DSHS Legislative Appropriations Request for Fiscal Years 2010

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DSHS Legislative Appropriations Request for Fiscal Years 2010 -11 Presentation to the Senate Finance Committee February 11, 2009 David L. Lakey, M. D. Commissioner

DSHS Legislative Appropriations Request Fiscal Years 2010 -11 • Base Budget § $5, 592, 709, 588 All Funds • Exceptional Items § $487, 069, 478 All Funds 2

DSHS Legislative Appropriations Request Fiscal Years 2010 -11 FY 2010 -11 DSHS budget by source $5. 6 billion biennial budget 3

DSHS Legislative Appropriations Request Fiscal Years 2010 -11 • Exceptional Items in priority order, ranked according to: – Maintaining operating capacity in existing programs – Ensuring compliance with current state and federal requirements – Moving health forward in Texas 4

MAINTAINING OPERATIONAL CAPACITY Exceptional Item #1 FY 2010* 1. Maintain Current Operations FY 2011* $39. 3 $44. 6 * All figures in millions • • State Hospital Capacity Mental Health and Substance Abuse Services Alberto N Settlement Family Planning Reimbursement Rabies Bait Drop Department Operational Costs Rio Grande State Center FTEs (funded through interagency contract) $62. 8 million GR/$83. 9 million All Funds 5

MAINTAINING OPERATIONAL CAPACITY Exceptional Item 1 – State Hospital Capacity Funding provided to add beds to the state hospital system. SB 867 (80 th Legislature) provides more flexibility for maximum security admissions. Initial crisis services funding allocated. 6

ENSURING COMPLIANCE Exceptional Items 2 - 8 FY 2010* FY 2011* 2. Regulatory Services $7. 3 $11. 5 3. Health Care Data $12. 7 $12. 3 4. Vital Records $3. 5 $3. 2 5. Data Systems $15. 7 $14. 6 6. Disaster Preparedness $16. 8 $7. 3 7. Stipends for Medical Residents $1. 4 8. Maintain Facilities $43. 3 $27. 5 * All figures in millions • Total of Exceptional Items 2 -8 equals $104. 9 M GR/$178. 3 M All Funds 7

ENSURING COMPLIANCE Exceptional Item 2 – Regulatory Services Increase in licenses for the Division for Regulatory Services 2002 -2007 100. 00% Texas is a growing state. 95. 00% 90. 00% 83. 07% 85. 00% 80. 00% 76. 60% 75. 00% 70. 00% Percentage of Increase 65. 00% From 2002 to 2007, the number of licenses in some programs increased by as much as 80%. 60. 00% 55. 00% 50. 00% 45. 00% 40. 00% 35. 00% 30. 76% 32. 52% Summary of all Regulatory licenses 30. 00% 24. 49% 25. 00% 13038 - Food and Drug 13039 - Environmental 20. 00% 15. 00% 10. 73% 13040 - Radiation 10. 00% 13041 - Professional Licensing 5. 00% 0. 00% Licenses by Regulatory Strategy 13042 - Health Care Facilities 8

ENSURING COMPLIANCE Exceptional Item 6 – Disaster Response • Gaps in Public Health Response • Key Personnel and Training – Equipment – Laboratory Courier System – Medical Special Needs Shelter Capacity – Local Health Services – Border Public Health Surveillance and Security 9

ENSURING COMPLIANCE Exceptional Item 7 – Stipends for Residents Psychiatrists and Child Psychiatrists, Texas - 2007 10

MOVING HEALTH FORWARD Exceptional Item 9 -13 FY 2010* FY 2011* 9. Substance Abuse Services $34. 8 $34. 9 10. Community Mental Health Services $38. 4 $47. 1 11. Chronic Disease $10. 9 $15. 0 12. Infectious Diseases $8. 1 $8. 8 13. Maintenance of Services - LMHAs $13. 4 * All figures in millions • Total of Exceptional Items 9 -13 equals $209. 0 M GR/$224. 8 M All Funds 11

