Regional System of Care Redesign: Effective Use of Inpatient and Outpatient Resources in the Continuum of Care
1. Community Strengths
a. Southwest Texas Crisis Collaborative
A major strength of the Bexar County service delivery systems is the Southwest Texas Crisis Collaborative (STCC), whose services could be extended far beyond Bexar County. STCC was created under the leadership of the Southwest Texas Regional Advisory Council (STRAC) after a series of studies conducted in Bexar County reviewed the effects of social determinants of health on people with mental illness, like housing/homelessness, income and education level, and the availability of behavioral health resources. In 2015 and 2016, the Meadows Mental Health Policy Institute was chosen by Methodist Healthcare Ministries of South Texas, Inc. to conduct an additional assessment of the mental health care system in Bexar County to identify system strengths and opportunities for improvement. The Southwest Texas Crisis Collaborative (STCC) was created to address service gaps identified in these studies, with a specific focus on finding ways to integrate service delivery and reduce high utilization of emergency department and jail services. STCC comprises hospital executives from the major hospital systems in Bexar County as well as leadership from the LMHA and the criminal justice system. STCC has overseen the creation of several programs designed to address these issues, including an online platform that combines client data for people with complex needs who cycle between jails, emergency rooms, and inpatient care; addressing law enforcement’s transport of emergency detention clients; and ongoing funding for psychiatric emergency service facilities. These interventions, particularly the online platform for tracking people across systems and the dramatic improvements in transporting emergency detention clients, can potentially be extended far beyond Bexar County.
“There is a fear that the state will think all mental health problems will be solved with the new building, and that will make it harder to get funding to address the real need to solve the problems.” — Mental Health advocate
“There is a mental health crisis and we need funding; it is only going to get worse.” — ED nurse
b. Private-Purchase Psychiatric Beds
A primary method of addressing the lack of available beds at SASH is for LMHAs to purchase private psychiatric beds from local hospitals. For instance, each of the LMHAs in the SASH catchment area purchase private psychiatric beds using a combination of state and local funds. The following two tables illustrate that LMHAs expended $12,136,503 to purchase 21,288 bed days from private psychiatric hospitals in fiscal year (FY) 2017, and expended $13,223,689 to purchase 22,397 bed days in FY 2018.
Several rural LMHA administrators indicated that being able to purchase private psychiatric beds was a “game changer” for their areas. One group of stakeholders reported that economic disparities within its region have forced the LMHA to dedicate its financial resources to community-based programming, making it necessary to use state dollars for private psychiatric beds for higher levels of treatment. Because of the lack of inpatient psychiatric services in their communities, rural LMHAs need to coordinate with multiple hospitals in metropolitan areas to utilize the state’s allotted private psychiatric bed dollars.
However, there are concerns that this level of funding may not meet the needs of some areas. One LMHA had $794,000 for private-purchase beds for the fiscal year starting in September, but those funds were depleted by February.
2. Continuity of Care
In addition to the recommendations discussed earlier that involve SASH providers in collaboration with community clinicians, several proposals focus on processes and agencies outside of SASH.
a. Outpatient Clinicians Can Renew Medications Specified in Discharge Summary
To present disruptions in treatment premised on an outpatient prescriber’s discomfort with renewals before conducting his or her own evaluation. We recommend establishing a standard of care that a psychiatric prescriber may accept a discharge summary from a psychiatric hospital as the basis for continuing medication even if they have done a full evaluation of their own. This does not necessarily mean robotically continuing treatment one has concerns about – rather, inpatient clinicians should be contacted when questions or concerns arise and such communication should receive high priority for response.
b. Improve Quality of Information Available to Clinicians over Care Settings
- Improve tracking of the clinical course of patients as they move through the mental health care system. Doing so facilitates the identification of “high utilizers” and their prioritization for hospitalization-preventive supports such as intensive case management.
- Shared medical records between pharmacies, state hospitals, LMHA’s and private hospitals, accessible to front line clinicians.
