a Provider”, the data reflects the three (3) most important factors for stakeholders when considering choosing a provider. The responses received continue to be no surprise to the Center as they reflect on going long term stakeholder input. From the responses received, we found that consumers and stake holders still hold convenient location (56%) and cost of services (50%) to be the top two factors in choosing a provider. Once they have reached a facility site - the actual wait time to see a doctor (or other staff person) (51%) becomes the 3rd highest factor. In 4th place is the ideal reflective situation that all services would be available at one location (40%) so that multiple



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trips or traveling from one facility to the other is not necessary – a “one-stop one-shop” model. The table graph below shows these findings and other factors as ranked by our stakeholders. The response rate to this portion of the survey was 40% (N=83).

Table 2

Most Important Factors to Choosing a Provider

0 10 20 30 40 50 60

Convenient Location

Transportation Available

Clean Environment

Cost of Services

Religious/Spiritual Values

Reputation of Provider

Pharmacy on Site

Length of Appt.

Wait Time to See MD

Bilingual Services

Cultural/Ethnic Sensitivity

All Services in Same Location

Other

Also of no surprise to the Center is that medications (44%) and physician services (45%) continue to be the most important or helpful services to those we serve and our other stakeholders with Counseling and Case Management services now tied as the 3rd highest selected choice at (40%). The response rate to this portion of the survey was 40% (N=83) and are reflected in Table 4, as shown below – “Most Important or Helpful to Consumers”.



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Table 3

Most important or Helpful Services to Consumers

0 5 10 15 20 25 30 35 40

Medications

Counseling Services

Physician Services

Case Management

Crisis Services

Other

In the next table, Table 5 - “Service Areas Where Choice of Provider are Desired”, the data collected shows what services would be most important to our stakeholders to have a wider pool of providers to choose from was gathered and analyzed. Here the response rate is 43% at N=88. The data analysis indicates that counseling services is still the number one (1) ranked service area where more choice of providers would be desired. Physician services continued to be ranked 2nd with crisis services ranked 3rd. From FY 2008 to FY 2010 increases in having more available provider choices in physician and housing service areas were noted. .



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Table 4

Service Areas Where More Choice of Providers is Desired

0 5 10 15 20 25 30 35 40 45 50

Counseling/Group Therapy

Housing

Employment Training

Physician services

Crisis services

Life Skills

Respite services

The last table “Degree of Satisfaction with Center Services”, Table 6, shown below shows that overall, stakeholders are satisfied with the current services available to them with 46 of the 80 respondents 57% indicating they were very satisfied and 22 indicating they were somewhat satisfied (27%). No persons expressed a very unsatisfied rating this year, with one (1) person each reporting a somewhat satisfied or neutral response.



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Table 5

Degree of Satisfaction with Center Services

0 10 20 30 40 50

Very Unsatisfied

Somewhat Unsatisfied

Neutral

Somewhat Satisfied

Very Satisfied

Additional written comments continue to show that people want the same specific counseling services to be available for group settings and as previously victims of sexual abuse. Along with medications and physician services more extended and weekend hours were specified previously. Other needs expressed center upon ongoing and common needs such as transportation, housing assistance, general employment and financial assistance, and medical, dental or vision care which have been ongoing community needs throughout the Center’s local planning process history. Written comments also reflect a strong desire for a one stop shop and decreased lobby waiting time for scheduled appointments.

SWOT Analysis

Inclusive of consumer and other stakeholder input, the Centers Executive Management Staff maintain, monitor and revise the following strengths, weaknesses, opportunities and threats, as well as gaps in services that will effect services over the current and next biennium.



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Strengths

1. Agency is established in community with a good reputation 2. Consumer and family comments can be addressed at board meetings 3. Dedicated staff 4. Efficient and systematic process for assisting mental health consumers to obtain psychiatric services 5. Excellent human rights advocacy 6. Financial support of Denton County government 7. Good relationship with local universities and schools 8. Good technical support from consultants and other agencies 9. Local business support in hiring consumers 10. Local community’s acceptance and support of consumers 11. Medication distribution system for mental health consumers 12. Mental Health Deputy program 13. Overall satisfaction by mental health consumers 14. Partnership with Texas Disability and Rehabilitation Services for vocational training 15. State consortia workgroups 16. Staff participation 17. Volunteer program 18. Desire to involve consumers and their families 19. Proven adaptability and flexibility 20. Adaptability to diminishing resources

Weaknesses

1. Under funding and funding reductions 2. Need to have implemented waiting lists for services 3. Grossly inadequate funding level at 41st of 41 remaining centers in the state of Texas 4. Lack of providers in more rural areas for County (Northeast and Western cities) 5. Lack of back up vehicles during service and maintenance of vehicles 6. Lack of day programs for older consumers 7. Low employee morale 8. Not enough staff recognition (e.g., attentiveness, raises)



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9. Staff turnover 10. Shortage of qualified professional provider staff 11. The need for improved communication between and among administration, staff, consumers, and families 12. The need for increased supervisory training 13. Tedious and cumbersome system of documentation 14. State mandates put Centers at a disadvantage to being competitive 15. Service populations are defined by state (we cannot choose who we serve) 16. Other than crisis services there are no weekend services hours

Opportunities

1. Advances in “de-stigmatizing” mental illness in mass media by increasing involvement of local faith-based organizations 2. Advances in mental health psychiatric medication 3. Availability of human resources from local universities (e.g., interns and volunteers) 4. Day programs (e.g., rehabilitation) for consumers unable to work 5. Establishing mental health managed care contracts 6. New funding from multiple sources

Threats

1. Continuing un-funded mandates 2. Restrictive legislation 3. Local Planning and Network Development (Provider of Last Resort) 4. Allocation in-equity 5. Continual shortage of Medicaid providers 6. Continuing stigma towards people with mental illness or developmental disabilities 7. Economic downturns have resulted in fewer jobs for persons with disabilities 8. Growth of Denton County creates increased demand for services 9. Increasing cost and shortage of affordable housing 10. Increasing transportation costs 11. Increasing costs of utilities 12. Increased work related stress 13. Loss of qualified staff to higher paying and less demanding jobs



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14. Possible decrease in funding for housing needs 15. Uncertain availability of public transportation do to budget cut backs and service reductions 16. Uncertain funding levels from the state authority and the legislature 17. Uncertain funding for Medicaid Services

With the initiation of this Local Planning and Network Development process and the development of an external network of providers, the Center strongly considered several factors to gauge its readiness for this endeavor. The strength of the Center’s organizational structure and technical experience and expertise including competency of staff in provider procurement, negotiation and management of contracts; utilization management and clinical authorization and claims processing. Established “Best Value” criteria from information such as stakeholder input, data related to quality, access, consumer choice and satisfaction, availability of current or potential contract providers, and the ultimate cost benefit, including the cost of any staff training associated with managing an external network of providers. The capability of the Center’s Information Technology (IT) system to accept and process an external provider’s clinical and fiscal information.