MOVING HEALTH FORWARD Exceptional Item 9 & 10 • Substance abuse and mental illness have a significant impact on Texans, their families and communities. – The economic cost of substance abuse in Texas for 2007 is estimated at $33. 4 billion including lost productivity, crime and the criminal justice system, premature death and morbidity, and the cost of substance abuse prevention and treatment. – Individuals with severe mental illness have a life expectancy that is years shorter than the overall population. 25 – Underserved populations with MH or SA issues often go to ERs for treatment. • Additional funding will mitigate the effects of substance abuse and mental illness on Texans and Texas. 12

MOVING HEALTH FORWARD Exceptional Item 11 – Chronic Diseases Obesity Prevalence Trends in Texas Adults 1990 to 2007 ~34% of Texans are normal weight ~29% of Texans are obese Texas Comptroller: www. window. state. tx. us/specialrpt/obesitycost/summary/ 13

MOVING HEALTH FORWARD Exceptional Item 12 – Infectious Diseases Racial Disparity in Persons Living with HIV/AIDS in Texas, 2003 -2007 The number (left graph) of black persons living with HIV/AIDS surpassed that of whites in 2005. The rate (right graph) in 2007 was nearly 5 times higher for blacks than for others. 14

DSHS Legislative Appropriations Request Summary 15

Issues for FY 2009 • FTEs – Funded from Interagency Contracts /Federal Funds • Capital Budget Authority • Medicare Part D Savings Use Plan 16

HHSC Exceptional Items Affecting DSHS • In the HHSC LAR – Medical Professional Recruitment and Retention – Vehicles – Information Technology – Data Center Services Increased Costs • In the HHS Consolidated Budget – Rate Increases for Providers – Staff Recruitment and Retention 17

DSHS Legislative Appropriations Request for Fiscal Years 2010 -11 APPENDIX A Exceptional Item Detail

MAINTAINING OPERATIONAL CAPACITY Exceptional Item 1 • State Hospital Capacity • Mental Health and Substance Abuse Services • Alberto N Settlement • Family Planning Reimbursement • Rabies Bait Drop • Department Operational Costs • Rio Grande State Center FTEs (funded through interagency contract) 19

MAINTAINING OPERATIONAL CAPACITY Exceptional Item 1 – State Hospital Capacity • Cost Drivers – 24/7 psychiatric and medical care – Maintaining capacity at 2477 beds – Increasing competition for clinical staff in local markets – Increased cost for pharmaceuticals – Outside medical costs – Increased cost of food – Other unavoidable costs 21

MAINTAINING OPERATIONAL CAPACITY Exceptional Item 1 – State Hospital Capacity • Inflation in Clinical Salaries – Competition in local markets for professions with limited labor pool – Average salary increase for clinical staff, rose by 6% above legislative pay increases (FY 2005 -07) – 64% of hospital employees are clinical staff 22

MAINTAINING OPERATIONAL CAPACITY Exceptional Item 1 – State Hospital Capacity • Pharmaceutical cost increases – Psychiatric drugs (82% of purchases) • 9% increase in cost – All other drugs • 25% increase in cost 23

MAINTAINING OPERATIONAL CAPACITY Exceptional Item 1 – State Hospital Capacity • Outside Medical Services – DSHS responsible for health care of patients – Need for these services is difficult to predict – Examples of individual patient medical costs in FY 2008: Cardiovascular End stage renal Dialysis Pneumonia Neck cancer Cardiovascular $133, 000 $334, 000 $177, 000 $148, 000 $145, 000 $178, 000 24

MAINTAINING OPERATIONAL CAPACITY Exceptional Item 1 – State Hospital Capacity • Examples of Other Operating Costs – Food – Equipment – Furnishings 25

MAINTAINING OPERATIONAL CAPACITY Exceptional Item 1 • Mental Health & Substance Abuse Services – Sustain substance abuse treatment rate increase in FY 2008 to stabilize provider base – Provide resources to sustain consumer-focused mental health contracts 26