3. Assisted Community Treatment and Adherence
Despite expansion of outpatient services and other recovery-oriented services a subset of patients with more severe mental illness often do not participate in outpatient services to the degree required to prevent relapse. For these individuals, Assisted Outpatient Treatment (AOT) is often beneficial as well as cost effective (70). These programs should have:
- Expanded capacity for AOT programs at LMHA’s along with funding for proper implementation.
- Increased ability to provide extensive case management, particularly for homeless or marginally housed individuals.
- Ability to ensure adherence with medication and other outpatient treatments
- Allow for return to hospital if outpatient treatment is not followed and early deterioration occurs.
We also encourage strengthening AOT approaches that (a) address factors that contribute to an individual’s nonadherence, (b) include incentives and other proactive measures to promote self-sufficiency with treatment adherence and reduce reliance on coercive measures, and (c) consider developing advance directives for patients to indicate what might help them during a crisis (71-74).
4. Expand Substance Abuse Treatment Services
There needs to be a recognition of the problem of dual diagnosis (mental illness and substance abuse disorder) wherein each disorder complicates the management of the other. To address these issues:
- Enhance treatment programs for pregnant women with substance abuse disorders with continued intervention for both infant and mother after birth in an attempt to break the inter-generational cycle of
- There are inadequate number of Fellowships in Addiction Psychiatry and Medicine in Texas, leading to a serious shortage of physicians skilled in this Additional state funded support to medical school to establish such programs should be considered.
- Identify methamphetamines as a Texas crisis, due to some parts of the state having more prevalence of methamphetamine use and abuse than
- Increase availability of and access to opioid Encourage Medication Assisted Treatment for opioid addiction (MAT, i.e., buprenorphine) treatment centers to include on-site mental health providers, for a “one-stop shop,” for co- occurring conditions. Encourage more prescribers to engage in MAT.
- Review funding rates to substance abuse service facilities, because capacity to provide treatment is impacted by reimbursement and current rates do not support The state should perform a comprehensive rate study based on best practices for each level of care to determine the best rates for recommendation (per House Select Committee Report).
- Support changes in Federal legislation to Title 42 of Code of Federal Regulations (CFR) Part 2 which prohibits sharing of substance abuse and other medical This makes establishing substance abuse clinics in multi-specialty medical or mental health clinics extremely cumbersome.
- Individuals dually-diagnosed with substance abuse disorders and behavioral health disorders often encounter community providers unwilling to treat them, particularly those with commercial Commercial insurers should be incentivized to develop provider panels for these patients and, both commercial and governmental insurers need to provide adequate coverage for their care.
- There is a growing need to develop substance abuse treatment for individuals with intellectual disabilities and other developmental
We expect that the following local initiatives will improve the targeting of substance abuse treatment and prevention resources to areas of greatest need.
- Bexar County’s Joint Opioid Taskforce has recommended that a Joint Substance Abuse Taskforce be created that focuses on all alcohol and substance abuse and that a Strategic Plan focused on needs assessment, asset inventory, and gaps analysis be completed.
- This new Joint Substance Abuse Taskforce will create a “community dashboard” that tracks the incidence and prevalence of opioid, alcohol, and substance use/abuse.
- The Joint Opioid Taskforce proposed the creation of and received funding for a full-time substance abuse planner/manager for County government.
5. Increased Support for Guardianship
A subset of patients with severe mental illness become so impaired in their reasoning due to psychosis, mania, or addiction that they lose the capacity to make medical or financial decisions. The mental health care system is ill-equipped to deal with these individuals. It is critical to provide, under the direction of the probate courts, guardianship for these individuals. To do so, we recommend:
- Identifying patients who lack capacity for making financial and medication decisions.
- Assigning guardians when families are unable or unwilling to carry out this role.
- Manage patient funds (especially disability payments) such they are appropriately spent on food, housing, and medical care.