As such the Center considers itself moderately experience in Network Development. More so in its network management of local service providers for its Mental Retardation Services Provider Network developed through open enrollment and RFPs. With a deliberately graduated schedule of procurement, the Center can develop a provider network for mental health services and continue to maintain the stability and integrity of the entire local service delivery system over time. While we do not have the infrastructure or historical experience or expertise to use some of the more complex contracting methodologies such as sub capitated contracts or under arrangement contracts - during the next year appropriate staff shall be training and or educated in these areas. Many of the gaps in services identified below by our stake holders are due to a lack of adequate funding. We continue to work with our legislative delegation and the Texas Council of community MHMR Centers to encourage greater funding for mental health and substance abuse programs.

Priorities and Gaps in Services Each of the tables included below represents the priorities and gaps related to each service area based on community input and internal and external analysis for adult mental health and children and adolescent mental health services.



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Table 6, Gaps in Services – Adult Mental Health

# Title Description/Purpose Identified Barrier

1 Respite Care To provide a break from the constant administration of care supervision by the family

Limited resources

2 Half Way House Transitional living from or avoidance of hospitalization

No available resources

3 Education/Training Support and information to persons and their care givers regarding mental illness

Limited resources

4 Transportation Services To social and non-medical events Limited resources available and are continually reduced by economic factors

5 Substance Abuse Treatment

Treatment for dual diagnosis and single diagnosed persons who may or may not be intoxicated at the point of their presentation

Limited resources

6 Homeless Outreach Provide outreach to persons who are homeless and have a mental illness

Limited resources

7 Criminal Justice and Diversion Programs

Provide intervention and collateral treatment of people with mental illness

Lack of resources

8 Supported Employment Provide job coaching and training in significant employment opportunities for persons with mental illness

Limited resources further diminished by economic decline

9 No Local Inpatient Hospital Care

Longer inpatient LOS through partial hospital stay services

Limited resources

10 No psychiatric ER/walk in services

Local treatment for persons with mental illness Limited resources



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Table 7, Gaps in Services - Children and Adolescents Mental Health


1 Respite Care Break from the constant administration of care supervision by the family

Limited resources

2 Transition Services End of school to adulthood, work , continued education and medical

Change in legal status, lack of comprehensive planning before graduation and assertion of independence

3 Juvenile Delinquency and Conduct Disorders

Provide intervention and collateral treatment of people with mental illness

Lack of resources

Treatment for dual diagnosis and single diagnosed persons who may or may not be intoxicated at the point of their presentation

4 Substance Abuse Treatment Substance Abuse Treatment Outpatient group therapy program for medication

compliance/relapse

Limited resources diminished by economic down turn and agency funding reductions

5 No local in patient hospital service

Local treatment for persons with mental illness Limited local resources

5 No psychiatric ER/walk-in services

Longer inpatient LOS through partial hospital stay services

Limited local resources

Table 8, Gaps in Services – Adult Mental Retardation


1 Respite Break from the constant administration of care supervision by the family

Limited resources

2 Advocacy Support for people who need spokespersons or representation to ensure their needs and rights are maintained

Lack of formally trained persons or groups to meet need

3 Wellness Clinics Preventative health care Lack of providers willing to accept Medicaid funding reimbursement for preventative health care and subsequent health related needs



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4 Housing Transitional living for adolescents and people moving out of more restricted environment

Existing residential options are not geared to the needs of these populations

5 Community Activities Recreational and civic activities as an alternative to stay at home routine

Lack of sufficient transportation, buddy support and communication of existing events

6 Employment Provide job coaching and training in significant employment opportunities for persons with mental illness

Limited resources further diminished by economic decline

Table 9, Gaps in Services - Children and Adolescents Mental Retardation


1 Respite Break from the constant administration of care supervision by the family

Limited resources

2 Transition Services End of school to adulthood, work, continued education, medical

Change in legal status, lack of comprehensive planning before graduation

3 Autistic Services Specialized services to deal with this and other pervasive developmental disorders

Lack of qualified and appropriate resources

Planned Changes

Crisis Services Redesign

Along with the initiation of the Crisis Services Redesign of FY 2008 came the introduction of the Mobile Crisis Outreach Teams. These teams have improved the responsiveness and the level of care available to our community. The dedicated full time employees providing crisis response services have increased the probability for providing other services in the less restrictive environment of Denton County and diminished law enforcement involvement through face to face assessments and intervention services provided by staff as their primary job duties. Through this process, the Center was able to expand the number of on call staff participating in the on call crisis response services through increased pay, stipends and training. This expansion of service providers has resulted in the reduction and utilization of hospitalization and law enforcement involvement through the use of a trained team concept. The increased number of on call teams has also lead to better service through reduced response times in the more rural areas of the County.



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DSHS has provided $1,503,000 in FY 2008 and will provide $2,600,000 in FY 2009 to fund the Crisis Services Redesign initiative. With the FY 2008 funding the first priority was to ensure a minimal level of crisis services that provides rapid and mobile response to crisis situations through the Center’s Crisis Hotline and Mobil Outreach Services. Having achieved this initial services level, the Center will work with our local stakeholders to further develop our Crisis Services Redesign implementation to establish or expand additional crisis services, such as: Walk-in crisis services, children’s outpatient crisis services, emergency psychiatric emergency services, extended observation, crisis stabilization units and crisis residential treatment/respite for adults and children. In FY 2010 DSHS expanded Crisis Services Redesign to include provision of SP 5 Transitional Services and SP 3 & 4 Intensive Ongoing Services under Rider 65, from the 81st Legislature. The Center’s allocations under this provision expanded to $3,916, 986.