MAINTAINING OPERATIONAL CAPACITY Exceptional Item 1 • Alberto N Settlement – Funding provides personal care services for children on Medicaid. – Funding was phased-in during FY 2008 -09. – This request maintains 2009 funding levels for crisis services. • Family Planning Reimbursement Rates (Non-Medicaid) – Reimbursement rates for oral contraceptives are significantly lower than costs. – The department faces possible loss of providers due to increasing financial pressures meaning a potential loss of primary care services for women. – This request would more closely align family planning reimbursement rates with costs. 27

MAINTAINING OPERATIONAL CAPACITY Exceptional Item 1 • Rabies Bait Drop – Rabies vaccination bait dropped annually in South and West Texas by airplane. – This funding will cover an increase in transportation costs for the program. • Rising costs across the agency – Laboratory – Hospital pharmaceuticals, medical supplies and food – Travel/fuel costs – Utilities 28

MAINTAINING OPERATIONAL CAPACITY Exceptional Item 1 FY 2010* FY 2011* $19. 7 $25. 0 Mental Health and Substance Abuse Services 8. 0 $8. 0 08 -09 Phased-In Services – Alberto N $1. 1 Family Planning Reimbursement $3. 6 Rabies Bait Drop $0. 8 Increased Costs $3. 2 $3. 5 Rio Grande State Center FTEs (IAC) $2. 7 $39. 3 $44. 6 State Hospital Capacity Total: * All figures in millions 29

ENSURING COMPLIANCE Exceptional Item 2 – Regulatory Services • DSHS Regulatory Division ensures the safety of the products and services Texans use every day. – Food – Hospitals, Surgical Centers and Dialysis Centers – Health professionals, including EMS, Medical Radiologic Technicians, Professional Counselors – Medical Devices – Radiation 30

ENSURING COMPLIANCE Exceptional Item 2 – Regulatory Services • Regulatory programs are supported by fees. • Regulatory programs provide standards to protect the public’s health and safety. • New licensees require resources for licensure processing, compliance inspections, response to complaints, and enforcement. • DSHS uses risk-based inspections in most programs. FY 2010* Regulatory Services FY 2011* $7. 3 $11. 5 * All figures in millions 32

ENSURING COMPLIANCE Exceptional Item 3 – Health Care Data • Funds are requested to improve the timeliness, completeness, and validity of health information collected through registries and disease surveillance systems. • Using more effective technology to replace sub-standard systems will: – Improve the collection of information on cancer, birth defects, trauma, lead poisoning, and occupational diseases. – Make data more timely and readily available to the public and researchers for prevention efforts and measurement of communities’ health status. – Make disease reporting for local hospitals and health providers more efficient. • The funding will establish a health care associated infections reporting system. • The funding will provide for linking of health information systems. 33

ENSURING COMPLIANCE Exceptional Item 3 – Health Care Data • Purpose of the Registries – Collect and analyze health information to improve the health of Texans • Uses – Public health and health-related research – Analysis of health issues to guide appropriate public health strategies or prevention efforts – Provide information to communities about environmental risks – Provide information to assist in consumer decision-making regarding health care 34

ENSURING COMPLIANCE Exceptional Item 3 – Health Care Data • Cancer Registry – Collects, analyzes, and disseminates data on cancer in Texas § Type, extent, location and initial treatment § Data for research, cancer prevention and control planning – Meets national standards – Supports cancer prevention and research priorities, including children’s cancer research – Helps communities assess risk § Kelly Air Force Base, San Antonio § Houston Ship Channel § El Campo trichlorethylene – Provides significant information for national data set 35

ENSURING COMPLIANCE Exceptional Item 3 – Health Care Data • Birth Defects Registry – Collects, manages, analyzes, and disseminates data § Occurrence of birth defects § Type of defect § When and where diagnosed – Identifies and describes patterns of birth defects in Texas, investigates clusters, and shares with researchers for epidemiologic studies – Evaluates strategies to reduce birth defects risks and factors impacting survival of children with birth defects – Identifies areas where children with birth defects have little access to pediatric genetics clinics – Evaluates factors playing a role in survival of children with birth defects 36