6. Forensic Patients and Competency Restoration Outside the State Hospital: Outpatient and Jail-Based Services
We discussed earlier the dire situation in which forensic placements are overrunning civil resources for inpatient care based on purely clinical criteria. Another vital point concerns ameliorating psychiatric symptoms of defendants before they even get to SASH.
For defendants held in jail pending evaluation or treatment to address adjudicative competence, the wait for transfer to the state hospital is lengthy. Whether Federal court cases like Trueblood ultimately produce a national standard for the care and transfer of these individuals, obstacles to promptly initiating treatment for those who really must be in a jail setting for competency restoration must be overcome.
We recognize that not every jurisdiction can have psychiatric care providers for their jails. The Sandra Bland Act has catalyzed efforts to more effectively screen and when possible treat detainees with mental health difficulties, offering new options that may be advantageous in this context. Telemedicine has been piloted in some localities, and evaluation of its outcomes should be undertaken.
It is essential that the financial resources for outpatient providers to fulfill this role be adequately available. Some local officials were concerned about outpatient competency restoration becoming an unfunded mandate that drains from already limited resources.
7. Rural Areas Need More Facilities for Intensive Acute Care
In addition to, and not instead of, the replacement of current SASH campus, regional “hub” inpatient facilities should be established to address the lack of intensive services in rural areas. The state provides funding to Local Mental Health Authorities (LMHAs) for a patchwork of other programs including Extended Observation Units (EOUs) which are 8-16 bed small units that can serve persons admitted on Emergency Detention for up to 48 hours, five Crisis Stabilization Units (CSUs) of 8-16 beds that may serve persons on Emergency Detention or under Orders for Protective Custody for up to 14 days, and a variety of contracts for the purchase and use of inpatient beds in private psychiatric hospitals. The missing element of the psychiatric inpatient care continuum is a system of state-funded, but locally operated psychiatric hospitals that serve as regional “hub” facilities. The vision of these hubs would be as follows:
- Their design and intent would be to supplement and complete, not supplant, the existing short-term, acute stabilization system that has many well-intended and effective outcomes, but is impaired by the inability to place individuals who require longer term treatment so that the system may continue to serve those who would benefit from the short-term treatment for which it is designed, funded, and regulated. These facilities would have the capability and be intended to provide acute crisis stabilization services to individuals committed under a Warrant for Emergency Detention or Order of Protective Custody. Additionally, they would provide longer term psychiatric treatment as needed to persons whose severity of illness requires a 45-day course of treatment to remediate the danger that the person presents to himself/herself or others as a direct result of the psychiatric disorder.
- A regional hub system would consist of state-funded 30-bed psychiatric inpatient facilities similar to the Sunrise Canyon facility in Lubbock and operated by the These facilities would be tasked to serve more than one LMHA and would be strategically located to maximize the workforce potential for the facility and reduce the amount of time required to transport a person to the site. They would be licensed and authorized to serve individuals on the same types of commitments as can be served by a state-operated hospital, so they would resolve the placement dilemma experienced by the existing acute care facilities (EOUs, CSUs, and private hospitals) and emergency rooms.
- To demonstrate local commitment, communities could be required to provide the funds to construct these Operational funds would be appropriated by the Legislature.
8. Children and Adolescents: Behavioral Health Care
a. Improve Access to Timely and High-Quality Outpatient Care for Youth
Some adolescents who require hospitalization for behavioral health disorders experience relatively sudden onset of a precipitous decline in functioning. It is far more common, though, that the critical event that led to inpatient care was the cresting of a lengthy history of chronic behavioral and emotional distress that has already exacted a heavy toll in diminished quality of life and negative self-image. Families are beset by exasperation, frustrations in seeking help, and, quite often, self- reproach.
