Dr. Ganju is project director of the Texas Mental Health Transformation State Incentive Grant. Send correspondence to him at 909 W. 45th, Austin, TX 78751 (e-mail: firstname.lastname@example.org). Fred C. Osher, M.D., is editor of this column.
In various ways the President's New Freedom Commission on Mental Health described the mental health system in the United States as fragmented, inadequate, and inefficient (1). The national picture is reflected in the Texas mental health system.
Editor's Note: This column is the tenth in a series of reports addressing the goals that were established by the President's New Freedom Commission on Mental Health. The series is supported by a contract with the Substance Abuse and Mental Health Services Administration (SAMHSA). Jeffrey A. Buck, Ph.D., and Anita Everett, M.D., developed the project, and Dr. Buck and Kenneth S. Thompson, M.D., are overseeing it for SAMHSA. The series features articles on topics such as employment, housing, and Medicaid policy as well as reports from each of the states that received a SAMHSA-funded State Incentive Mental Health Transformation Grant.
Paradoxically, this situation has developed nationally—and in Texas—as a result of the successful development of a community-based mental health system. Over the past three decades, an increasing number of persons needing mental health care have received services in their home communities. As more people have remained in the community, a multitude of programs and services, including those related to housing, employment, criminal justice, child welfare, and education, have developed to meet the needs of adults and children with mental health disorders. The different eligibility criteria, standards of care, funding sources, reporting requirements, and regulations, along with a lack of coordination among the various federal, state, and local agencies involved, have resulted in the fragmented and disjointed nature of the mental health system. This column reports on efforts in Texas to overcome fragmentation and fully incorporate mental health as an integral component of public health and early-intervention efforts.
The need for transformation
A project that matched data from multiple agencies in Texas determined that youths in the child welfare system who eventually became involved with the juvenile justice system had significantly more behavior problems, substance abuse issues, and family members with a criminal history (2). In addition, youths in the child welfare system with behavior problems had significantly higher levels of earlier school discipline problems than other youths in the child welfare system. Other data indicated that 46% of all emergency room visits in Texas involved behavioral health as a primary or contributing factor (3). In addition, 26% of all hospital admissions were found to be related to behavioral health issues.
These data begin to suggest the nature of the larger, fragmented, multiagency mental health system. Texas essentially has a "back end" mental health system, in which persons must be increasingly dysfunctional to gain access to and receive services, putting pressure on social services, education, and justice systems and highlighting the need for mental health services in these systems. When coupled with demographic projections for the state, these data suggest huge increases in future costs for the juvenile justice, child welfare, and criminal justice systems. The inability to identify at-risk youths and intervene early creates a potentially enormous burden on the Texas economy if current rates of institutionalization and incarceration continue (4).
This perspective is buttressed by formal needs assessment initiatives that involved consumers and family members, local stakeholders, and state agency personnel (5). Some of the key areas identified were early identification; intervention and easier access; resources for safe and affordable housing; increased "voice" for consumers and family members; improved interagency coordination; a lack of mental health professionals, especially in rural areas; a lack of adequate training supports; and a need for better data sharing and information exchange across agencies.
Approach to transformation
To address these needs Texas has embarked on an ambitious mental health transformation initiative to fully incorporate mental health as an integral component of public health and early-intervention efforts. Although many aspects of transformation were under way before the publication of the President's New Freedom Commission report, these activities now receive additional support through a Transformation State Incentive Grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). Texas is one of nine states to receive such a grant.
The initiative has a vision for transformation: within a public health framework, all Texans will have quick and easy access to early intervention and mental health services and supports of high quality. To move forward with transformation, and in line with federal grant requirements, the governor has designated a broad-based interagency Transformation Workgroup. Members are executive-level staff of state agencies, four consumers and family members, and representatives of the Texas legislature and the governor's office. This workgroup essentially serves as the "board" for the transformation effort and is supported by an implementation team of staff and contractors. Several multiagency teams have been formed to address key priority areas: consumer and family member initiatives, workforce development, data and technology, housing, employment, criminal and juvenile justice, children and adolescents, and older adults.