ENSURING COMPLIANCE Exceptional Item 3 – Health Care Data • EMS/Trauma Registry – Collects, analyzes, and disseminates information on: § Emergency medical services runs § Occurrence of trauma, including: ¡ Spinal cord injuries ¡ Traumatic brain injuries ¡ Submersion injuries – Investigates the causes of injuries, their distribution, health outcomes, and associated costs – Analyzes ambulance diversion patterns – Compares patients across service areas to improve timeliness and quality of patient care – Identifies hazardous environments, such as dangerous intersections – Evaluates local injury prevention planning • EMS providers, acute care hospitals, and trauma centers report trauma cases to the EMS/Trauma Registry. 37

ENSURING COMPLIANCE Exceptional Item 3 – Health Care Data • Child and Adult Blood Lead Surveillance System – Works to prevent and eliminate child lead poisoning in Texas by: § Testing and monitoring children who are at risk for lead poisoning and ensuring treatment if necessary § Identifying and removing lead hazards in the child’s environment § Educating the public and healthcare providers about lead poisoning and how it can be prevented • Additional funds will assist the Child and Adult Blood Lead program to: – Replace an aging information technology system. – Meet requirements for screening, notification, case follow-up, and outreach education. – Improve the screening rate for Medicaid children (currently 20 -30%). – Meet obligations from the settlement of the Frew lawsuit. 38

ENSURING COMPLIANCE Exceptional Item 3 – Health Care Data • Occupational Disease Conditions Surveillance – The Texas Occupational Disease Reporting Act mandates reporting of the two principal causes of work-related pneumoconiosis (interstitial lung disease), asbestosis and silicosis. – These are diseases that lead to lung impairment, disability, and premature death. – From 1968 to 1999, asbestos deaths among U. S. residents age 15 and over have increased from fewer than 100 to more than 1, 250 annually, with no apparent leveling off to this trend. – In 2005, there were 202 newly identified individuals with asbestosis and 138 new reports of silicosis in Texas. 39

ENSURING COMPLIANCE Exceptional Item 3 – Health Care Data • Healthcare Associated Infections (HAI) – Leading cause of death from infectious disease in the U. S. – 200, 000 infections and almost 9, 000 deaths in Texas each year. – Staph infections (including MRSA) account for 25% of HAI. – In Texas, HAI-related healthcare costs are estimated at more than $500 million annually. – Up to 60% of HAI infections are preventable through improved application of existing infection control recommendations and guidelines. 40

ENSURING COMPLIANCE Exceptional Item 3 – Health Care Data • Healthcare Associated Infections (HAI) - SB 288 required DSHS to: – Establish a Healthcare Associated Infections (HAI) Reporting System. § Hospitals and Ambulatory Surgical Centers – Develop and publish a summary of infections reported by healthcare facilities. – Provide education and training to healthcare facility staff. – Provide accurate comparison of HAI data to help the public make informed decisions about choosing healthcare facilities. • To implement SB 288, DSHS will: – Adopt CDC’s National Healthcare Safety Network as the HAI Reporting System. § National trend – many other states will use this system as well. – Employ staff to analyze source of infections and ensure accuracy to reporting. • Accuracy of information is critical: – Facilities will use the information to improve. – Consumers will use the information to make choices. 41

ENSURING COMPLIANCE Exceptional Item 3 – Health Care Data FY 2010* FY 2011* Disease Registries – Chronic $4. 2 $2. 6 Disease Registries – Healthcare Associated Infections Reporting $1. 5 $2. 8 Blood Lead Testing & Follow-Up $6. 0 $6. 4 Newborn Screening Linkage $0. 8 $0. 3 Center for Health Statistics $0. 12 $0. 13 $12. 7 $12. 3 Total: * All figures in millions 42