However, the opportunities to provide families with effective treatments before these problems escalate are usually missed. Access to behavioral health services in both the rural and urban portions of our region for youth remains poor. Wait lists just for intake evaluations are typically on the order of weeks to months. For many common disorders, such as ADHD and its related behavioral disturbances or depression, combined treatment modalities involving medications and psychotherapy are the standards of care and show the largest effect sizes in treatment studies. Combined treatments also have lower rates of premature discontinuation from care. However, resources for behavioral health therapies are scant, a problem that is exacerbated in our rural and frontier areas that send need to hospitalize adolescents when crises emerge.
Coupled with the shortage of child and adolescent psychiatrists in Texas and elsewhere in the U.S., the early onset and chronic nature of youth behavioral health difficulties made service integration with primary care a viable means to improve access. Indeed, in Bexar County a behavioral health/primary pediatrics collaborative program was implemented in 9 pediatric care settings that evaluated and treated over 10,000 youngsters in four years, only a small minority of whom would have received services otherwise. This program was supported with 1115 waiver funding but had to be discontinued when the Texas DSRIP program reconfigured last year.
We therefore support the recent calls by others for the inclusion in the LAR for funding to enhanced community-based mental health services for youth. We also encourage development and evaluation of care models to improve access and quality.
It may take some time to establish the impact of better outpatient services on hospital admissions for youth, but there is no doubt at all that they would immediately affect quality of care for children discharged from inpatient care who often cannot be seen in a timely fashion for follow-up services. We return to the topic of follow-up care in the next section on improved post-discharge quality of life.
b. Education and Behavioral Health
School based mental health programs can make a significant impact in improved access for youth. The Meadows Foundation in Dallas has long supported nationally recognized programs of this this type. The University of Maryland’s Center for School Mental Health also sets the standard for these projects. When they can be implemented alongside school health clinics with prescribers who have access to specialist consultation via telepsychiatry then appropriate pharmacotherapy may be more widely available as well. However, one limiting factor has been engagement with families during school hours, and parents increasingly have less flexible work schedules. Some early evening hours in sites where this proves important would benefit from support.
c. Day Treatment
We noted earlier the need for more day treatment services. We urge collaboration with state and local educational authorities to improve the availability and programming for such services. Many youth facing adversity in school settings due to psychiatric disorder opt, on paper at least, for home schooling; while no doubt a valuable option for families, in practice the effect is tantamount to dropping out and stifling development of functional capacities outside one’s home.
d. Non-State Hospital Alternatives as Both Diversion and Aftercare Resource
State agencies should consider expansion of Residential Treatment Center (RTC) beds for children with severe mental illness, both for children in foster care and for children in their own families. Moreover, families should not have to relinquish parental rights in order for their children to access necessary treatment. The long- term effects of child abuse/neglect often require extended treatment before a child is ready for adoption. Children with severe mental illnesses should not be “boarded” in psychiatric hospitals due to lack of RTC placements.
9. Children and Adolescents: Prevention
a. Child Abuse Affects Future Psychiatric Services Needs
Child Abuse/Neglect as factors in mental illness. An extensive body of evidence now shows that childhood abuse and neglect are among the major factors in both childhood and adult mental illness. It is important to note, however, they are not the only causes, many cases of serious mental illness, including depression and anxiety, occur in loving families where there has been no abuse or neglect. Nonetheless, studies strongly suggest that preventing or intervening with early life adverse events could prevent or lessen the impact of mental illness. A meta-analysis combining 37 studies that involved over 3 million individuals looked at the impact of sexual abuse as a risk factor for psychiatric disorder (75). They found a highly significant association of between sexual abuse in both men and women and lifetime diagnoses of anxiety, depression, PTSD, eating disorders, and suicide attempts but not schizophrenia. The Center for Disease Control (CDC) surveyed 17,337 adults enrolled in a health maintenance organization and looked at the relationship between numerous forms of Adverse Childhood Experiences (ACE) and adult psychopathology (76). For individuals with four or more ACE’s, there was a highly significant increase in the risk for depression, anxiety, panic attacks, suicide attempts, substance and alcohol abuse but also in obesity, smoking, chronic obstructive pulmonary disease (COPD) and heart disease.