Provider Network Development

Provider Recruitment While the Denton County service area can be an attractive location to providers as individuals as noted below, the primary issue which would need to change or improve in order to further entice providers into the area is financial funding. Increased funding for mental health services by the State would greatly increase interest for both internal and external qualified providers in Denton County. And until there is a greater service funding yielding higher rates of reimbursement, the vast majority of private behavioral health providers – both individuals and organizations – will remain reluctant to participate in a public health care (Medicaid & MHGR-oriented) system that is overloaded with high cost/high utilization consumers

While all Local Mental Health Authorities across Texas are inadequately funded to serve their communities needs as a whole, Denton County historically been the lowest per capita funded Center for mental health services in Texas through FY 2008 and remains next to last since FY 2009. This factor will be of significant importance as the Center and Denton County remains disproportionately under funded to meet the service needs of its ever increasing population in a State wide contract procurement process. Although the Center recognizes the primary barriers and challenges to attracting external providers to this market are fiscal, there are many positive aspects to living and working in our Denton County communities which one should consider to offset some of the travel, environmental, and population based concerns:



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• If one dislikes the hustle and bustle of metropolitan traffic, a smaller community within the Northern and Western communities of Denton County may be ideal

• The Center’s catchment area is close enough to the Dallas/Fort Worth metroplex that you have enhanced shopping and entertainment beyond the local community

• Real Estate is usually more economical in the suburban and rural areas of Denton County

• Good Economic Market, despite Texas and US economic down turns and slowed growth

• Close enough that you could commute from Dallas or Fort Worth

• Convenient access to DFW Airport, Love Field or Alliance Airport

• Unique family centered fun with Six Flags, several water parks, and the Wax Museum

• Professional NFL, MLB, NBA, NHA, MLS along with NASCAR and IRL racing

• Rivers, streams and lakes offer a variety of recreational and profession water sports with access to numerous beach areas

• Local State Parks in near vicinity

• Convenient location to two major university campus: UNT, TWU, other regional colleges and a host of satellite programs from UT, TAMU, Baylor and UH

Provider Availability

In order to determine the viability of expanding our network of external providers, The Center continuously conducts on going analysis to assess the level of interested provider availability. In the past, this analysis has included a review of the 2004 Provider of Last Resort Plan/Request for Information. This April 2004 summary from the Center’s completed Request for Information (RFI) process was developed and initiated as a means of determining interest in a comprehensive treatment network for people with mental illness and mental retardation. Respondents were asked to provide information on various services and include any topics or question the respondent or any other interested parties believed important to address in any future Request for Proposal (RFP). The RFI document included a geographic description of the local service areas, giving the respondents the opportunity to indicate their preference to serve the entire local service area or a portion thereof. This process resulted in 2 respondents to the MH services portion of the RFI. Since that time none of those respondents currently has a contract with the Center for a provision of MH services. When reviewing the results of this RFI as they relate to known local provider availability, the results continue to be somewhat limited even today The 2004 RFI still appears to fairly represent the minimal interest of qualified mental health service providers in our service area. The Center’s current providers collectively have expressed no interest in terminating their contractual relationships with the Center and desire to continue their contractual relationship when the time for renewal arises.



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As noted, expansion of the network with additional external providers will be a slight challenge; however there appears to be some potential to expand choice in the network if provider interest continues.

LOCAL PLANNING

A list of participating individuals and organizations who have participated in the current planning cycle in each information gathering event or method, including advocacy organizations, local governmental entities and other public and private stakeholder organizations is included on page 7 of our Local Network & Provider Plan. The number of participating individuals is also listed by consumer, family member or other interested individual.

The Center also tracks all provider contract inquiries on a tracking log with disposition as well as the adding of all interested providers to our mailing list for procurement notices as such contacts are received. The Center will also mail all procurement notices to those individuals/groups listed with DSHS as interested providers for the Denton County service area. That listing is found beginning on page 3 of the Local Network & Provider Plan. Center staff also attend other community meetings as requested and provides presentations, overview and updates on Center activities as a way to reach out to the community and ensure a wide spread awareness of related activities in order to promote public input prior. All presentations are logged and public comments added to our tracking and response logs for incorporation within the Local Network Development planning process. The Center has held seven (7) LPND meetings throughout its service area which resulted in 5 individuals, 6 family members and 6 other stakeholders being able to give verbal input. The Center also received back to date 21 of 100 surveys distributed which were utilized to obtain input from individuals in our local community. Participant results are down from previous years for obtaining information for our Local Planning Process. As noted above, multiple meetings were held in the Northern and Southern parts of our County to obtain input from our local community in regards to service needs and priorities for children, adolescents and adults; development of an external provider network; and other significant issues and concerns brought for by the participants. At a minimum, the goal of each meeting was to education those attending on the LPND process and obtain answers to the following questions;

1) What are the most important factors you look for in a provider of services? 2) What service do you receive that is the most helpful to you? 3) What service would you most like to have a choice of providers for? 4) From your experience with the Center, what are /where the gaps in services?



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5) Do you have other thoughts that you would like to share related to this process or your services?

Apart from the training aspects noted above the initial intent of each meeting was to serve as a public forum, but each of the attended meetings became a focus group based on the interested persons area of concerns or business type.

Ongoing significant comments or concerns:

• Concern that developing such a system would cause administrative costs to increase

• Concern with protecting the safety net and critical infrastructure currently in place within the Center

• Concern expressed that the Center move slowly and only procure for services identified by our local community

• Concern expressed that the decentralization of the delivery service system would fracture and fragment the communities recognition of capacity concerns

• Concern with increasing capacity of services not just an increase in providers to choose from

• Comments made that transportation needs remain central to all discussions

Strategies to Protect Critical Infrastructure

Over its existence the Center has had extensive experience contracting with external providers. We have also given exhaustive consideration to the wide range of issues and challenges inherent in the contracting process. We have had major contract providers discontinue services within the established notification guidelines. And as external providers are trained to provide services, it is prudent that the internal network remain operational as a safety net. Along with this critical eye towards maintenance of the ‘public safety net’ with a viable clinical and oversight infrastructure, all reasonable contracting options will be reviewed for ‘Best Value’.

As we move forward with our contracting procurement process, we feel this past experience and enhanced oversight coupled with relevant

feedback from our local stakeholders and the support of our PNAC and BOT to proceed in a thoughtful well vetted manner that considers our local stake holder interests and needs will result in the preservation of a viable provider network, the community safety net and an effective oversight process under the Center’s authority functions.

