A Crisis in Care
by E. Brown; http://www.fwweekly.com; 10/8/14

Texas’ massive health services agency, which oversees the state’s psychiatric hospitals and several other aspects of healthcare, is failing to do its job. Its aging hospitals have been in crisis and less than staff, and patients are falling from the cracks inside a system that values paperwork over actually helping people.

Those are some from the key findings with the staff with the Sunset Advisory Commission in the examination of Texas’ Department of State Health Services. The report left open the possibility the commission could recommend a pervasive restructuring or dismembering from the agency.

Based about the review, there exists a potential for “sweeping changes” through the state healthcare system, State Sen. Jane Nelson said in an e-mailed statement. The Republican from Flower Mound chairs the sunset commission along with the Senate Finance Committee. She said she's going to work with Senate and House colleagues to draft a package of bills to handle the report’s findings when the Texas Legislature convenes in January.

Sunset commission staffers acknow-ledged the size with the job facing DSHS, which can be responsible for a lot more than 200 programs, but summarized the company as a “jack of most trades plus a master of none.” They noted, for instance, that this supply of psychiatric beds in Texas decreased by 19 percent throughout the last 12 years whilst the state’s population grew by 25 percent. The report said the vast majority of Texas counties are suffering a drought of a different kind than usual: They are actually federally designated as developing a shortage of mental nurse practitioners, concise that, regardless if hospital beds were available in many cases, patients cannot be admitted because there were not enough doctors, nurses, and also other workers to manage them.

From a base in Big Spring, as an illustration, West Texas Centers provides state mental health services across 23 counties. In only one county it is possible to psychiatrist to whom troubled residents can make. For the rest, West Texas Centers as well as 15 mental health clinics are often the first and last resort, providing care with a 24-hour hotline, nursing staff at the clinics, and entry to psychiatrists through televised meetings. Even with clinics spread throughout the region, patients routinely drive an hour and a half to reach care.

“It’s plenty of territory,” CEO Shelly Smith said. “We don’t have public transit; patients will not be able to afford to travel 100 miles to far-off places for treatment, therefore we try to push the assistance out to individuals.” In the rural areas her clinics serve, “There aren't other psychiatric resources around except us,” she said. “So it always falls returning to us. We run just about on a shoestring budget in terms of staffing.”

The DSHS review wasn’t comprehensive, but sunset staffers found many problems nonetheless, including with the business’s overall direction. DSHS directors, the report said, spend a lot time creating fires that the agency lacks strategic leadership.

DSHS, created in 2003 by merging four other agencies, still hasn’t was able to accomplish the tasks which are set for it back then, reviewers concluded. More than a decade from then on consolidation, the department still hasn’t was able to mesh the original assessment and referral process for mental health insurance substance abuse patients, the report said.

Nor has the business addressed a number of other longstanding concerns, “despite clear and repeated direction” through the Texas Legislature among others, the sunset staff found — and despite a significant infusion of income into the agency through the legislature recently. Audit findings dating returning to 2009, detailing the need to improve the security from the state’s vital-records system, still haven’t been addressed.

The report also reflects a thing that patients, their loved ones, and medical professionals have been saying for many years: DSHS is likely to get caught up in bureaucracy and “meaningless outputs” in lieu of focusing on delivering choose to those who require it.

The report, released in May, has drawn little news media coverage. A few weeks ago, most with the critical recommendations with the report were endorsed, some in amended form, by the Sunset Advisory Commission itself, composed of Texas House and Senate members.

Then on Friday, another related sunset staff report was issued that can spell the finish of DSHS as it's currently organized. The latest review, since the rest of the health bureaucracy in Texas, required even broader changes, affecting every factor of healthcare, from rehabilitation services to mental health to child protective services.

“The time of reckoning for that difficult problems facing the health insurance human services system has arrived,” the modern report concludes.

Bill Kelly of Houston, using the advocacy group Mental Health America, said he believes many people have become complacent about mental healthcare in Texas.