ENSURING COMPLIANCE Exceptional Item 4 – Vital Records • Vital Records – birth and death records • Federal mandates – The REAL ID Act of 2005: – Require states to issue secure driver’s licenses and identification cards – Will require other states to verify validity of birth certificates for individuals born in Texas – Consequences of not complying – Texans will have to prove identity beyond a driver’s license in banks and federal buildings and prior to domestic flights • Enhancement of Texas’ death registration system FY 2010* Vital Records * All figures in millions FY 2011* $3. 5 $3. 2 43

ENSURING COMPLIANCE Exceptional Item 5 – Data Systems Maintain and Enhance Technology • 400 programs in nine health regions, 11 state hospitals, and a major laboratory • Patient records, client case files, pharmacy inventories and disease registries at risk • Internet connectivity between offices unreliable • Major telephone outages • Impacts: – Patient health care and client management for mental and behavioral health – Preparedness and response activities – Protection of sensitive data – Data center consolidation 44

ENSURING COMPLIANCE Exceptional Item 5 – Data Systems FY 2010* FY 2011* Network Interoperability, Video & Voice Communications and Security $6. 6 $5. 8 Seat Management $1. 5 Consolidated Health Care Data Collection $1. 2 $1. 0 Clinical Management for Behavioral Health Services $2. 7 $3. 8 Hospital Automated Medication Dispensing System $3. 6 $2. 5 Total: $15. 7 $14. 6 * All figures in millions 45

ENSURING COMPLIANCE Exceptional Item 6 – Disaster Response • Disaster Recovery and Public Health Preparedness – Enhancing response for all-hazards, natural or manmade – hurricanes to salmonella – Equipping staff for effective response and personal safety – Improving timeliness of laboratory tests, environmental analysis and disease surveillance – Maintaining skilled workforce for rapid deployment in event of emergency or disease outbreak – Expanding local health services – Enhancing public health surveillance and security on the border 46

ENSURING COMPLIANCE Exceptional Item 6 – Disaster Response Salmonella Saintpaul Outbreak 47

ENSURING COMPLIANCE Exceptional Item 6 – Disaster Response • INSERT SLIDE ON HURRICANES Storms lined up across the Atlantic – September 2008 48

ENSURING COMPLIANCE Exceptional Item 6 – Disaster Response Impact of Hurricane Ike 49

ENSURING COMPLIANCE Exceptional Item 6 – Disaster Response FY 2010* FY 2011* Public Health Emergency Preparedness Response $3. 9 $3. 4 Response Equipment $4. 0 -- Laboratory $2. 1 $1. 0 Shelters – Renovation of State Facilities $4. 0 -- Local Health Services Expansion $0. 5 Border Public Health Surveillance and Security $1. 0 Behavioral Health Positions in DSHS Regional Offices $0. 6 $0. 7 Recruitment and Retention $0. 8 $16. 8 $7. 3 Total: * All figures in millions 50

ENSURING COMPLIANCE Exceptional Item 7 – Stipends for Residents • DSHS is experiencing difficulty recruiting & retaining medical staff. – Only 6. 4 psychiatrists per 100, 000 Texans – 67. 9 physicians per 100, 000 Texans • This funding will provide stipends for residency placements in state hospitals and for preventive medicine residents to strengthen the public health workforce. • Medical residents are a cost-effective means of increasing medical care in underserved areas and in hospitals. • Physicians often remain in the community where they served as medical residents. FY 2010* Stipends for Psychiatric & Preventive Medicine Residents FY 2011* $1. 4 * All figures in millions 51

ENSURING COMPLIANCE Exceptional Item 7 – Stipends for Residents Psychiatrists and Child Psychiatrists, Texas - 2007 52

ENSURING COMPLIANCE Exceptional Item 8 – Maintain Facilities Building & Equipment Repair & Replacement • Hospitals must comply with Life Safety Code and Joint Commission accreditation standards. • Broken, unsafe or unusable equipment and patient furniture must be replaced to provide a safe patient environment. 53