It is important that experience, training, quality monitoring and fiscal stability be assessed continuously over each planning cycle prior to

further reduction of the internal network. We believe that when contracted services are stabilized, an increased percentage shall be contracted out by the Center. Most importantly, in the management of a multi-provider network, is the hardwiring of mechanisms to ensure true continuity and the sense of a seamless service delivery system for those receiving care. Fidelity is also required as a part of the contractual requirements of all RDM-related contracts to ensure the Texas Implementation of Medication Algorithms (TIMA) requirements are included in all psychiatric contracts.



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Meaningful fidelity is accomplished through consistent continuous training, supervision and oversight to prevent migration away from established principles and practices for the duration of the provision of services. In order to ensure consumers receive the necessary services from within the designated service package, providers shall attend mandatory quarterly meetings, staffing and/or training programs. All providers will be notified by the LMHA at least 15 days prior to the date of the staffing. All providers shall be subject to on-site audits, desk reviews, provider assessments, surveys, profiling and credentialing to assure compliance with the contract and applicable federal and state laws.

Time to Re-Establish Lost Service Capacity

The Center has established a ninety-day period to reestablish all services. This time frame is based on historical experience for when a clinical

staff person separates from the Center. The Center typically has to work quickly to continue services for that person’s case load or schedule. Often the only recourse is the shifting of existing staff or contracting for additional help - including locum tenens doctors and nurses or contracting with recruiting firms in other cases. Such efforts create added workloads and unexpected costs to the Center. One of the challenges expected when we begin contracting out even larger portions of services in Texas will be the ability to reestablish those services, particularly when the size of the provider side of the Center is much smaller than the external provide. Our past experience in hiring for an LPHA was an average of 12 weeks and for physicians was an average of 4-6 months. This has the added feature of potential financial penalties if the Center’s collective effort fails to meet contractual minimums. Therefore; until a strong base of external providers is established - that can assist the Center in covering unexpected lapses in service delivery, this will remain a challenge and is not fully reflected in the “90 day standard to reestablish services”..

Procurement and Transition Timelines

Structure of Procurement

Mode of Procurement

Prior to procurement, all materials will be made available for public comment for at least 14 days. Open Enrollment (RFA) - This option will be utilized for any service/service package where the Center has set rates determined. The requirements under open enrollment are that contracts are not negotiable- everyone gets the same rates and same contract terms and the Authority cannot reject any applications which meet these terms. This is less costly on the front end from the contracting and credentialing perspective and best used in cases where acceptable rates are known.



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RFP (Request for Proposal) - This option will be utilized for any service/service package that the Center has a rate range. The requirements under an RFP allows for individualized contracts. The Center sets the highest reimbursement rate, but providers can bid in lower for the business, and not all providers need to be accepted who respond. This is more costly on the front end from the contracting and credentialing perspective, but can have a cost savings in the long term if rates are lower.

Timing of Procurement It is also advised that within each service population area (Adults, Children & Adolescents), the Center begin procurement with the lowest level of care first and graduate up to higher levels of care. This in our experience lends itself well to providers grasping the basics of our contracts and minimum requirements first before taking on additional more acute care requirements with higher patient impact. The training is extensive and taking it in graduated pieces would hopefully ease the transition for providers and for patient care, ensuring the success of the programs. As each service level is procured, the Center’s Network Management will set go-live dates for existing consumers to be eligible to transfer to new providers as the PNL becomes available at the Center for new consumers, it will also be rolled out for existing consumers and offered as a choice at each treatment plan update.

Proposed Timeframes

This cycle would repeat itself every 2 years. The Center will open additional procurements within the two year cycles if needed to meet:

• A shift in consumer needs (e.g.: service package increases)

• To fill for loss of capacity in a certain package due to loss of provider(s)

• To meet geographic, language, and cultural needs as gaps are identified Rate Structure

There are 4 main options as the Center looks at each service reimbursement:

• Pay Medicaid Rates minus an 11% administrative cost for data up streaming

• Pay Medicaid Rates and Provider does own data entry

• If current service costs internally are above Medicaid Rates- consider paying a range above Medicaid to compensate for additional work demands (Example: Medicaid +10%-20%) as long as this rate remains below the Center’s current costs

• If current service costs internally are below Medicaid Rates- bid the service out under an RFP- listing the highest acceptable rate as 11% below current costs.



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Labs

Current options available to external providers related to lab services are:

• Have all external providers utilize current Center contracted vendor o Patient goes direct to current contracted vendor for draws and labs are routed back to external provider by vendor o Patient draws/specimen collection occurs at MD office with a courier service to contracted labs if feasible and labs are routed back to

external provider by vendor.

• If External Provider has a lab on-site, the Center could consider a separate lab contract if costs are contained comparable to current internal lab contract (cost neutral).

When EKG’s are clinically required, the current options available to external providers are –

• Route order with Consumer to a Center clinic.

• If External Provider has EKG contract or means, can contract with the Center for this service as long as costs are at or below current Center costs.

Pharmacy/PAP

Current options available to external providers related to pharmacy services are more limited due to the requirement that PAP (prescription assistance programs) applications be monitored and completed as needed prior to medication refills. This functionality in Denton County accounts for over $115,000 in funding, which is saved and reallocated into services, hence it is critical that this functionality not be effected negatively by an external provider network. PAP will be a requirement of all service contractors and the Center will work with each Provider/Consumer to ensure that medications are accessible in as convenient a means as possible. Current options:

• Utilization of contract based pharmacies

• Utilization of contract pharmacies (if able to get same price containment and data reporting which may not be feasible and if able to place PAP program on site cost effectively).

• Fax and fill procedures between the external location and Center Rx and/or direct to Consumers home (via Mail)

Current options available to external providers related to Injection services are:

• Orders are sent to the Center’s internal sites and consumers come to those clinics to receive their injections during scheduled appointments



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• External Providers provide the injections on site under contractual agreement with the Center (must be cost neutral to Center and in compliance with PAP)

Fidelity and Continuity of Care

The Center is working towards the ability to monitor in “real time” the required documentation and service requirements through the development of an Electronic Medical Record through which provider access will facility Fidelity and Continuity of Care Review. Fidelity is otherwise accomplished over time through training, supervision, and continuous reassessment to prevent movement away from principles and practices for the duration of the provision of services. In order to ensure that consumers receive the necessary services from within the designated service packages, providers shall be required to attend specific mandatory meetings, staffing, and or training programs. The provider will be notified by the Center of such meetings or training programs 14 days prior to the date of the meeting or training program. The provider will be notified by the Center of any staffing 30 days prior to the date of the staffing. Not withstanding the meetings and training, the provider shall be subject to on-site audits, desk reviews, provider assessments, surveys and profiling, credentialing and compliance with applicable federal and state laws. Case managers will work to ensure continuity of care by monitoring services provided by external providers. They shall be responsible for ensuring that individuals are receiving services from within the designated service package appropriate to their level of need. A survey will be developed for consumers seen by LMHA providers as well as contract providers to assess satisfaction with access and the services provided. The survey will be mailed to a random selection of these consumers on an annual basis. Service coordinators will document consumer satisfaction with providers as a part of their monthly contacts.