The logic model for transformation in Texas essentially consists of building a sustainable infrastructure that results in a culture of partnership and "systemness" across agencies at both state and local levels and of developing adequate resources, both fiscal and human, to provide a wide array of high-quality services consistent with a recovery and resilience orientation. This public health and early-intervention framework represents a radical shift given that current eligibility criteria have a narrow focus on populations that are the most dysfunctional.
How will such transformation occur? Experts who have studied transformation across a range of industries and organizations have identified some general principles that constitute the knowledge base and the best thinking about transformation (6,7,8). In general, three distinct but overlapping components are needed: building consensus about the need, urgency, and vision for transformation; promoting and learning from the implementation of innovative structures and practices; and sustaining and disseminating the innovations that are key components of the envisioned system. Commitment of leadership, buy-in of stakeholders, and communication are critical initial aspects; demonstrable, measurable successes that result from innovation are equally important; and plans to sustain such success systemwide are the last stage of transformation.
In a state as diverse as Texas, transformation presents a formidable challenge. But the broad approach is to build on current strengths and initiatives, address pivotal needs and priorities, implement innovations through demonstration projects or community projects that will serve as learning experiences, and document "successes" and "wins" in terms of measurable outcomes and benefits. A basic assumption of this approach is that transformation has to occur at both state and local levels. Activities at the state level will not result in improved access or outcomes for consumers unless transformation also occurs at the local level. Focusing on certain key activities is necessary, and the role of consumers and family members is paramount in defining, advancing, and sustaining transformation.
Fortunately, Texas has several strengths on which to build its transformation initiative. Through a historical capacity to develop partnerships with universities, the state has supported a research agenda incorporating results and lessons learned into practice. The Texas Medications Algorithm Project (9,10), which has been the basis of initiatives in other states as well, is an example of such a partnership.
More recently, the state has restructured health and human services agencies so that public health, mental health, and substance abuse are part of the same agency. This organizational merger has also fostered interagency initiatives that involve criminal justice, juvenile justice, rehabilitation services, and early intervention. Various sites within the state that are implementing systems-of-care initiatives funded by SAMHSA's Center for Mental Health Services also provide models for interagency initiatives at the community level. In addition, as a result of a legislative mandate, the specialty mental health system has implemented a Resiliency and Disease Management System, which promotes evidence-based practices for both adults and youths on a statewide basis.
Texas has also developed a Web-based electronic health record system—the Behavioral Health Integrated Provider System (BHIPS)—which recently won the prestigious Davies Award for innovative uses of information technology in health care. The system supports both clinical treatment and billing for the state's addiction providers and is a model that is being disseminated nationally (11). This system is being expanded and piloted to include mental health services.
Building on these strengths, the state has identified key initiatives to establish a multipronged approach to transformation. These include community collaboratives to instigate transformation at the local community level, development of consumer and family member networks, workforce development, use of data and technology, policy and legislative change, and special interagency programmatic initiatives proposed by the Transformation Workgroup related to peer support, housing, employment, school-based services, and older adults.
Community collaboratives for transformation
Eight communities have been selected through a competitive process to move forward with transformation at the local level. Major objectives of these community collaboratives are to address mental health transformation priorities at the local level and to develop models and tools for community collaborative development in other parts of the state.
Requests for application were sent to county judges, with the expectation that existing or newly created broad-based community coalitions consisting of consumers and family members, elected officials, providers, and leaders from businesses and philanthropic organizations would respond through county commissioners' courts. Communities with history and experience in such partnerships were given preference.
Selected communities will receive technical assistance and support to advance their transformation initiatives. Each community will receive resources for information technology innovations; however, for the most part, the transformation initiatives will be supported through community resources. The eight communities that were selected represent the broad diversity of the state and include urban-metropolitan areas, rural areas (including a rural "frontier" area) and the Texas-Mexico border area. These different areas were defined as part of the application process so that each could be represented in the transformation initiative.
The eight communities will work together as part of a transformation learning collaborative. Also, the other 12 communities that applied will be part of a larger group of communities that will participate together in the transformation effort. As part of the plan to go to scale on a statewide basis, these eight communities represent the first wave of transformation at the local level. This experience will then be the basis for broader diffusion and dissemination.