Of growing concern is that childhood abuse and neglect have long lasting effects on the brain development (77). Many studies report that individuals exposed to abuse as children show alterations in their endocrine stress response, referred to as the hypothalamic pituitary axis (HPA). In essence, persons with a history of abuse tend to have an excessive stress response by releasing abnormal amounts of cortisol and adrenaline in response to life events. Abuse persons may experience alterations to their immune systems, producing an inflammatory response that may be damaging to variety of organs and be related to chronic disease (77). In children, severity of early life stressors are associated with smaller brain volumes in areas that are critical for memory and advanced thinking.(78) This agrees with several other studies showing reduced hippocampal volume (a part of the brain also critical for memory and processing experience) and over-activation of the amygdala (a brain region critical in fear and anger responses) (78-80).
Child Abuse and Neglect are major problems in Texas. The data are sobering. According to the Texas Department of Family and Protective Services (DFPS) Databook (https://www.dfps.state.tx.us/About_DFPS/Data_Book/default.asp), there were 174,740 child abuse investigations in fiscal year 2017. “Reason to Believe” was ruled in 33,750 of these cases. Each “case” may represent many children in a family, thus there was a total of 289,796 victims of child abuse/neglect in Texas in fiscal 2017 (38.64 per 1000 children in the state). The number of children taken into state custody was 48,889, while 29,803 children were in state custody as of August 31, 2017, with only 7,236 eligible for adoption.
Accordingly, it would be worthwhile to promote and invest in prevention and early intervention programs, including Home Visiting, STAR, CYD, Child Abuse Prevention Grants, Project Healthy Outcomes through Prevention and Early Support (HOPES), among others.
There is a high rate of teen pregnancy among youth in foster care and young people who have aged out of foster care (81, Table 14b Pregnancies of Women Age 13-17, Table 14b Pregnancies of Women Age 13-17) Girls age 13 to 17 are five times more likely to become pregnant than the general population; 60% have given birth by age 24 (82). As a result, parents who were former foster children often have their children removed from them, continuing the cycle (83). Efforts to alleviate these trends emphasize prevention of teen pregnancy in foster care and the support pregnant or parenting youth in foster care by building their parenting skills. These efforts will support parents and reduce child maltreatment and the negative effects removals can have on children, parents, and the child welfare system. Current approaches to do so include the Helping through Intervention and Prevention (HIP) program, a program specifically designed to serve current or former foster youth who are pregnant or parenting.
b. Support Youth in Foster Care and Youth Aging out of Foster Care
Foster parenting is a heroic, voluntary commitment. Moreover, for children with special needs, Texas already recognizes that foster parents need additional resources. We encourage an evaluation of the adequacy of these supports specifically in the context of youth with behavioral health needs. The same supports should be consistently available to those providing care in the context of kinship fostering arrangements. Peer support by experienced foster caregivers is an important asset that agencies can formalize. Peer specialists can be “on call” when difficult situations arise.
Respite services are also highly valued by provider families.
Data from 2009 to 2015 shows roughly 4,000 psychiatric admissions for foster care children each year. Moreover, the number of total days foster care children together spend in psychiatric facilities past their initial 8 to 10 days of treatment covered under Medicaid has risen during this time. In June 2009, foster children spent a total of 10 extra days in the facilities but by August 2015 that number had grown to 768 days (84).
Despite growing appreciation of the need to support youth transitioning out of formal foster care as they become young adults, their outcomes remain highly problematic. They are at risk for behavioral health and substance use disorders that can escalate to crises needing hospitalization (82). Transition services for youth aging out of foster care to potentially reduce these risks include the Preparation for Adult Living (PAL) curriculum, whose expansion we encourage. Through life skills training, the PAL curriculum aims to help youth in foster care build core life skills, such as personal and social relationship skills, communication skills, and health and safety skills. Early positive experiences with mental health care may promote sustained involvement as adults to meet one’s needs.