Enhanced Staff Qualifications All providers, whether internal or external, must be trained and competent in the tasks to be performed. Qualifications for individual practitioners must at a minimum meet the Mental Health or Intellectual & Developmental Disabilities Community Service Standards in order to provide services. All individuals providing services must also undergo a complete criminal background check in accordance with the requirements Texas Health and Safety Code, §250.006 and not have any items that automatically preclude employment by those standards.

Provider Standards At a minimum, providers must be agreeable to the following standards of care:

• Comply with minimum standards for individual practitioners who are providers of mental health services based on the RDM Utilization Management Guidelines or the minimum standards for individual practitioners who are providers of Intellectual & Developmental Disabilities.



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• Demonstrate competence in RDM training areas

• Utilization of the Uniform Assessment Tools to determine necessary levels of care for the client

• Compliance with Clinical Guidelines that establish service packages for both children and adults that ensure the provision of evidence-based services and guide decisions on eligibility and appropriate discharge from a service package

• Management of limited resources though established utilization management processes

• Compliance with the requirements of the DADS or DSHS performance contract

• Compliance with established Quality Management and Data management processes

• Maximization of available funding strategies

• Demonstrated ability to work with other providers and community organizations to provide continuity of care and linkages to community-based support systems

• Provide consumers with access to services that is equivalent to or better than that provided by Center

• Collaboration with area Advocacy organizations working on consumers behalf

• Demonstrate positive consumer outcomes and positive consumer satisfaction

• Absence of liability, malpractice, fraud indicators

• Demonstrate how they will involve consumers, LARs, and families at the policy and practice level

Table (10) – Staff Qualifications

Provider Qualifications for Adult Services

Practitioner Qualifications

1. Pharmacological Management: MD, RN, PA, Pharm.D, APN, LVN

2. Psychiatric Diagnostic Interview Examination: LPHA

3. Counseling: LPHA or LPHA Intern

4. Routine Case Management: QMHP-CS, or CSSP

5. Rehabilitative Services: QMHP-CS, Licensed medical personnel, CSSP, or Peer Provider

6. Supported Employment: QMHP-CS or CSSP or Peer Provider

7. Supported Housing: QMHP-CS or CSSP or Peer Provider



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8. Crisis Intervention Services: QMHP-CS

9. Crisis Transportation: No restrictions

Provider Qualifications for Children’s Services

Practitioner Qualifications

1. Intensive Case Management: QMHP-CS, CSSP

2. Skills Training and Development: QMHP-CS, CSSP

3. Medication Training and Support: QMHP-CS, CSSP

4. Routine Case Management: QMHP-CS, CSSP

5. Family Partner: Paraprofessional

6. Parent Support Group: paraprofessional, QMHP-CS

7. Psychiatric Diagnostic Interview Examination: MD psychiatrist (preferably a child psychiatrist)

8. Pharmacological Management: MD, RN, PA, Pharm D, APN, LVN

9. Family Training: QMHP-CS, CSSP

10. Family Case Management: QMHP-CS, CSSP

11. Crisis Intervention Services: QMHP-CS

12. Safety Monitoring: QMHP-CS or trained and competent adult

13. Crisis Transportation: No restrictions

14. Crisis Respite: Trained and competent adult

15. Extended Observation: Meet staffing requirements in Performance Contract (Information Item V)

16. Children’s Crisis Residential: Meet staffing requirements in Performance Contract (Information Item V)

17. Counseling: LPHA, intern

18. Group Counseling: LPHA, intern

19. Family Counseling: LPHA, intern

20. Multi-systemic Therapy (MST) team member: LPHA or QMHP-CS under supervision (as permitted by MST certification)

21. Engagement Activity: paraprofessional or QMHP-CS



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Consumer Choice

External provider access to services shall be equivalent to or better than the current level of access provided by the Center’s internal provider services. At intake, consumers will be assessed utilizing the stipulated tools and program guidelines required by DADS or DSHS as indicated. Clinical staff will educate the consumer and or their LAR on available services based on those assessed needs and the benefits of such services. The consumer and their legally authorized representatives (LAR) as appropriate will then be provided with a Network Provider Listing (NPL) to allow them to choose a provider that best meets their needs. The list is intended to be an objective source of comparable information about each provider, including how a consumer can obtain more detailed information. This list will also be posted on the Center website and distributed at least annually to local consumer and advocacy groups. Each provider is responsible for their own marketing, however, the Center will conduct at least 1 annual Provider Fair- where consumers will have an opportunity to interact with various providers and ask questions to gather more information. Additional plans for maximizing consumer’ choice of external providers and access to services is included on page 18 in the Center’s Local Network Development Plan.

Diversity

In order to better understand the changing diversity of the Center’s local community the following information from the US Census Bureau (refer to table 10, below). That information was reviewed and analyzed to show the following:

According to the 2009 updates, 32% of the people living in Denton County are non white persons, 17% are of Hispanic or Latino origin, 8% are black, 5.5% Asian, less than 1% report being of Alaskan, Native American or other Pacific Islander decent. 1.5% reported being of two or more races. This data reflects a larger growth in Asian populations than is being seen across the state at 3.4% and a smaller growth rate among Hispanic/Latino noted across the State at 36%. It is the position of the Center that all persons receiving services have the opportunity to communicate effectively with providers, regardless of the cultural background from which the individual comes or the language which the person may speak. The Center provides translators to those persons requesting such assistance as needed and allows and encourages the full participation for all consumers and their families.

Table 11, DENTON COUNTY DEMOGRAPHICS

Source: the US Bureau of Census, 2009 Estimates

Race Total % 2009 % 2007

White 418,197 68% 69%

Hispanic/Latino 101,989 17% 16%

Black 48,844 8% 9%

Asian 33,751 5.5% 3%

Two or more races 9,472 1.5%

American Indian or Alaska Native 4,471 0.7%

Native Hawaiian or Other Pacific Islander 444 0.1%

3%

Total 636,557



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Cultural and Linguistic Diversity Issues

Cultural and linguistic diversity issues in the local community are addressed in the Center’s Local Provider Network Development Plan on page 20. That plan includes discussion on any contract issues regarding the use of external providers and ensures that cultural and linguistic diversity is addressed by external providers contracting with the Center as we require of our internal provider network.