“The product is in crisis,” he said. “Like a lot of social services on this state, we haven’t invested properly in mental health. The infrastructure in DSHS clearly must change. This won’t be considered a one-bill solution.”

Susan Garnett remembers just what it was like in 2003, in the event the legislature created DSHS by merging the Texas Department of Health, Texas Department of Mental Health and Mental Retardation, Texas Health Care Information Council, and Texas Commission on Alcohol and Drug Abuse.

“Texas was broke then,” recalled Garnett, the CEO of MHMR of Tarrant County. “So 2003 became a tremendous cost-saving session. There was fervor over Health and Human Services and concerns about its growth. It was really about streamlining, along with the intention was for efficiency. But while these pieces were being build, there wasn’t any legislative direction about integrating services.”

Garnett’s organization contracts with DSHS along with other government and groups to provide services in Tarrant County.

With the sunset report along with other major attention being paid to mental health delivery, Texas seems to finally be addressing the issues that arose from that merger, she said.

Nelson: There is a possibility of “sweeping changes” through the state healthcare system. Nelson: There is a potential for “sweeping changes” throughout the state healthcare system.

Since then, DSHS has become mired in lawsuits and criticism from health groups. During that period, the state’s per capita paying for mental health services, always low when compared with other states, has dropped even further, from 46th in 2001 to dead last this season. A study by the Kaiser Family Foundation that year found that Texas spent typically $38.38 per person on mental healthcare in comparison to a national average of $122.90.

The chronic not enough community resources that resulted has generated a system where jails now provide much more mental health treatment in Texas than the business tasked with the task. In 2007 the advocacy group Disability Rights sued DSHS because mental patients were languishing for years in jail without either being tried or getting treatment, charged with crimes that have been often related to their psychiatric and drug-abuse problems.

Disability Rights won the lawsuit, but Texas jails are still serving because default hospitals for nearly all Texans with mental illness. According to a recently available article in The Texas Observer, Harris County Jail alone treats “more psychiatric patients than all 10 of Texas’ state-run public mental hospitals combined.”

Beth Mitchell, lawyer and director of Disability Rights, said more and more inmates might have avoided jail if adequate treatment had been accessible in their communities and when more courts took part in jail-diversion programs. Such programs pick out “at-risk” those with mental illness for specialized job- placement and treatment programs.

Dire statistics and ruined lives didn’t drive the legislature for this; it took a national tragedy to get that about. In December 2012, Adam Lanza killed his mother in Newtown, Conn., then drove to Sandy Hook Elementary School and killed 26 children and staffers before turning his gun on himself. That and many mass shootings that year spurred a broad re-examination of mental health treatment within this country. Many Texas legislators, including Nelson, cited that tragedy as offering the impetus for any re-examination of Texas’ mental health code, its mental health services system, and its particular historically inadequate funding.

Mental health groups in Texas worked with legislators to boost the annual budget of State Health Services by fifteen percent in 2013. The move drew wide bipartisan support, Nelson said.

The unprecedented increase added $260 million to DSHS’ annual budget. The largest chunk, $48.2 million, attended community clinics to deal with a backlog of requests for help which in fact had patients waiting around eight months for treatment. Another $43 million visited expand badly needed beds and resources at community clinics. The remaining funds were utilised to create jail-diversion pilot programs and new programs to the homeless mentally ill.

At on the same time, the Hogg Foundation for Mental Health, along with groups, began a campaign to convince the state of hawaii to overhaul its mental health code, which governs policy in handling and treating patients. The effort was led by Dr. Susan Stone, a lawyer and psychiatrist doing work for Texas Appleseed via a grant in the Hogg Foundation.

Stone died unexpectedly in 2013, but her recommendations, some of which were enacted into law last session, stand as the model for future efforts to revamp the mental health code. Two of nine bills based on her findings passed; those measures need the standardization of medical forms, that have varied from county to county, and enable minors 16 and older to get outpatient mental health treatment without parental permission.

