System System Transformation in Transformation in

Texas:Texas:Agenda for 2006-Agenda for 2006-

20072007Dave Wanser Ph.D.Dave Wanser Ph.D.

Deputy Commissioner for Deputy Commissioner for Behavioral and Community Behavioral and Community

HealthHealthDepartment of State Health Department of State Health

ServicesServices

Current Behavioral Health Care System

“For too many Americans,the services and supports they need remain fragmented, disconnected, and often inadequate, frustrating the opportunity for recovery….

Instead of ready access to care, the system presents barriers that all too often add to the burden of mental illness (and substance abuse) for individuals, their families, and our communities.”

Achieving the Promise: Transforming Health Care in America

The Texas Approach to The Texas Approach to TransformationTransformation

Overarching goal is to improve the mental health Overarching goal is to improve the mental health of all Texans and meet the President’s NFC of all Texans and meet the President’s NFC goals.goals.

New Freedom Commission Goals are shared by New Freedom Commission Goals are shared by those participating on the TWG:those participating on the TWG: The Governor’s Office; Department of State Health The Governor’s Office; Department of State Health

Services; Texas Health and Human Services Services; Texas Health and Human Services Commission (Medicaid); Department of Family and Commission (Medicaid); Department of Family and Protective Services; Criminal Justice Department; Protective Services; Criminal Justice Department; Juvenile Probation Commission; Texas Youth Juvenile Probation Commission; Texas Youth Commission; Consumers; Family Members; Texas Commission; Consumers; Family Members; Texas Education Agency; Aging and Disability Services; Education Agency; Aging and Disability Services; Workforce Commission; Veteran’s Administration; etc.Workforce Commission; Veteran’s Administration; etc.

TWGTWG Agency Resources Spent on Agency Resources Spent on Mental HealthMental Health

$ Spent by Member Agencies on Mental Health Services in 1999($1.003 Billion)

Member Agencies

The Texas Approach to The Texas Approach to TransformationTransformation

The grant funding is seen as a catalyst to jump The grant funding is seen as a catalyst to jump start some of the efforts of framing the public start some of the efforts of framing the public health approach. The 2 primary areas of focus:health approach. The 2 primary areas of focus: Developing and supporting local behavioral health Developing and supporting local behavioral health

collaborativescollaboratives Using cutting edge technology to change work Using cutting edge technology to change work

processes across agenciesprocesses across agencies Improvement of the system will be targeted to Improvement of the system will be targeted to

the IOM Quality Chasm principles:the IOM Quality Chasm principles: Apply evidence to health care delivery;Apply evidence to health care delivery; Use information technology;Use information technology; Align payment policies with quality improvement;Align payment policies with quality improvement; Prepare the workforcePrepare the workforce..

Child Abuse or Child Abuse or NeglectNeglect

Physical abusePhysical abuse Sexual abuseSexual abuse AbandonmentAbandonment

Adverse Childhood Experiences as a means

to Understand the Public Health Approach

Trauma in Child’s Household • Substance Abuse• Parental divorce• Mentally ill or suicidal household member• Violence to mother• Imprisoned household member

Effects of TraumaEffects of Trauma Difficulty controlling Difficulty controlling

angeranger HallucinationsHallucinations DepressionDepression Panic reactionsPanic reactions AnxietyAnxiety

Adverse Childhood Experiences

Health Risk Behaviors • Smoking• Obesity• Suicide• Alcoholism• Drug abuse• Sexually transmitted disease• Self-injury• Eating disorders

Disease and Disease and DisabilityDisability

Heart diseaseHeart disease CancerCancer Chronic lung diseaseChronic lung disease EmphysemaEmphysema HIV/AIDSHIV/AIDS

Adverse Childhood Experiences Long-Term Consequences

Social Problems • Homeless• Prostitution• Delinquency, violence and

criminal behavior• Re-victimizations: rape;

domestic violence• Unemployment• Intergenerational

transmission of abuse

Adverse Childhood Experiences & Attempted Suicide

0

5

10

15

20

25

0 1 2 3 4

Behavioral Health Issues Behavioral Health Issues Impact Costs and Outcomes Impact Costs and Outcomes

in Other Systems in Other Systems 75% of children placed in foster care have 75% of children placed in foster care have

parents with behavioral health problemsparents with behavioral health problems 75% of kids in the juvenile justice system 75% of kids in the juvenile justice system

have behavioral health problemshave behavioral health problems 30% of kids in the juvenile justice system 30% of kids in the juvenile justice system

will end up in the adult justice systemwill end up in the adult justice system 46% of all ER visits have behavioral health 46% of all ER visits have behavioral health

issues as a basis or contributing factorissues as a basis or contributing factor 30% of all truancy is related to behavioral 30% of all truancy is related to behavioral

health problemshealth problems

Potential of a Public Health Potential of a Public Health Approach:Approach:

What we will make a priority of What we will make a priority of all agenciesall agencies Focus on prevention and early intervention and Focus on prevention and early intervention and

adopt a family based approachadopt a family based approach Implement national outcome measures and focus Implement national outcome measures and focus

on how cultural issues impact disparities in on how cultural issues impact disparities in access and outcome.access and outcome.