CAPACITY DEVELOPMENT

Cost Efficiency Cost efficiency is addresses in the Center’s Local Provider Network Plan on page 21. There we address how the Center will maximize preservation of every possible service dollar while maintaining our required authority functions. Included in that plan are discussion of how administrative costs and service directly related to those required authority functions, and the Center’s strategies for maximizing overhead and administrative costs, achieving purchasing efficiencies and efforts to work jointly with other local authorities on planning, administration, purchasing and procurement, other authority functions or service delivery.

Previous Network Development Efforts Although the Center was already actively involved in the Procurement and Contracting for services, in March 2004 a Request for Information (RFI) process was developed and initiated as a means of determining interest in a comprehensive treatment network for people with mental illness and mental retardation. Respondents were asked to provide information on various service packages and include any topics or questions the respondent or any other interested parties believes important to address in any future Request For Proposal (RFP).

The RFI document included a geographic description of the local service areas, thus giving the respondents the opportunity to indicate the preference to serve the entire local service area or a portion hereof. The RFI document included the verbatim service descriptions from our local authorities FY 2004, Texas Department of Mental Health and Mental Retardation (TDMHMC) Performance Contract, Attachment IX - Exhibits A, B, and C.

Respondents were given an opportunity to express interest in providing the entire service package or individual services within the package.

The Center’s deadline to respond to its request for information (RFI) was 19 April 2004 and the center received a total of 16 unduplicated respondents.



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March 2004- April 2004 � DSHS mandated RFI for all MHMRA services (MH and MR)

Results- � 16 responses

� 13 MR Services providers � 16 MH Adult Services providers � 16 MH Children and Adolescent Services providers

Outcome - This RFI did not include rates, training requirement, or contract terms per DSHS guidance, and provided only limited value in network development information. Of the 16 respondents to the Mental Health services portion of the RFI, 2 responded to providing all of the entire available service packages. None of those currently has a contract with the Center for a provision of services.

The Center does already currently contract for services in some discrete Mental Health packages, but not to the same degree that it has

developed a network of Mental Retardation / Intellectual & Developmental Disabilities Services. The two factors which primarily contribute to this are previous stakeholder input requesting the Center ensure stability in its psychiatrist assignments and a desire by its psychiatrist to become full time employees. It has been felt that this will eliminate consumers from having to see different psychiatrists - especially during unscheduled or crisis service intervention. Also to create a favorable position to the Center and those we serve by providing wraparound services and continuity of care that would increase overall care and satisfaction among stakeholders.

The 2004, procurement process and the advent of the framework for Resiliency and Disease Management present several challenges which

needed further analysis before an intelligent and informed decision could be made in regards to contracting for additional services. A few of the initial queries included:

• With the requirement of the Center to provide service coordination, how does this effect rehab services which may be provided to this individual?

• In instances where rates have not been previously established, the Center runs the risk of creating a network with providers and limited resources or limited providers and limited resources. Would the logical resolution include, developing an efficient Disease Management Delivery system and then in conjunction with the Public and Network Advisory Committee do an evaluation of the Centers Mental Health services to determine which services could reasonably be procured using the requirements of public input, ultimate cost benefit and client care?



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• Does contracting services or a portion thereof for Adult Mental Health Service Packages 3 and 4 affect the integrated team structures for which they are designed?

These were only a few of the unknowns which made developing a solid procurement plan involving MH-Adult services challenging at that

time and remain so to date.

Barriers The Center has identified a number of anticipated and encountered barriers to service procurement over the past years of local provider network development. This barriers and an associated plan to address each identified barrier are discussed in the Center’s Local Provider Network Development Plan on page 26 of that document.

Long Term Planning The Center is responsible for developing, updating, and maintaining a local service area plan that complies with the requirements of the DSHS Performance Contract. This plan is designed to develop a local network of mental health service providers that will at a minimum meet the local needs and priorities of consumers and stakeholders, provide consumers a choice of providers, improve access to services, make the best use of available funds, and promote partnerships among consumers, providers, and caregivers. As the Center continues the enhancement of its local network of providers, the diverse role of the Center will inevitably change over time. The Center currently acts as the Local Mental Health and Retardation Authorities as well as a provider of those services. The ultimate goal of this process and plan is to incorporate strategies to ensure continuous consumer access to services while the Center increasingly expands its network of external providers and steadily decreases its share of internal service provision. The desired outcome is for consumers to have choice from among multiple service providers and for the Center to provide management and oversight of the provider network. Under the local network planning requirements, it is important to remember that the Center will continue to be required to capture, retain, and report certain information to both DADS and DSHS and to continue to manage key internal processes. These operations and internal processes are applicable to all consumers and all services, whether provided internally by the Center or externally by another provider. These key operations include providing certain services and adhering to acceptable clinical practices, generating and managing operational revenue, accommodating state reporting and fiscal requirements, and managing the general operations of standard business and clinical practices. As the local network of providers develops gradually over time, the Center must continue to maintain at least a “safety net” share of service provisions as well as manage all internal operational processes in order to continue to maintain the effectiveness and efficiency of the Center while minimizing disruptions in service delivery to consumers and meeting the mandated objectives of the local network.



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While the most crucial objective of the network planning is the assembly and management of an external network of providers, this cannot be accomplished through the demise of the Center and the local safety net. Assembly and management of a network of providers must be well planned and sequenced with the Center’s technical expertise to do so. External providers, too, should be well versed in and prepared for any contractual arrangement undertaken. As the Center progresses through this second 2-year planning cycle and its associated procurements requirement, we will analyze and assess the availability of interested providers to determine the stability of the current network as well as the cost effectiveness of provider contracts in order to ensure that the proper shift of overhead and administrative costs is financially sound and reasonable. The Center shall also use this time period to evaluate certain operations and functions of network development.

