Written by Mary Ann Roser

Diagnosed with schizophrenia, “Doug” was known as a “super-utilizer” at Houston Methodist Hospital. In 2014, he was in the emergency department or inpatient unit of the hospital 17 times. 

The director of psychiatry for the systems eight hospitals, Heather Chung, MSN, Ph.D., NE-BC, wanted to change that pattern.

Chung hoped a new pilot program could stabilize Doug and perhaps avoid hospitalization. Consequently, she became deeply invested in his care. Whenever Doug showed up at the hospital, a staff member called Chung. She spent countless hours working with the care team and community providers to get him therapy in the facility where he lived; enroll him in adult day care; and provide other services to change his habit of seeking care first at the hospital emergency department.


Chung

“It took me two years to reduce his hospital visits to twice a year,” Chung said.

Taking a holistic, individualized approach, starting with the 2014 pilot is part of Houston Methodist’s answer to increasing access to community-based behavioral health services and reducing inappropriate ED use and chronic hospitalizations of individuals with behavioral health diagnoses. Called Psychiatric Transitions in Care, the program is funded through the state’s Medicaid 1115 Waiver’s Delivery System Reform Incentive Payment program. DSRIP provides $3.1 billion a year to hospitals and other providers statewide to collaborate on projects to improve health care outcomes through increased access, innovations in care and infrastructure development. 

Psychiatric Transitions in Care is among the many strategic partnerships between Texas hospitals and community organizations aimed at matching patients who need behavioral health treatment with the right care at the right place and right time.

Improving timely access to behavioral health care is a complicated problem to solve, but Texas lawmakers have also been trying. In the last three legislative sessions, they have substantially increased funding for behavioral health beds and services. They also have begun capital projects to expand, update and replace aging and deteriorating state-owned psychiatric hospitals.

Combined state and federal funding for behavioral health in Texas reached $7.6 billion for 2018-2019, up from $6.9 billion in 2016-2017, according to the state Legislative Budget Board. Licensed psychiatric beds in Texas, public and private totaled 7,305 in 2017, up 40 percent from 2008.

Even so, large gaps remain in a state where nearly one in five adults experiences mental illness each year. Texas ranks 50th in access to mental health care, according to a report by the nonprofit Mental Health America. Comprehensive programs that integrate physical and behavioral health care are few and far between. Repeat hospitalizations are common as individuals with behavioral health conditions cannot access the care they need and experience repeated crises as a result.

In addition, the opioid epidemic and natural disasters, such as Hurricane Harvey, have stressed provider capacity at a time when behavioral health worker shortages are worsening. Many of these professionals are nearing retirement age, as the state’s population continues to grow.

State Funding

At the same time, the state’s psychiatric hospitals are teeming with forensic patients — individuals accused of a crime or ordered by the court to receive psychiatric treatment because they’ve been deemed incompetent to stand trial or not guilty by reason of insanity. Their average length of stay is 187 days, twice as long as that of other patients.


Hansch

Because of the increasing number of forensic commitments and ongoing demand from other patients for psychiatric beds,the Texas Health and Human Services Commission—the agency responsible for administering Medicaid and other essential health and human services for vulnerable Texans—is spending $121.5 million this fiscal year for more than 600 beds in private facilities.

This legislative session, Texas lawmakers are discussing further expanding access to behavioral health services in high schools as a way to decrease the number of violent incidents. Greg Hansch, interim executive director of the National Alliance on Mental Illness-Texas, said he is hopeful lawmakers will build on their investment in mental health. Meanwhile, hospitals like Houston Methodist are getting creative.

Hospitals Respond

Today, Houston Methodist runs Psychiatric Transitions in Care at three of its hospitals. Patients with behavioral health diagnoses are assessed by social workers who determine what is needed to stabilize and most effectively treat them. The hospitals rely on nine community partners, as well as home health aides who make at least one visit after the patient has left the hospital.

Chung is convinced that the social determinants of health — from the patients’ income to their education to the neighborhood in which they live — must factor into any solution to provide better care and achieve improved health outcomes. To do that takes more resources and time than Chung and her team ever imagined, but the approach is working, she said.

“We need more super-utilizer programs,” she said, adding that she is thankful the Medicaid 1115 Waiver’s DSRIP program offered a way to pay for Houston Methodist’s approach. “The dollars have offered an opportunity to peel layers of health care we would not have peeled before.”


Law Enforcement Navigation

While the Houston Methodist initiative targets patients coming through the door, several other Texas hospitals have community partnerships that divert patients before they ever arrive.

The Law Enforcement Navigation program in Bexar County is one. It involves health systems across the county, along with the San Antonio Police Department and other organizations. The goal is to quickly get patients to the right place for care; reduce ED traffic and jail time for people with behavioral health diagnoses; and share the responsibility for providing care across the system. 


Vasquez

“Before, we just went to University Hospital and we were spending hours there,” said Sgt. Bart Vasquez, supervisor for the mental health detail at SAPD. It was even worse for the patients, he added.