Consumer and family member "voice"
Consumer and family member leaders in the state-level Transformation Workgroup have identified several priority areas: communication and consensus building across consumer and family member organizations, promotion of a recovery and resilience orientation, development of peer support services, and development of consumer and family member networks. In initial meetings, consumers and family members of all the state agencies on the Transformation Workgroup (including 12 state agencies and the Department of Veterans Affairs) have been represented. A major objective is the development of consumer networks in areas served by the community collaboratives.
Workforce development and training
Transformation depends on the ability of the system to expand the capacity to provide more and higher-quality services. In an early-intervention framework, this includes the capacities of other systems beyond the traditional specialty mental health system—for example, the school system and the criminal and juvenile justice systems.
Two major initiatives in Texas are occurring in this area. First, through an amalgam of funding sources, health specialists are being placed in all 20 of the state's regional education service centers. The specialists, in turn, provide training and technical assistance to school districts in the geographic area for which they are responsible. Each health specialist will receive specific mental health training and additional support as the specialist works with school health personnel and teachers in the school districts. As part of this activity, a mental health component is being integrated into the mandatory health curricula.
Second, in collaboration with the Hogg Foundation for Mental Health, a Texas Mental Health Training Institute is being established to provide a centralized locus for training initiatives and workforce development initiatives. The major focus of this collaboration is to develop a sustainable training infrastructure in the state that will build needed competencies in the existing and emergent workforce.
Dialogue is also occurring with university and community college personnel related to preservice training, but the potential of having an impact on college curricula or licensing standards is seen as a long-term strategy.
Data and technology infrastructure are key areas that support transformation through three mechanisms: enhancing connectivity and coordination of mental health care across both state and local agencies in real time; supporting infrastructure development, such as training initiatives and the creation of consumer networks; and providing data to document transformation successes and outcomes in a quality improvement framework.
At both the state and local levels, systems to increase connectivity and integration are under development. At the same time, the expansion of the state's BHIPS system is being piloted to include mental health components. In certain communities, instant messaging systems have been used to coordinate services across mental health and jail systems. Such innovative initiatives are also being explored through the community collaboratives component.
A major strategy of the transformation effort is to develop products and deliverables in appropriate time frames to inform policy related to mental health transformation in legislative sessions.
At the request of the Texas Senate Committee on Health and Human Services, the Transformation Workgroup developed and submitted recommendations for the future mental health system in Texas. These recommendations became the basis of an omnibus mental health transformation bill that was considered during the most recent Texas legislative session but did not pass, primarily because of competing priorities rather than any objections at a policy level. However, several bills related to transformation on data sharing did pass. Building on this experience, the core transformation components (an orientation to recovery and resilience, early detection, data sharing, and standardized metrics and outcomes) will be the basis of proposals developed for the next legislative session.
Special services initiatives
On the basis of various needs assessment activities, priorities have been identified for housing, employment, children and adolescents, older adults, and the criminal justice and juvenile justice systems. Implementation initiatives developed by interagency workgroups are under way for each of these priority areas.
Mental health transformation presents a tremendous opportunity for a quantum jump to address the issues of organizational schisms and the lack of adequate infrastructure and resources that have plagued the specialty public mental health system. At the same time, there is a certain degree of hubris to think that mental health issues will be the driver of major reform in the functioning of multiple agencies across federal, state, and local government.
A major challenge is to integrate new initiatives with their own logic and imperatives under a transformation rubric. For example, as a result of efforts by a broad-based coalition of policy makers, providers, consumers, and advocates, the Texas legislature recently appropriated $82 million for mental health crisis redesign. Similarly, over $500 million related to behavioral health services was appropriated to other state agencies. Planning efforts are focusing on how to relate transformation principles and objectives to these initiatives. Inherent in such initiatives is the recognition that a federal grant that constitutes .1% of the public health agency's annual budget is not going to result in transformation. The grant can leverage change, but it is incumbent on the system to direct new and existing resources in transformative ways.
Although integration of mental health with public health and a multiagency approach has obvious benefits, the explicit broadening of such a perspective requires buy-in and commitment of organizations and groups with diverse missions where the link to mental health is often seen as tenuous. A major aspect of transformation is to shape and define the belief that benefits are perceived as "wins," at least in some measure, by all involved.