HHSC: Joint Committee on Access and Forensic Services: Workgroup Recommendations, July 29, 2018

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August 14, 2018

Meeting Summary

S.B. 1507, 84th Legislature, Regular Session, 2015, directed DSHS to reconvene the advisory panel established by H.B. 3793, 83rd Legislature, Regular Session, 2013. The charge of the advisory panel is to develop, make recommendations, and monitor the implementation of updates to a bed day allocation methodology for allocating to each designated region a certain number of state-funded beds in state hospitals and other inpatient mental health facilities for voluntary, civil, and forensic patients, and a bed day utilization review protocol that includes a peer review process. The legislation also requires the department to establish a forensic work group made up of experts and stakeholders to make recommendations for a comprehensive plan for the coordination of forensic services. Because these groups have shared members and closely related charges, the department is forming a joint committee. (Joint Committee on Access and Forensic Services: Workgroup Recommendations ). Committee members can be found by following the link.

Introduction
The meeting was convened by Stephen M. Glazier, Chair (Representing the Texas Hospital Association). A quorum was not present at the beginning of the meeting.

Approval of minutes from April 25, 2018, committee meeting. Initially, the minutes could not be approved for lack of a quorum. Later a quorum was established and the minutes were approved as written.

Policy issues and Meeting Highlights

The joint committee met to review and discuss recommendations they had proposed. Suggestions were made for edits and changes.
They also reviewed the draft utilization review report. Three factors are clearly correlated with readmission rates: the proportion of civil vs. forensic utilization, length of stay, and use of contracted beds. These factors are closely related. Though counter-intuitive, people with the most follow-up often had higher re-admission rates.
The Legislative report draft was presented and members commented. No vote on the report was taken since it is a staff report, though input was appreciated.
The Joint Committee received the recommendations on housing from the Behavioral Health Advisory Committee that included:
- Recommendation #1—Conduct an Environmental Scan to document current status, needs, opportunities, and challenges for Recovery Housing and Mental Health Boarding Homes throughout Texas. Findings will inform policy changes, best practices, and training and technical assistance resources.
- Recommendation #2—Expand HHSC’s Supportive Housing Rental Assistance program to all 39 Local Mental Health Authorities/Local Behavioral Health Authorities.
- Recommendation #3—Expand Housing and Community-Based Services Adult Mental Health (HCBS-AMH) to include services for homeless individuals.
- Recommendation #4—Increase access to alcohol and drug free recovery housing and incentivize a voluntary certification program using national best practices standards.
  Recommendation #5—Improve legislative reporting on local boarding home ordinances to better understand their impact on housing options for person who are disabled by behavioral health issues. Findings will inform policy changes.
- Recommendation #6—Establish and implement a small-group home model with 24-hour, 7-day-a-week staffing for those with the most severe cases of mental illness.

Resolutions and Meeting Conclusion

There being no further business, the meeting was adjourned.

Report from the Access Subcommittee on the 2018 Utilization Review.
Two documents were made available for review:

The Report related to Review of Readmissions 2018
DRAFT Report related to Utilization Review

Report of the Access Subcommittee: Review of Readmissions 2018

Summary of Findings:

Three factors are clearly correlated with readmission rates: the proportion of civil vs. forensic utilization, length of stay, and use of contracted beds. These factors are closely related. Civil patients have much shorter lengths of stay than forensic patients, and are often treated in contracted beds. Local authorities with the highest readmission rates have a very high proportion of civil utilization, very short lengths of stay, and higher utilization of purchased beds. In contrast, those with the shortest readmission rates had far higher forensic utilization, significantly longer lengths of stay, and relied primarily on state hospitals.
In addition, close proximity to a facility providing easy access for law enforcement and patients appears to be a contributing factor.
Patients with length of stay from eight to 30 days have higher rates of readmission than those with shorter or longer lengths of stay. This is the population requiring extended acute care, which is generally available only in a state hospital. Limited capacity at state hospitals has resulted in more of these patients being treated in private psychiatric hospitals that are not equipped to address their complex needs.
The pressure or need to make space for individuals in crisis waiting for care may lead to some patients being discharged before they are optimally ready and appropriate community supports are in place.
Data suggests that local authorities are prioritizing patients with more acute needs in allocating their aftercare resources. Despite this attention, these patients re-admit more frequently.
Comparing short-term patients, readmission rates are lower for patients discharged from a state hospital than from a contracted bed, reflecting greater challenges in maintaining close communication and coordination with private psychiatric hospitals.
Most discharged patients are not connected with ongoing services at the local authority, and less than one third of adults discharged from a civil or voluntary commitment are authorized in a full level of care 30 days after discharge.
he quantitative and qualitative components of the review suggest readmission rates are driven in large part by a lack of appropriate community supports for high-need clients. In particular, the limited availability of appropriate and supported housing environments, substance use disorder treatment, and peer support services is a major barrier to long-term stabilization and recovery.
Challenges with client engagement also contribute to higher readmission rates.
Peer bridgers, or navigators, are an effective resource to improve successful transition to the community.
In addition, there are opportunities for process improvement, including implementation of evidence-based client engagement practices and early identification of individuals at high risk of readmission.