ENSURING COMPLIANCE Exceptional Item 8 – Maintain Facilities Infrastructure Description • 11 State Mental Health Facility campuses • 3, 032 acres, 552 buildings, 4. 9 million square feet • $866 million replacement value • Average is 55. 2 years old. • Most buildings were well built and remain structurally sound, but are in need of renovation to meet today’s standards and programmatic requirements. • Over 84% of total building area is dedicated to patients and patient support. 54

ENSURING COMPLIANCE Exceptional Item 8 – Maintain Facilities FY 10 -11 Capital Construction Needs • Identified deficiencies (deferred maintenance): $233 million • $198. 3 million in capital construction needs have been identified for FY 10 -11 funding for State Hospitals. • Of that, $70. 9 million has been identified as the most critical. 55

ENSURING COMPLIANCE Exceptional Item 8 – Maintain Facilities Categories of Capital Equipment • Furniture • Medical/Adaptive • Food Service • Grounds • Heating • Air conditioning • Motorized • Emergency • Other • Average life expectancy of most of the State Hospital capital equipment is 5 to 8 years. • Average years of actual use for much of the State Hospital capital equipment is 11+ years, far surpassing its life expectancy, creating a potential risk to patients and staff. 56

MOVING HEALTH FORWARD Leading Causes of Death – Texas 2005 and 2001 DSHS Center for Health Statistics 57

MOVING HEALTH FORWARD Actual Causes of Death* Shaped by Behavior *Texas 2001 Chronic Disease in Texas 2007, DSHS 58

MOVING HEALTH FORWARD Exceptional Item 9 – Substance Abuse • Increase treatment rates to maintain provider base • Increase treatment capacity to serve individuals • Expand prevention services • Provide Medicaid outpatient benefit to leverage federal funds 59

MOVING HEALTH FORWARD Exceptional Item 9 – Substance Abuse ER COST OFFSET - $47 Average per Client per Month 35% REDUCTION Fiscal Year 2005 Texas average monthly emergency room costs were 35 percent lower for Medicaid clients with substance abuse problems who received needed DSHS substance abuse treatment. Source: FY 2005 ER Cost per Medicaid Client per Month for Those Who Needed Substance Abuse Services But Did Not Receive Them (Untreated) vs. Those Who Needed Substance Abuse Services and Did Receive Them (Treated): Initial data set consisted of all persons who had Medicaid paid Substance Abuse ER visits during FY 2005. Clients were divided into those who received DSHS Substance Abuse services based on match between DSHS Substance Abuse dataset with Medicaid dataset. Dependent variable was Total ER costs or dates or service during FY 2005. Data sources: DSHS Substance Abuse services = BHIPS, Medicaid ER = TMHP AHQP Claims Universe. Prepared by Research Team, Strategic Decision Support, HHSC, 3/23/2006. 60

MOVING HEALTH FORWARD Exceptional Item 9 – Substance Abuse • Reduced use of medical services, leading to cost savings • Lower medical costs by reducing low birth weight babies, Fetal Alcohol Spectrum Disorders and use of neonatal ICU • Benefit to the child welfare system through services to women of childbearing age • In 2006, twenty percent of inmates in TDCJ were convicted of drug offenses – That does not count those convicted of other offenses to which substance abuse was a contributing factor • Services eligible for Medicaid leverage state funds with federal funds (40 percent state/60 percent federal) 61

MOVING HEALTH FORWARD Exceptional Item 9 – Substance Abuse FY 2010* FY 2011* Treatment Services $15. 6 Prevention Services $4. 5 Medicaid for Outpatient Substance Abuse Services $13. 8 Increased Contract Management Costs $0. 9 $1. 0 $34. 8 $34. 9 Total: * All figures in millions 62

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services • Impact of Mental Illness – Individuals with severe mental illness have a life expectancy that is 25 years shorter than the overall population. – Significant mental illness is often linked to obesity, smoking and substance abuse. – Underserved populations with MH or SA issues often go to ERs for treatment. – One-third of military service members returning from current conflicts are affected by PTSD, major depression or traumatic brain injury. 63