10. Recommended Statutory and Process Changes
a. Limit Length of Stay for those on IST Commitments
Lengthy, and in some cases open-ended, commitments to restore competency for those found IST has had adverse impact on the state hospital system’s ability to fulfill its clinical mission and role in today’s system of care. We urge immediate firm adherence to current statutes that limit total competency commitments to 180 or 120 days depending on nature of defendant’s charges. Based on literature reviewed above and what is common knowledge about latency of treatment response in psychotic illness among different patient groups, we also strongly recommend statutory change to limit hospital commitments for IST to 60 and certainly not more than 90 days. Of course, individuals posing serious threats to safety can be reviewed to determine if they fulfill civil commitment criteria. If a person with mental illness has recovered to the point that he or she can return to the community and is not committable on grounds of dangerousness, he or she should not be held in the state hospital simply because he or she cannot be restored to competency to stand trial.
b. Situations where Court Orders to Compel Treatment are Necessary
- We recommend that a compel psychoactive medication order be enterable at the same time as the Order of Protective Custody (OPC), at same At present, is a delay between these two legal proceedings and a psychotic or suicidal patient can only receive emergency medication. Allowing scheduled psychoactive medication to started right after the OPC will actually speed the patient’s recovery and reduce the amount of time in the hospital.
- Allow Crisis Stabilization Units (CSU) to obtain compel medication orders on their Currently, many individuals on 45-day commitments must remain in the CSU or other interim facilities because of the shortage of SASH civil beds. CSUs are not allowed by law to compel medications but routinely have obtained orders to compel those same medications at the State Hospital at the same time of obtaining the 45-day temporary commitment order. Individuals, who through no fault of their own, cannot be placed at the State Hospital may legally refuse medications at the CSU which are necessary to properly treat the individual. The CSU’s inability to administer medications that the State Hospital would be authorized to compel means that the individual is being forced to stay at a location which cannot legally provide the very treatment the individual needs and would be receiving at the State Hospital. Such scenarios effectively “stall” the individual’s treatment and lead to longer hospitalizations.
- At present, persons committed to take to be involved in Assisted Outpatient Treatment (AOT) cannot be compelled to take medication, leading to deterioration in their When clinically indicated, judges should have the capacity to issue compel medication orders for patients in AOT. This would allow caseworkers to use the moral authority of the court to encourage patients to take medication by mouth or to attend clinics where long-acting injectable antipsychotic can be administered. This will enhance the ability of the individual to remain in the community.
c. Allow electronic applications for Emergency Detention by LMHA and MH Officers in the jails, as well as physicians.
Allow electronic applications for Emergency Detention by LMHA and MH Officers in the jails, as well as physicians. At present, there are two ways to effect an Emergency Detention under Chapter 537 of the Texas Health and Safety Code (THSC):
- peace officer’s apprehension without a warrant where officer completes only a “Notification of Emergency Detention (573.002); or
- an adult files an application for emergency detention with a judge/magistrate to obtain a court-ordered warrant for apprehension of the individual 573.012):
- application must be presented personally to the judge/magistrate (573.012(a)(1), EXCEPT…
- an applicant who is a physician may present application via secure electronic means (email, closed circuit TV, satellite, ) as long as method allows for interactive communication between applicant and judge (573.012(h).
We recommend revising 573.012(h) to allow LMHA personnel and Mental Health deputies in the jails to apply electronically, as only physicians currently are permitted. The advantages of such a change are:
- Speeding up the detention process by cutting out travel time to and from the judge’s site;
- get psychiatric patients out of the ERs faster, freeing up ER beds for medical emergencies or other psychiatric crises needing immediate stabilization;
- get the individual to the proper assessment and treatment facility more quickly;
- allow more individuals in psychiatric crises to be seen in the same time period;
- reduce travel time and exposure to danger for crisis workers, particularly in rural communities where there are long stretches of road without cell service in case of an emergency and which may be frequented by illegal drug traffic; and
- reduce the inherent rural danger of accidents on deer-infested roads