Summary of Key Data 1. Three closely-related factors are clearly correlated with readmission rates: the proportion of civil vs. forensic utilization, length-of-stay, and use of contracted beds.

Close proximity to a facility providing easy access for law enforcement and patients appears to be a contributing factor. Seven of the top ten local authorities have a state hospital or community mental health hospital within the local service area.

Patients with length of stay from eight to 30 days have higher rates of readmission than those with shorter or longer lengths of stay.
The pressure or need to make space for individuals in crisis waiting for care may lead to patients being discharged before they are optimally ready and appropriate community supports are in place. This issue came up on multiple occasions during utilization review teleconferences, particularly with reference to the extended acute population receiving care in contracted private psychiatric beds. It is consistent with data showing higher readmission rates for the extended acute population and patients treated in contracted beds.
Local authorities appear to be prioritizing patients with more acute needs in allocating their aftercare resources. Despite this attention, these patients re-admit more frequently.
Patients with a follow-up contact within seven days of discharge have higher readmission rates than those without a follow-up contact.
The group of local authorities with the highest readmission rates had the highest rates of seven-day follow-up. This can be counterintuitive given the assumption that follow-up would reduce readmissions.

Q: Do we know why this is the case? A: One of the things they see is a high correlation with the sicker patients and readmission rates. The ones discharged after three days were not really that sick. Somehow, when we look at those having follow-up, they are the really sick patients. The survey gives us information but not conclusions. People could be readmitted because they get a follow-up. Those without a follow-up probably end up in the county jail. The data raises questions because there is really a lot more that we can do. There can be a lot of potential reasons.

C: When you look at the civil population, a contract bed could provide shorter lengths of stay. The speaker stated she would have to look at the data.

A larger percentage of readmitted patients are in an intensive level of care 30 days after their initial discharge when compared with patients who are not readmitted.

Similarly, patients in more intense levels of care and those in transitional levels of care have higher readmission rates than other patients, including those not in care 30 days after discharge.
Comparing short-term patients, readmission rates are lower for patients discharged from a state hospital than from a contracted bed, reflecting greater challenges in maintaining close communication and coordination with private psychiatric hospitals.

Survey responses and teleconference discussions highlight the greater effort required to maintain close coordination with private psychiatric hospitals.

Most discharged patients are not connected with ongoing services at the local authority, and less than one third of adults discharged from a civil or voluntary commitment are authorized in a full level of care 30 days after discharge.

Q: Do we track voluntary commitments to see if they have been in the criminal justice system? A: The only way we would know that is if they had been receiving services through the local authority. There are criminal histories that are gathered for forensic admissions. It would be good to gather criminal background information for civil commitments to point out if we missed something.

C: Those that receive the 7-day follow-up have a higher readmission rate. It is important to look at these issues across state hospital beds and contracted beds.

C: We want to reduce readmissions by providing better after-care and improvements in services.

C: A couple of variables are people discharged to homelessness and options that LMHAs have for transitional residential treatment options. Value-based bundle payments for private bed contracts can result in increased bed capacity and reduction of readmissions. You have to be able to build a bundled payment that has value. Also, a crisis can occur because they have “been using.”

Utilization Review DRAFT Overview:

Texas Health and Safety Code (THSC), Section 533.0515(e) directs the Department of State Health Services (DSHS)1 to submit a report summarizing the activities of HHSC and the advisory panel, identified herein as the Joint Committee on Access and Forensic Services (JCAFS), related to an updated bed day allocation methodology and utilization review protocol. In addition, this report is to provide information on:

The actual value of a bed day for the two years preceding the report and the projected value for the five years following the report;
An evaluation of factors that impact the use of hospital beds by region;
The outcomes of the implementation of the bed day utilization review protocol on the use of state-funded hospital beds; and
Any recommendations of HHSC or JCAFS to enhance the effective and efficient allocation of state-funded hospital beds.

The bed day allocation methodology and utilization review protocol adopted in 2016 have been successfully implemented. The JCAFS recommended no changes to the allocation methodology and minor revisions to streamline the utilization review protocol.