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services • Mental Health Crisis Services were phased-in for 2008. • The base bill maintains 2009 funding levels for crisis services. • Crisis mental health services funded by the 80 th Legislature have been implemented and are showing indicators of success. – – – – FY 2007 FY 2008 AAS Accredited Hotlines 1 38 Mobile Crisis Outreach Teams 4 Crisis Stabilization Units 3 3 Extended Observation Units 3 Crisis Residential Facilities 10 Crisis Respite Facilities 4 14 Outpatient Competency Restoration 38 6 13 1 4 64

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services Percent of Crisis Service Episodes Followed by a Psychiatric Hospitalization within 30 Days SFY 2008 Annual Target = 17% Sources: DSHS Client Assignment and Registration (CARE) system and DSHS North. STAR Data Warehouse, 10/02/2008. 65

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services Need for Crisis Expansion Betty Hardwick Helen Farabee Central Plains Tarrant County MHMR Heart of Texas West Texas Burke Center Bluebonnet Tri-County El Paso Spindletop Austin-Travis County MHMR Hill Country Areas Currently Funded for Expanded Crisis Services Nueces County MHMR Tropical 66

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services • Part 1: Expand options to underserved communities with crisis funds, assuring targeted services to children and adolescents – Provide more Psychiatric Emergency Services Centers and Children’s Crisis Projects (e. g. , Respite) – Serve an additional 8, 736 individuals/year – Serve an additional 226 children/year 67

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services IMPLEMENTATION OF CRISIS REDESIGN Average Monthly Number of Persons Receiving Community Mental Health Front-Door Crisis Services Increasing Sources: DSHS Client Assignment and Registration (CARE) system. Note: SFY 2008 YTD includes persons served with old + new GR. 68

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services Need for Transitional Services Sources: DSHS Client Assignment and Registration (CARE) system, DSHS Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW), and DSHS Behavioral Health Integrated Provider System (BHIPS). 69

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services • Part 2: Transitional services for difficult to engage high-need individuals – Goal is to break the cycle of crisis-stabilization-crisis – Serves 4, 163 adults/year – Serves 630 children/year 70

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services Need for Intensive Ongoing Services Average Monthly Service Package Distribution for Adults after Receiving Crisis Services (03/2008 -05/2008) ADULT RDM LEVELS OF CARE Level 1 Pharmacological Management, Patient and Family Education, and Routine Case Management Level 2 Pharmacological Management, Patient and Family Education, Routine Case Management, and Counseling Level 3 Psychosocial Rehabilitation Level 4 Assertive Community Treatment 71

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services • Part 3: Increase capacity for intensive services for current clients – Focus on difficult-to-serve clients transitioning from crisis – Serves 1, 984 persons in FY 10 and 3, 967 in FY 11 72

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services • Veteran’s Mental Health – Training for public behavioral health practitioners in evidence-based practices for PTSD – Web-based application for simplifying determination of eligibility – Support for coordination among agencies 73

MOVING HEALTH FORWARD Exceptional Item 10 – Mental Health Services FY 2010* FY 2011* Psychiatric Emergency Centers & Children's Respite Services $14. 2 Transitional Services $12. 5 Intensive ongoing services targeting recipients of transition services $9. 6 $19. 2 Veterans Mental Health Training and Coordination $1. 1 $0. 1 Increased Contract Management $0. 9 External Evaluation of Crisis Projects $0. 2 $38. 4 $47. 1 Total: * All figures in millions 74

MOVING HEALTH FORWARD Exceptional Item 11 – Chronic Diseases – 70% of deaths are related to chronic disease – 10% of population have major limitations in daily living – About 75% of health care costs come from obesity, high blood pressure, high cholesterol and Type 2 diabetes – Tobacco is implicated in 25, 000 deaths in Texas annually – Cost of $3. 3 billion to Texas businesses in 2005 75