The importance of this evaluation is to gauge the stability and effectiveness for increasing the Network of Providers during the current planning cycle. The evaluation shall include but not be limited to:

• Redefining areas where technical assistance or additional training may be warranted; i.e., provider profiling, claims management, etc

• Identifying gained experiences to better meet the goals of the plan

• Determining whether the needed expertise was obtained to utilize one of the more complex procurement/contracting methodologies such as procuring an entire comprehensive service delivery package or sub-capitation

• Determining if staffing is adequate to manage a larger network of providers

• Determining if the network has remained financially viable

• Ultimately the Center will be assessing the Network’s readiness for further expansion

The Center plans to start its next input gathering process approximately 6 months after the submission of this local service area and network development plan for the 2 year cycle including FY 2012 and 2013. There is an expectation that the Center will have gained added expertise so as to procure more services during the next planning cycle. The prospect of providers interested in providing entire service packages will optimistically have increased as well. There is also the expectation that consumers will be more familiar with choosing a provider, thus the input gathered on where they may want more choice in the future may be more focused, direct and meaningful, thus resulting in the Center better meeting the needs and priorities of Denton County. Short List Potential Goals for the next planning cycle (FY2012-13) include:

• Procuring provisions of Mental Health services. The current plan does not include procurement of any full service packages due to lack of provider interest in entire service packages. During FY11, management will work to ensure the development of a Network of External



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Providers to provide full service packages and/or in the alternative discrete service provisions. While the percentage of full service packages has not been established at this time, provisions of services will be procured during the next plan cycle if there is provider interest and availability then.

• Children’s Services (internal provider) proposes to develop a network of providers to assist in transitioning children receiving services in SP4 to local community physicians for continued care maintenance. The idea is to allow those served to flow through the Center system instead of reaching the least intensive service package and remaining in Center Services. Interested provider availability is a challenge to this potential internal goal being met.

• Expansion of provider choice in rural Denton County where provider availability is currently limited. While the Center’s desire would be to procure entire service packages, provider interest has continuously been a challenge for the rural portions of the county. In the event entire service packages are not supported by provider interest, the Center will seek to procure discrete services as indicated by consumer and stakeholder input as well as interested provider availability.

• During this current plan the Center chose not to procure rehabilitative services outside of the full service package despite expressed interest for the discrete service in order to meet the expressed needs of the local community and to avoid the appearance of “cherry picking” of services which were not identified as an area where more choice was desired. It is the Centers intent to attempt to procure such services via an entire service package during subsequent planning cycles if supported by interested provider availability. Guidelines, recommendations and legal guidance are currently in the process of being developed regarding implementing and monitoring such “under-arrangement” agreements. Finding interested providers may not be an anticipated challenge for this service provision standing alone. However; it may be a challenge as the Center attempts to procure the entire service packages during future cycles. In the event the Center is not able to find providers interested in providing the entire service package providers interested in the discrete provision of rehabilitative services shall be sought.

• At a minimum procure additional mental health service provisions. Ideally, we aspire for any additional service procurement to be inclusive of full service packages, not just discrete service provisions, as are being procured during this planning cycle. As interested provider availability increases and minimum levels of choice and access are achieved, the Center shall continue to make a good faith effort to increase its network of external providers and strengthening its role as an Authority and Network Manager.

• The Center anticipates furthering network development in the next biennium as the following issues are met:

1. The Center develops greater expertise at managing a network of providers; 2. More interested providers become available in our area;



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3. Available interested providers demonstrate the ability to fulfill the contractual obligations; 4. interested providers become more comfortable with and willing to participate in the procurement process; 5. Increased funding is obtained to create more appeal to interested providers to bid in the procurement process; 6. The Center becomes more proficient at procurement; and best value in services is maintained.

During the transition to a network of interested external providers, the Center will ensure they are trained to provide services in compliance with the rules and standards set by the Center in accordance with the DSHS Performance Contract. It is also prudent that the internal network remain operational as a provider of services to ensure the Center’s community role as the safety net for available on going and crisis services. It is our belief and understanding that training, quality monitoring and oversight along with fiscal stability need to be assessed over each procurement cycle prior to further reduction of the internal network. This would include a complete cost analysis to ensure that proper shifts in administrative functions have occurred to complement network development. In the subsequent years, as service areas which have been successfully contracted for and stabilized, they shall be considered for further network expansion and may have an increased procurement. The Center shall also make a good faith effort to procure additional service provisions including entire service packages and/or rehabilitation services as provider interest supports. This continued graduated approach during the next planning cycle shall also incorporate new input gathered from the local community regarding additional service areas where choice is desired. Based upon DSHS stakeholder comment on our previous plan submissions to further describe the transition period required to achieve full utilization of available external capacity, the Center notes as above and in other sections of this LSAP and our LPND plan, the references made to a very speculative incremental 10% increases in service capacity expansion each year over time. This initial assessment was adjusted so that our provider network for counseling services retained a 20% internal provider level and pharmacological services were with drawn from procurement as we have not been able to identify interested providers and thus the actual external provider consumption of all MH GR funding. As such we have not yet determined the exact percentage of our internal service delivery system to retain overall or a precise level required to ensure coverage of our bond debt structure through 2024. We will work closely with our current external providers and other interested providers to assist them with the growth, development and stability of our local network of providers. We will also closely monitor the capacity of our external provider network and expand our contract procurement efforts as appropriate. Adjustments through future LPND plan revisions will be made as we progress through the next two year planning cycles until we are able to satisfy the current bond debt carried by the Center.

Other current factors outside the Center’s direct control are expected to have a direct impact on network expansion. It is expected, DSHS will be making critical determinations in the near future on issues such as – 1) funding of costs associated with authority activities; 2) revision of the RDM service package delivery requirements; 3) rates for services 4) determination of funding of a reserve capacity in order to ensure the continuous



4 November 2010


provision of services in the event a network provider terminates their contract, 5) timeline for the rollout of CMBHS and 6) how that will impact the Center and its contract provider network along with 7) the integration of the federal health care reform mandates

In the case of RDM revisions, those changes may improve or diminish provider interest. The same is true for rate setting and the federal health care reform mandates. Current providers will also likely be impacted in future contracting decisions by these changes. The Center is confident that with our significant IDD services contracting experience and the enhancement of our MH contracting experience that with focused and consistent decision making, the availability of adequate funding at the federal, local and state level, and a strong desire to meet consumer needs this will allow us to be able to comply with both the spirit and letter of the law as it pertains to LPND.

The Center will continue to focus on the identification and implementation of best practices to more effectively serve individuals with

complex healthcare and behavioral health challenges. Additionally, all facility operations, services and supports will be continuously improved to ensure full compliance with all requirements. Examples of ongoing improvement initiatives include the following:

• Recruitment and retention initiatives will continue to address difficult-to-fill positions (e.g., physicians, nurses, occupational and physical therapists, speech/language pathologists) and positions with high turnover rates (e.g., direct care staff).