Utilization review activities in fiscal year 2017 and 2018 examined overall patterns of bed day utilization and readmissions. The 2017 utilization review had no impact on bed day utilization; the evaluation of the 2018 review is pending. Participants agreed the process was useful in identifying factors impacting bed day utilization, strategies for addressing issues related to bed day utilization, and resource needs. Geographic access to a state or community hospital appears to be a key determinant in bed day utilization and readmission rates. The reviews also highlighted difficulty local authorities have in accessing appropriate care for individuals needing extended acute psychiatric stabilization. Data suggests that local authorities are prioritizing patients with more acute needs in allocating their aftercare resources. Despite this attention, these patients re-admit more frequently.

Significant investments have been made in programs that divert individuals from unnecessary hospital admission. Increasingly, the greater challenge is appropriate and timely hospital discharge. The results of the utilization review suggest the need for transitional step-down facilities, safe and affordable housing options, and other community supports necessary for individuals to engage in services and establish meaningful connections in the community. In addition to housing, substance use treatment and peer services are identified as critical needs. Special consideration is needed to provide post-discharge options for forensic patients that satisfy the courts and other community stakeholders.

Recommendations to consider for the 2018 legislative report.

The Chair stated that the report should be boiled down to some prioritized key points. JCAFS Workgroups reported on their recommendations. This would make it more readable for the Legislature. It is a staff report and does not require approval from this committee but the staff would like input from this work group. Courtney Harvey made the presentation and lead the discussion. She stated that many work group recommendations can be combined and paired down.

Workgroup 1: Workforce Identified Issue: Insufficient Workforce Workgroup Recommendations:

Provide full scholarships for people wishing to go to medical school with the understanding that they will work in the public mental health system, especially rural areas, for 5 years after completion of their Psychiatric residency. Do the same for clinical and counseling psychologists;
Increase the number of psychiatric residencies in the state;
Provide paid pre- and post-doctoral internships for clinical and counseling psychologists and develop a loan forgiveness program or pay part of the educational loans for every year they work in the public mental health system;
Provide loan forgiveness programs for physician extenders such as clinical nurse practitioners and physician assistants;
Provide summer fellowships, clerkships, and specialty curriculum tracks for undergraduate students interested in the mental health field;
Provide scholarships or partial scholarships for Certified Peer Support training and Recovery Coach training;
Increase Graduate Medical Education slots specific for residency in community psychiatry;
Student loan forgiveness for multiyear employment contract to local mental health authorities (LMHAs) or state hospitals;
Use networking available with Chairs in Psychiatry to explore opportunities to incorporate community psychiatry training in their residency program or develop additional academic/public partnerships with aim at increasing available workforce or telehealth opportunities;
Offer stipends to psychiatric residents, nursing trainees, and physician assistants willing to sign contracts to work in LMHAs or state hospitals over a multi-year agreement; and
Loan forgiveness for nursing students, specifically, Advanced Practice Nurses or Family Nurse Practitioner’s with mental health certification for multiyear employment contracts to LMHAs or state hospitals.

Comments:

Paying for people in training too early may result in people leaving early and the loan repayment payment is lost.
Loan repayment is an issue for professionals in state hospitals.
If people are paid adequately, they will stay working at the state hospitals so pay may be the issue and not loan repayment.
Loan repayment should be “weighted to toward the back.”
Not all people working at state hospitals come out with heavy loan debt. We have to balance pay with loan forgiveness.
What about a contract hooked to loan repayment? Presently people come in and leave when they want. The state cannot compel performance if a person does not want to be there.
A mechanism would have to be in place that supports that commitment.
Loan repayment is pre-taxed.

FOCUS: The discussion is focused on competitive pay scale across disciplines and also a loan repayment. The language has to be clear.

Workgroup 2: Resource Needs Identified Issues:

Lack of affordable and safe housing; and
Access and discharge to and from state hospitals.

Workgroup Recommendations:

Expand Affordable Community-Based Housing Options:
- Create incentives to develop affordable/supportive housing opportunities for persons with Intellectual and Developmental Disabilities (IDD) and behavioral health (BH) disabilities.
- Encourage both for profit and non-profit developers to include supportive housing units through the scoring criteria of the Qualified Allocation Plan for the Low-Income Housing Tax Credit program.
- Create a supportive housing set aside linked with policy priorities to explicitly create integrated supportive housing for institutional populations.
- Provide funding for capital investments to build permanent housing, transitional housing, and recovery housing for persons with IDD and BH disabilities.
- Replicate or expand existing programs, like the Supportive Housing Rental Assistance program, to incorporate more disability populations like persons with IDD and BH disabilities.
Expand Access to Tenancy Support Services:
- Provide funding and request Legislative approval to develop a Medicaid waiver benefit that will provide more comprehensive tenancy support services for persons with IDD and BH disabilities.
- Develop and support ongoing training opportunities for the existing workforce to provide tenancy support services to persons with IDD and BH disabilities.
- Expand and enhance state funded Housing Navigator capacity across the state.
Greater development of community based services that further evolve the continuum of care (e.g. forensic nursing homes for patients that have been on long-term forensic commitments who no longer pose a credible risk of harm to others, who nevertheless are “stuck” in state hospitals, more housing/supportive housing options, group homes, etc.);
Significant expansion of community services to support implementation and expansion of pre-charge diversion programs to include on-site diversion staff in jail settings;
Statutory changes as needed to prevent individuals deemed Incompetent to Stand Trial for relatively low offenses from being served in the most restrictive setting such as state hospitals;
Consider a formalized conditional release program for forensic patients modeled after those in some other large states.

Comments.

Recommendations should target housing, specifically.
There have to be regulatory authorities overseeing the housing options.
We have talked about transitional housing as well as step-down housing and these could be two different recommendations.
We need a range of affordable safe housing that must be in fidelity with the research.
Linda Frost stated that she has concerns about calling some housing options ‘forensic.’
We may not have to get into that kind of detail in the recommendations.
We are saying to appropriators that we need more options.
Can we leverage existing statutory authority to implement housing improvements?

FOCUS: Supporting expanding housing options with regulatory oversight and look at existing language.

Mr. Johnson asked if the items will be adopted. A: No, this is just informational.

Workgroup 3: Step-Down Facilities Identified Issues:

Limited state hospital capacity and growing state population;
Options for patients needing extended stabilization;
Facility-based step-down alternatives from state and local hospitalization, including options to support engagement; and
The availability of aftercare services and supports once discharged from the step-down alternatives with a focus on housing supports, substance use treatment, and linkage to an appropriate level of care that will address identified needs.

Workgroup Recommendations:

Explore financing options and regulatory issues for establishing step-down models of care;
Leverage existing statutory authority to develop or expand regional transitional step-down units for individuals on civil or forensic commitment; and
Explore blended facility-based models of care with 24-hour, 7-day-a-week staffing for those with the most severe cases of mental illness.

Comments.

These recommendations were pretty paired down already and have a FOCUS.
These recommendations address arranging for supports for recovery oriented care.
The discussion around the transitional centers is it is a step down and a step up.

Workgroup 4: IDD-BH Issues Identified Issues:

Examine how individuals with IDD move through the system, and barriers to placement in the community or a state supported living center;
Trauma-informed care for individuals with IDD-BH needs; and
Step-down facilities for individuals with IDD-BH needs.

Workgroup Recommendations:

Increase training in Trauma Informed Care (TIC) and the implementation of evidence-based practices that align with the TIC paradigm for agencies that serve individuals with IDD or co-occurring IDD-BH conditions;
Increase the availability of Home and Community-Based Services and residential treatment options for individuals with IDD or IDD-BH conditions transitioning from state hospitals or state supported living centers; and
Ensure the availability of treatment providers that meet the specialized needs of people with IDD and complex BH needs.

Comments

This is critical for the adolescent population as well.
SSLC role in placement could be expanded.
Specialized mobile crisis teams that are trained with law enforcement (START Teams) and these should be funded. (START is an evidence-based approach to care.)
There are a number of options to be included in this whole area like cross-training for outreach teams.
With ‘money follows the person,’ there are hubs for psychiatry and behavioral specialists. These are at-risk with the funding running out. We do not want to go backward and lose regional hub supports.

The recommendations will be paired down and sent back out to the members for review and then inclusion in the legislative report.

Review of the preliminary draft 2018 legislative report. Tamara Allen made the presentation on the report preliminary draft. The front sections are drawn from last year’s report. Issue sections include:

Factors that influence state funded beds.
Outcomes of Utilization Review.
There are recommendations based on staff discussion to date but [they] do not include what was just discussed. Those will be added.
The Work Group reviewed a document not made available to the public.