Other measures proved too controversial with the time, including a bill that will have allowed hospital staff to forcibly detain patients for approximately four hours in certain circumstances, allowing time for a psychological evaluation. Another bill that failed might have eliminated mental health warrants, which some groups said were being unevenly used over the state and unnecessary in many circumstances.

Jacques Ntonme, director at Texas Appleseed, worked alongside Stone during her research to the state mental code. He said his group gets ready to occupy the battle for reform again in the event the legislature convenes in January.

Julie Belindo has spent high of her life watching her sister Angela languish within the mental health services system in Texas and other states.

Growing up in Denver, Angela blossomed into a prize-winning artist and in the end graduated from Stanford University. One of Angela’s paintings hangs in Julie’s living room in Arlington; her eyes seldom left becoming she recounted her sister’s descent into depression and hallucinations.

“Angel was vivacious, beautiful, and talented,” Julie recalled. “She always had the superior prize in senior high school competitions.”

Garnett: “There wasn’t any legislative direction about integrating services.”

After college, Angela gone after Santa Fe, where she did secretarial jobs and worked for a nonprofit that helped underprivileged youths. Angela’s mother Sharon Belindo said it was shortly afterward, in 1988, that her daughter began showing signs of mental illness. Angela was 28.

“I would be a dietician in Oklahoma and invited Angel to go in with me,” she recalled. “While she was helping me at the job, someone came over and said, ‘Is this your daughter? Maybe you’d better come get her.’ Angela couldn’t sit still. She seemed to have a fever or something. I took her home. She sat down for the walkway, outside. She was screaming. She only agreed to be out of it. So I finally called inside a friend who said ‘We need to take her for the hospital.’ ”

That began an odyssey for many three women, through this country’s mental health services system as well as shortfalls. Shortly after showing her first signs of mental illness, Angela moved to Arlington along with her parents. The 10 years that followed were some with the hardest in Sharon’s life, Julie said. Sharon began attending National Alliance on Mental Illness meetings and doing her better to understand Angela’s condition.

Julie, moving into Virginia with the time, recalled that Angela was regularly going to a physician through MHMR of Tarrant County. After a decade of intermittent employment, with periods where she was more stable and fewer stable, Angela moved back to Santa Fe, driving a vehicle Julie had given her.

It was during this time period that Angela’s life began a precipitous decline. Away from the structure of her family, Angela began tinkering with illegal drugs, often mixing them with her prescribed medications. After being arrested for shoplifting, Angela was sent to the New Mexico Behavioral Health Institute at Las Vegas. When she was released four months later, Julie and Susan drove her back to Arlington.

Angela’s worst relapse took place 2011, soon after she had moved back to Texas. At times she would babble incoherently for too long periods; inevitably, such episodes intensified into uncontrollable screaming. Eventually, after several visits in the police, Julie and her mother got Angela committed towards the Trinity Springs Pavilion for Psychiatric Services in the John Peter Smith hospital system.

“I researched all of the places she might go,” Julie recalled. “Private clinics were never a choice because of cost. If I would be a millionaire, I’d have sent her somewhere else.”

A next day of Angela was admitted, Julie got a trip that floored her: JPS doctors had declared Angela stabilized — and he or she was being released.

When Julie attended get Angela, her sister didn’t seem stabilized, just sedated. “She smelled like urine, so I knew she had peed on herself,” Julie said. “We didn’t have a choice but to consider her back. They said there was clearly nothing they could do. They probably gave her the antidepressant Ativan. It slows you down.”

Returning from work in the morning, Julie found out that Angela been readmitted to JPS. To this day, Julie isn’t sure if it was Angela’s existing condition or myriad of prescription pills that triggered her deterioration around that period. Angela stopped talking altogether and became unresponsive to her sister. Infected, open sores on Angela’s ankles drew her family’s alarm. A nurse told Julie that her sister has to be hitting her legs together when she slept and said they might keep her bandaged.