Expand the use of cutting edge technologyExpand the use of cutting edge technology Demonstrate successful integration of physical Demonstrate successful integration of physical

and behavioral healthand behavioral health Seek public/private partnershipsSeek public/private partnerships Work to develop and maintain a shared Work to develop and maintain a shared

transformation agenda with stakeholders at both transformation agenda with stakeholders at both the state and local levelthe state and local level

Change minds, change systems, change behaviorChange minds, change systems, change behavior

Texas TransformationTexas Transformation 1. 1. Texans understand mental health is essential to overall healthTexans understand mental health is essential to overall health

Build capacity of primary care providers to identify, treat and refer across disciplinesBuild capacity of primary care providers to identify, treat and refer across disciplines

Use local behavioral health collaboratives to leverage policy changeUse local behavioral health collaboratives to leverage policy change

2. 2. MH care is consumer and family drivenMH care is consumer and family driven

Reduce barriers to treatment and reduce stigma with new program and purchasing Reduce barriers to treatment and reduce stigma with new program and purchasing modelsmodels

3. 3. Disparities are eliminatedDisparities are eliminated

Inter-operability of data systems creates a roadmap for opportunitiesInter-operability of data systems creates a roadmap for opportunities

Leveraging lessons learned from other initiatives, e.g. work with faith communityLeveraging lessons learned from other initiatives, e.g. work with faith community

4. Early screening, assessment and referral are common practice4. Early screening, assessment and referral are common practice

Use of technologyUse of technology

ACE framework shared by member agenciesACE framework shared by member agencies

Behavioral health/ primary care and public/private partnershipsBehavioral health/ primary care and public/private partnerships

5., 6. Excellent care is delivered and research accelerated, technology is 5., 6. Excellent care is delivered and research accelerated, technology is utilizedutilized

Demonstrate return on investmentDemonstrate return on investment

System wide use of evidence based frameworks and practicesSystem wide use of evidence based frameworks and practices

A Borrowed Approach to A Borrowed Approach to Community CollaborationCommunity Collaboration

Community collaboratives have been very Community collaboratives have been very effective in mobilizing communities to address effective in mobilizing communities to address issues in access to healthcare for underinsured issues in access to healthcare for underinsured populationspopulations

Membership consists of business leaders, Membership consists of business leaders, elected officials, community leaders, consumers. elected officials, community leaders, consumers. ProvidersProviders

Follows a structured and facilitated process for Follows a structured and facilitated process for needs assessment, planning and implementationneeds assessment, planning and implementation

Linkages to other local collaboratives through Linkages to other local collaboratives through statewide framework leverages political impact.statewide framework leverages political impact.

Use Technology to Transform the Mental Use Technology to Transform the Mental Health SystemHealth System

TransformationWorking Group

LocalCommunity

Collaboratives

Service Providers

State LevelData

Integration

System

Electronic MedicalRecord

Video ConferenceCapacity

Interagency

Instant Message Capacity

Data produced from the interagency integrated data base……

….informs the Local Resource Inventory and Needs Assessment.

CommunityCollaboratives ensure Service Providers …..

…..have access to technological innovations needed to most efficiently deliver services

Telemedicine

Federated Data SystemSTATE LEVEL CONNECTIVITY ANDINTERAGENCY DATA MATCHING

LOCAL LEVEL BENEFICIARIES OF INSTANT MESSAGING FEATURE

Internet

Data Center

Port 80 (http) encrypted tunnel

TEXAS OPEN COLLABORATION SYSTEM (TOCS)

The Instant Messaging ClientEncrypts all data transferred to and from the data center. This encrypted data is sent over a port 80 (http) tunnel which allows connection through commonly implemented firewalls without additional “holes” being opened. The Instant Messaging client can be loaded directly from the edapt.us portal or via download from a public internet server.

Port 80 (http) encrypted tunnel

HHSCPOLICY

VPN

TOCS Federated

Data

The Federated Data system combines data from and runs queries against various data sources:

Only “need to know” data is accessible via the chat client. This support agency policy for HIPAA and other regulations as a matter of policy.

Virtual Private Network (VPN)

Housing

Aging and Disabilities

(DADS)

Education(TEA)

DFPS

VocationalRehab. (DARS)

Veterans Health Administration (VA)

Juvenile Justice

Criminal Justice

Employment

TYC and TJPC

Child and Adult Protective Services

Mental HealthSubstance Abuse

Primary Care/MedicalDSHS

Veterans HealthClinics

Local CommunityMental Health Centers Substance Abuse

Providers

Jails

Adult ProbationDepartments

Juvenile ProbationDepartments

TYC ParoleOffices

Local area on Aging offices

Schools

CPS OfficesRTC and other Institutions for youth andAdults with MH