• Increased clinical, professional and paraprofessional staffing necessary to meet the increasing demands of effective service delivery for persons with very complex behavioral health challenges including:

o Increasing the number of certified behavior analysts available; o Increasing the number of psychiatrists available to provide comprehensive diagnostic and clinical support services for individuals with

complex behavioral health challenges; and, o Increasing the effective integration of both psychological and psychiatric services to assist individuals to function at the greatest level

of independence possible while receiving services at the Center and/or in a more integrated setting should that be their choice.

• Increased efforts to identify and secure appropriate community-based services and supports for families of school-aged children seeking IDD services and supports who are currently being admitted to state supported living centers

• Continued expansion and improvement of staff selection, staff training and staff retention efforts to assure that persons providing services and supports for the Center are competent and well-equipped to carry out their job responsibilities.

• Expanded focus on health, physical and nutritional management services for persons with complex healthcare needs.

• Expanded focus on increasing functional communication abilities of persons served by the Center through:



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o Increasing the number of trained and qualified speech/language pathologists with specialized skills in the area of functional communication; and,

o Increasing the availability and use of adaptive communication devices, both manual and electronic, to assist individuals to communicate more extensively and effectively.

• Continued focus on provision of comprehensive information on services and supports available in both institutional and community-based settings throughout the MH and IDD service system in Texas for all persons currently receiving and seeking services and supports.

IMPLEMENTATION

Procurement Timeline

Table 12, Procurement Timeline

Date(s) Method

(RFA or

RFP)

Service or

Combination of

Services to be

Procured

Geographic

Area(s) in Which

Service(s) will be

Procured

Percent

of Clients

Rationale

1 Jan 2010 RFA Counseling Denton County 80% An established contract for this service area exists, but in order to enhance consumer choice desired by our local stakeholders an open RFA is in place. To date this RFA has not yielded any new interested providers and the DSHS mandated LPND process has resulted in the loss of interest and contracts with two previous providers.

1 July 11 RFP Crisis Hotline Denton County 100% Established contract with consideration for an RFP to determine best value when a viable other interested provider is identified.

1 July 11 RFP Crisis Detoxification & Residential Substance Abuse

Denton County 100% Established contract with consideration for an RFP to determine best value when a viable other interested provider is identified.



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1 July 11 RFP Crisis Emergency & Non-Emergency Transportation Services


1 July 11 RFP Family Partner Denton County 100% Established contract with consideration for an RFP to determine best value when a viable other interested provider is identified.

1 July 11 RFP Inpatient Hospital Services Denton County 100% Established contract with consideration for an RFP to determine best value when a viable other interested provider is identified.

1 July 11 RFP Intensive Crisis Residential Treatment Services


1 July 11 RFP Laboratory Services Denton County 100% Established contract with consideration for an RFP to determine best value when a viable other interested provider is identified.

TBD RFA / RFP

Physician - Pharmacological Management /

Telemedicine

Denton County TBD If no increased funding allocations are forth coming from DSHS our plan is to transition existing FTE physician positions into contracted external providers based on a percentage of their average work load and existing FTE status.

1 July 11 RFP Pharmaceuticals Denton County 100% Established contract with consideration for an RFP to ascertain best value.

1 July 11 RFP RNs Denton County PRN Established contract with consideration for an RFP to ascertain best value.

N/A N/A Veteran Services Denton County NA Self sufficient after 2011



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STAKEHOLDER COMMENTS ON PLAN AND LMHA RESPONSE

PUBLIC COMMENTS ON THIS PLAN WILL BE ACCEPTED THROUGH

31 August 2011

PLEASE SUBMIT YOUR COMMENTS TO:

By e-Mail: [email protected] By Fax: (940) 383-1804 By Mail: Denton County MHMR Center

Quality Management Department P O Box 2346 Denton, TX 76202

Table 13, Stakeholder Comments on Plan

and LMHA Response

Comment Stakeholder

Group(s)

LMHA Response and Rationale

None received to date N/A • Accepting the comment in full and making corresponding modifications to the plan;

• Accepting the comment in part and making corresponding modifications to the plan; or

• Rejecting the comment. Please explain the LMHA’s rationale for rejecting the comment

___________________________________ ___________________________________ __________________________________

Markham H Jones Date Pam Gutierrez Date Bill Drybread Date

Director of Quality Management Chief Operations Officer Chief Executive Officer



4 November 2010


Resources

• 2010 Populations Estimates, North Central Texas Council of Governments, May 2010

• 2006-2008 American Community Survey US Census Bureau

• City of Denton Annual Citizen Update, March 2010 (Source: U.S. Census Bureau, Census 2000 Redistricting Data (Public Law 94-171) Summary File, Matrices PL1 and

PL2) • Denton Chamber of Commerce 2005 Newcomer and Relocation Guide, March 2005

• Denton County Mental Health & Mental Retardation Center, Local Service Area Plan, FY 2006 – 2007

• Discovering Denton County, a publication of the Denton Record Chronicle, 25 June 2006

• Guidelines for Local Service Area Planning, February 2005

• FY 2010-2011 Performance Contract, Texas Department of Aging & Disability Services

• FY 2010-2011 Performance Contract, Texas Department of State Health Services

• Long-Term Forecast – The Texas Economy, Denton Business and Community News, Dr Ray Perryman V-219, page 6, July 2008

• People MapStats, Denton County, Texas 10 July 2009

• Profile of General Demographic, Selected Economic, Housing and Social Characteristics: 2000, Denton County, Texas, United States Census Bureau, Census 2000

• Texas Department of Aging and Disability Services, Legislative Appropriation Request 2012-2013, Volume 1-3

• Texas Department of State Health Services, 2012-2013 Legislative Appropriations Request, Stakeholder Meeting, David L Lakey, MD, DSHS Commissioner, 29 April 2010

• Texas Department of State Health Services, Spending Reduction Plan for the 2010-2011 Biennium with Additional Reductions for 2012-2013, David L Lakey, MD, DSHS Commissioner, 6 July 2010

• Texas Health and Human Services System Strategic Plan FY 2007-2011, 7 July 2006

• Texas Health and Human Services System Draft Strategic Plan FY 2011-2015, May 2010

local service area plan - denton county mhmrdentonmhmr.org/pdf/lsap.pdflocal service area plan fy...

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