In 2015, the Southwest Texas Crisis Collaborative, a division of the South Texas Regional Advisory Council, collected data across Bexar County that showed nearly half of all patients who were held in the ED for being a danger to themselves or others had no physical health condition that would warrant ED use. Yet, patients were spending an average of nine hours there—using precious resources that could be needed for individuals with traumatic injuries, broken bones and heart attacks, according to Sarah Hogan, MA, LPC the collaborative’s director.

With $4.9 million from Methodist Healthcare Ministries of South Texas Inc. and another $5 million from local health care organizations, as well as support from local governments and others, the group set up a communications center called MEDCOM to direct law enforcement officers in parts of Bexar County to the nearest facility with a behavioral health bed. By February 2018, the system was countywide, Hogan said. 


Hogan

“It’s a two to three-minute phone call” to MEDCOM, she said. After taking the patient to the facility, the officers are back in service.

In the past year, 9,310 patients who were held in a hospital for treatment and stabilization due to presenting a serious threat of danger to themselves or others were diverted from hospital EDs to a psychiatric bed at a more therapeutic and appropriate care setting — a 50 percent reduction from preceding years, Hogan said.

About 98 percent of the police force dealing with mental health cases are now calling MEDCOM first, Vasquez said.

“You’re in and out in 10 minutes, and the patient is getting the right treatment, in the right place,” he said. “It’s a great thing.”

Parkland’s Approach

In Dallas, the psychiatric bed crunch is more severe than in some other parts of the state. Unlike San Antonio, for example, Dallas lacks a publicly funded state psychiatric hospital, said Kurtis Young, social work director of the behavioral health department at Parkland Health & Hospital System.


Young

In a year’s time, “we lost over 400 beds...and had to change how we operate,” Young said.

The bed shortage also was frustrating to Dallas Fire-Rescue, which was struggling to keep up with demand for care, Young said.

With money from the W.W. Caruth Jr. Foundation at Communities Foundation of Texas and others, the Meadows Mental Health & Policy Institute partnered with the City of Dallas, Dallas Fire-Rescue and Parkland Hospital in January 2018 to launch the Rapid Integrated Group Healthcare Team Care pilot in January 2018, called RIGHT Care. Hospital social workers work alongside the fire department’s paramedics and trained Dallas Police Department officers two shifts daily, seven days a week, serving South Dallas, the area generating the most psychiatric emergency calls.

In addition, a Parkland psychiatric social worker is at Dallas’ 911 call center to triage mental health calls and assign the multi-disciplinary response teams. The teams average four to six calls per shift.

They use a donated police department vehicle, equipped with a computer, protective doors, clothes and bottled water. Sometimes, the problem can be handled in the field. Other patients might be referred to a community partner.

RIGHT Care collaborates with area hospitals as well as the North Texas Behavioral Health Authority, Dallas MetroCare Services and the Child & Family Guidance Center, among others.

“We just passed 3,000 encounters in February, and of those 3,000, only 108 were arrested,” Young said.

Without the program, the arrest rate would have been several hundred, he said. “It just made a world of difference.” Parkland also is expanding its behavioral health beds, doubling a 14-bed psychiatric unit to 28 beds and has created an 18-bed emergency observation unit, Young said.

Parkland also is expanding its behavioral health beds, doubling a 14-bed psychiatric unit to 28 beds and has created an 18-bed emergency observation unit, Young said.


Rural Texas

Much of Texas, however, doesn’t have access to those kinds of resources. Three million Texans live in counties that have no psychiatrist, according to NAMI-Texas. About 200 of the state’s 254 counties have a mental health workforce shortage, causing some Texans to travel long distances for care.

For others living in shortage areas, telehealth is becoming more common, and some communities are using money from the Medicaid 1115 Waiver to finance projects.

One such project, the Telehealth Counseling Clinic, provides free virtual therapy to low-income people in the Brazos Valley of Texas. The providers are psychology doctoral students from Texas A&M University.

The need for more outpatient services, while acute in rural areas, remains a problem in urban areas, too, said Hansch, who is with NAMI Texas, and Colleen Horton, director of policy at the University of Texas Hogg Foundation for Mental Health.

Texas is fortunate state lawmakers have prioritized mental health funding, Hansch and Horton said, but the state must continue pushing for services all along the continuum of care, while devoting attention to the social determinants of health. That care continuum includes crisis intervention, detox facilities, crisis respite and more, Horton said.


Horton

“We especially need more step-down, supportive housing in communities where people can remain in close contact with their families and community support systems,” Horton said. “We need a strong system of peer support services that helps support those transitioning from state hospitals back into the community. These peer providers have been shown to be effective in keeping people engaged in their treatment plans and reducing hospital admissions. Without these services and more, individuals leave the hospital only to cycle back in.”

That’s the cycle some Texas hospitals and their partners are starting to break.

* This article has been updated for accuracy.