Repeatedly, Julie attempted to find and talk on the doctor accountable for Angela’s care. Each time, she got exactly the same reply — he wasn’t there. The only thing JPS staffers could tell Julie and her mom was that Angela had schizophrenia. Even now, Julie clearly remembers the automated way the nurses rotated throughout the clinic, spending almost no time with individual patients.

After that, JPS officials had Angela used in North Texas State Hospital, near Wichita Falls. To Julie, it seemed a trade of 1 impersonal, ineffective setting for the next: Angela and also the other patients were handled in a “mass cattle mode,” inside main meeting area, Julie recalled. Her sister would spend on a daily basis huddled in a very corner in the room, refusing to communicate with anybody. During that point, in 2012, Angela’s father John died from West Nile virus, can not visit his daughter to say goodbye.

After a year along with a half, state hospital personnel told Julie and her mother that they were unable to improve Angela’s condition and were getting able to move her to your nursing home.

Matt Roberts, executive director at Mental Health America of Greater Dallas, said Angela’s placement in a very nursing home is definitely an example of your state system that continually fails to adequately treat patients.

“If she is in a very nursing home without adequate psychiatric care, then precisely what does that say in regards to the care we're providing like a state?” he explained. “Even people with severe mental medical problems can recover and lead productive lives. Are we providing these people with all the resources they require or just giving up on them?”

The sunset staff’s first recom-mendation was for Texas to deal while using crisis in its mental hospitals. Action needs to be taken immediately, they concluded, to handle the “outdated condition of hospital facilities, critical shortages of clinical staff, and a lack of effective communication with all the judicial system.” One result in the system’s failure to provide adequate care: progressively more lawsuits against DSHS facilities, putting the business at financial risk.

The report included recommendations that State Health Services immediately review its hiring practices to ensure how the hospitals are appropriately staffed and also to expand the business’s contracts with community mental health providers. And, sunset staffers concluded, DSHS should be restructured being more tuned in to such problems.

“That goes over all my take around the report,” Roberts said. “We need more patient beds in local communities.”

Christine Mann, press officer for State Health Services, said her agency is beginning to handle the staff shortage problem. Part of that solution involves increasing the hiring process and increasing staff pay, which is “generally lower compared to the industry average,” she said.

“To help address this matter, the (recent legislative session) appropriated $14.7 million to provide a ten percent pay increase for many psychiatric nurse assistants,” she said.

Until the down sides are fixed and funding levels are increased, Mann said, State Health Services will continue to depend on contract staff and also other temporary assist to cover the staffing gap.

In Arlington, this news that Angela was going to be placed in a very nursing home shocked Julie and her mother, nonetheless they had no recourse. They found the very best nursing home they can afford. Julie’s greatest concern — that Angela would lose access to psychiatric treatment — proved true. Angela distrusts the elderly care facility staff and blames her family for the situation.

Julie happens to be trying to find out if Medicaid covers in-home care, which she hopes will allow her to get her sister home.

Neither Julie nor Sharon thinks that Angela ever received medicine or care at North Texas State Hospital.

“With the minimal sum of money we have, we'd to settle for that minimal amount of care,” Julie said. “It’s tough to see your family go into a situation like that.”

Bill Kelly has seen DSHS’ inefficiency firsthand as public policy director at Mental Health America of Greater Houston. He said physicians he’s spoken to possess trouble understanding how to bill or coordinate services with all the huge state agency.

“It’s a $6.5 billion department, and there’s a great deal of red tape to fight through,” he was quoted saying. “In talking to contractors like hospitals and smaller providers, the feedback MHA of Houston directors receive is that the process becomes onerous understanding that it’s almost too tough to deal with.”

DSHS’ obsession with red tape is a serious factor in many problems noted within the report. Not enough staff in the state hospital? That’s due in part with a bureaucracy where basic personnel actions can take greater than a year — so very long that applicants sometimes just threw in the towel. And the sunset staffers found out that, much too often, DSHS tends to substitute the filling in of forms for just about any actual showing that patients are helped. Julie Belindo, left, along with her mother Sharon: “If I would have been a millionaire, I’d have sent her elsewhere.”