Comments from Members about the DRAFT Report which will include some of the items:

Overutilization is equal to the state hospitals in the area. This statement may not be true. Staff stated that it came from the teleconferences. Maybe the conclusion should be stricken since it is unclear what is impacting the re-hospitalization.
The utilization protocol was looking at expectations.
People being discharged into homelessness may be a causative factor for re-hospitalization.
Comparing state hospitals and contracted beds. The conclusion drawn may not be correct. There is a higher forensic population in the state hospitals.
Some patients refuse aftercare and the report should look at the why readmissions occur.
We have to be sure we are making an apples-to-apples comparison.
On Page 12, the conclusion and second part of the statement regarding private psych hospitals. There is a need for extended acute care capacity and 7, 8, and 9— those all suggest the need for additional capacity. There has not been enough done on the focus on aftercare.
That will take a lot of investigation. Is our paradigm needing to shift where we do outreach and make home visits?
We have to take care not to make conclusions that are not warranted.
Having step-up and step-down facilities is impacting the need for hospitalization.
There is a really strong statement about housing being the most urgent deficit in the mental health system. Housing may not be the most urgent deficit though a very high need.
An important piece of the pie is stepping back and looking at the role of the state hospitals and the populations served. Soon, we will be all forensic and serving people with comorbidity. Future meetings should look at the role of state hospitals in the future. Comparing us to short-term civil hospitals won’t get us very far since we no longer serve the same populations.
We have no choice in providing forensic services. We have to provide those.
What are we willing to invest in preventive intervention… all the way back to children experiencing trauma. If we do not stop the pipeline then we will never have enough beds.
If you need an ACT team for success then you need a permanent supportive housing model.
There are two aspects: mental health but not committed a crime or low-level crime and the other is the forensic side where mental health is criminalized. Some are serious criminal offenses. There is a sizable wait list for those who have committed serious crimes.
We should encourage better resource-sharing across the system including human commodities and telemedicine.

A final version will be moving up through the process prior to the next meeting.

Potential special teleconference meeting to review the draft 2018 legislative report Pulled from the agenda.

Presentation from the Behavioral Health Advisory Committee Housing Subcommittee. Behavioral Health Advisory Committee (BHAC) provides customer/consumer and stakeholder input to the Health and Human Services system in the form of recommendations regarding the allocation and adequacy of behavioral health services and programs within the State of Texas. The BHAC considers and makes recommendations to the HHS Executive Commissioner and Texas Legislature consistent with the committee’s purpose.

BHAC Housing Committee

In 2017, the subcommittee was established. The Housing Forum on Recovery Residences and Mental Health Boarding Homes, 2018 had Six Recommendations that included forming this standing subcommittee.

Members: State Agencies: HHSC, TDHCA, TDCJ, TJJD, TWC, TEA; Community: Hogg Foundation, NAMI, Grassroots Leadership, Texas CJC, local homeless CoC. There are monthly meetings that focus on accessing housing, barriers, and solutions:

Funding
Fair Housing
Rent, credit, criminal histories
Workforce knowledge, skills, and abilities

Access to housing was a gap on the Statewide Behavioral Health Strategic Plan and was recognized as an issue to be addressed on the Statewide Behavioral Health Coordinating Council.

Recovery is a person-driven process.

Individuals should be able to choose housing that best supports their current goals.
Choice is limited by what’s available, marketing and consumer education.
What’s available is limited by funding, infrastructure and knowledge transfer.

One size does not fit all and there are diverse and evolving needs, even with a particular population. The housing effort faces many barriers: financial, criminal justices, employment. In reality, people are placed in what is available rather than was is the most cost-effective fit which results in over support, under support or wrong support. They have made a series of recommendations.

Recommendation #1

Conduct an Environmental Scan to document current status, needs, opportunities, and challenges for Recovery Housing and Mental Health Boarding Homes throughout Texas. Findings will inform policy changes, best practices, and training and technical assistance resources.

Recommendation #2

Expand HHSC’s Supportive Housing Rental Assistance program to all 39 Local Mental Health Authorities/Local Behavioral Health Authorities.

Recommendation #3

Expand Housing and Community-Based Services Adult Mental Health (HCBS-AMH) to include services for homeless individuals.

Recommendation #4

Increase access to alcohol and drug free recovery housing and incentivize a voluntary certification program using national best practices standards.

Recommendation #5

Improve legislative reporting on local boarding home ordinances to better understand their impact on housing options for person who are disabled by behavioral health issues. Findings will inform policy changes.

Recommendation #6

Establish and implement a small-group home model with 24-hour, 7-day-a-week staffing for those with the most severe cases of mental illness.

Need for a Comprehensive Housing Strategy

Cross agency priority
Map what is needed
Identify funding resources
Identify who takes the lead Will require broad commitment and coordination

Public comment. No additional public comment was offered. A request was made that metrics would be presented at every meeting. The state hospital staff have pulled some very interesting data. That is being pulled together for presentation at the next meeting. We must have a public presentation of the status of the backlog.

Adjourn. There being no further business, the meeting was adjourned.