MOVING HEALTH FORWARD Exceptional Item 11 – Chronic Diseases Obesity Trends* Among U. S. Adults 1998 1990 2007 No Data <10% 10%– 14% 15%– 19% (*BMI 30, or about 30 lbs. overweight for 5’ 4” person) 20%– 24% 25%– 29% ≥ 30% Source: CDC Behavioral Risk Factor Surveillance System 76

MOVING HEALTH FORWARD Exceptional Item 11 – Chronic Diseases • Many of these conditions are preventable. • We can reduce the disease burden and the economic burden by promoting: – Avoidance of tobacco – Healthy eating – Physical activity – Maintaining a healthy weight – Controlling blood pressure and cholesterol 77

MOVING HEALTH FORWARD Exceptional Item 11 – Chronic Diseases • Obesity – Interventions to improve nutrition and increase physical activity – Improved screening, diagnosis and treatment for cardiovascular disease and stroke – Support of the Mayor’s Fitness Council Grant program • Tobacco – Expand cessation services for Texans who want to quit – Increase partnerships with communities with anti-smoking activities • Newborn Screening – Expand detection of cystic fibrosis and case management – Early intervention to improve lung functioning 78

MOVING HEALTH FORWARD Exceptional Item 11 – Chronic Diseases FY 2010* FY 2011* Obesity Prevention $3. 3 $5. 9 Tobacco Prevention $3. 8 $4. 7 Cardiovascular Council Projects $1. 0 Cystic Fibrosis $2. 9 $3. 4 $10. 9 $15. 0 Total: * All figures in millions 79

MOVING HEALTH FORWARD Exceptional Item 12 – Infectious Diseases HIV/AIDS in Texas: Persons Living with HIV/AIDS, New Diagnoses of HIV/AIDS, and Deaths among those with HIV/AIDS New diagnoses are holding steady. The number of persons living with HIV/AIDS is rising because they are surviving longer. 80

MOVING HEALTH FORWARD Exceptional Item 12 – Infectious Diseases In 2007, the incidence of Tuberculosis in Texas was 43% higher than the U. S. incidence rate and second only to California. 6. 3 4. 4 Tuberculosis Incidence Rates, Texas and U. S. , 1998 -2007 82

MOVING HEALTH FORWARD Exceptional Item 12 – Infectious Diseases 83

MOVING HEALTH FORWARD Exceptional Item 12 – Infectious Diseases • CDC recommends expanded testing for HIV – Earlier detection leads to earlier, more effective treatment – Reduces the rate of transmission • Texas is second nationally in TB cases • Exceptional Item 12 includes: – Improved HIV testing – Expand improved testing for TB and STDs – Tuberculosis services – Upgrade cervical cancer screening 84

MOVING HEALTH FORWARD Exceptional Item 12 – Infectious Diseases FY 2010* FY 2011* HIV/STD Viral Hepatitis Testing $4. 4 $4. 7 Tuberculosis Services $3. 2 $3. 6 Cervical Cancer Screening $0. 5 $8. 1 $8. 8 Total: * All figures in millions 85

MOVING HEALTH FORWARD Exceptional Item 13 – LMHA Services • Increased Costs for Local Mental Health Authorities – Increasing cost for pharmaceuticals, laboratory services and utilities – Growing demand – Increased efforts to keep individuals with mental illness out of the criminal justice system FY 2010* Maintenance of Services at LMHAs FY 2011* $13. 4 * All figures in millions 86

Other Agency Legislative Appropriations Requests • Health and Human Services Commission – Critical health care shortage positions • Physicians, psychiatrists, nurses – Waiting lists for Children with Special Health Care Needs, Children’s Mental Health Services – Consolidated enterprise requests for technology and vehicles • Department of Assistive and Rehabilitation Services – Accessibility of information technology • Comptroller’s Judiciary Section – Sexually Violent Predator Monitoring Program 87

DSHS Legislative Appropriations Request for Fiscal Years 2010 -11 APPENDIX B Exceptional Item Method of Finance