Julie Belindo, left, with your ex mother Sharon: “If I was a millionaire, I’d have sent her elsewhere.”

Sherry Cusumano, board president from the National Alliance on Mental Illness office in Dallas, said counsel to measure outcomes validates an issue she has long held.

DSHS “measures a whole lot of things, nonetheless they have yet to measure outcomes,” she said. “What impact can be your intervention having? It’s challenging to do, nonetheless it has to be done. If patients are certainly not experiencing remission, then our tax dollars aren’t being utilized effectively. I’m not trying to paint villains, but the method is difficult to deal with, and the people we serve desire a much more cohesive effort.”

The report’s overarching theme is of an overburdened agency that bounces in one emergency to a different, frequently moving on with a new crisis before the last one is actually dealt with.

“The sheer scope and complexity of DSHS’ many responsibilities poses challenges to its management and focus,” the sunset staffers wrote. Their report questions the wisdom in the 2003 consolidation and repeatedly mentions the potential for disbanding the business.

The failure of DSHS to start out dealing with mental health disorders and alcohol abuse as two parts from the same picture continues to be a longstanding problem.

Garnett declared that when State Health Services was formed, the medical community was re-evaluating how mental health disorders and alcohol abuse should be treated. While medical researchers began treating both the conditions together, DSHS never adapted to the modern approach, she said.

“Now hopefully we’ll see legislative guidance to get those two pieces together,” she said.

There’s one more aspect of the review procedure that has to be finished ahead of the sunset commission could make final recommendations around the future of DSHS. As unlikely as it can certainly seem, there's yet another bureaucracy above DSHS — the Health and Human Services Commission, which oversees the services agency as well as the departments of Aging and Disability Services, Assistive and Rehabilitative Services, and Family and Protective Services. The sunset staff review of the Health and Human Services Commission premiered on Oct. 2.

Ken Levine, director with the Sunset Advisory Commission, said public hearings and staff testimony about the HHSC report are scheduled for Nov. 12 and 13, along with the sunset commission is because of vote on the recommendations on Dec. 10.

As using the DSHS report, the Health and Human Services sunset review concludes that this 2003 consolidation of agencies could be the “obvious starting point” for your health system’s current woes. The report’s first recommendation demands consolidating every one of the far-flung elements with the state health system into one agency.

Part of the basic problem, the report said, may be the “incompleteness of the setup” of the Texas health system that was done in 2003. That resulted in vague lines of accountability and overlapping services, all of which must be fixed, the reviewers said. The fact that Health and Human Services oversees this immense system while also managing their state’s Medicaid program only contributes to these problems, they concluded.

The current fragmented health system has led to the “five system agencies developing about 100 websites and looking after 28 separate hotlines. The system’s piecemeal procedure for developing these resources requires users to navigate a more and more complex network of info, frustrating even savvy stakeholders familiar with the system,” the report said.

Nelson said the sunset review for the Health and Human Services Commission might help her evaluate whether DSHS “should continue in the current form, an improved form, or otherwise not at all.”

Cusumano acknowledged that she's got already seen DSHS officials responding positively on the sunset review findings.

“But we’ll see in which the rubber meets the path,” she said.

Back in Arlington, Julie Belindo said she is glad she moved to Texas to be near her family. She knows that her sister may never improve, but she still believes that a elderly care facility is not the ideal situation to get a person like Angela, who needs psychiatric care.

“If this is her fate, and if this will be the best she will ever improve, then there should be something more” for Angela among others like her, Belindo said.




“Under the care of Leo J. Borrell, M.D. since December 2001, I have seen a remarkable improvement in my mother’s condition. She is responding dramatically to the new regiment Dr. Borrell has prescribed”

- Beth Rose


Feb 3, 2008

The Interdisciplinary Team; The Role of the Psychiatrist

by Dr. Leo J. Borrell, featured in Assisted Living Consult for November/December 2006. A HealthCom Media Publication