Recommendation 2, Strategy 1:
Increase Functional Bed Capacity – Housing Options

Strategy 1: Increase opportunities for hospital discharge by rapidly creating alternative residential care and housing options by identifying private, philanthropic, or alternative public funding to support the growth of the continuum of care.

• Prioritize housing in regions of the ASH service area that currently
  have limited options; and

• Continue to work with HHSC to optimize performance of the HCBS-AMH program.

As we complete the new hospital, we next focus on optimizing its performance by increasing its functional bed capacity. Functional bed capacity begins by optimizing the use of ASH for what it is designed within its existing cost structure, namely acute and subacute inpatient care. To accomplish this goal, we must first create a continuum of alternative residential treatment and housing options that include step-down and rehabilitative facilities, quarter- or halfway houses, and other forms of housing with a range of affiliated wrap-around services. For this report, we will refer to this range of housing types as ‘housing options’ with the intent that they provide recovery support in the least restrictive, best-designed setting possible. Although progress is being made toward creating these housing options, it is still not adequate to manage the need as evidenced by the hospital waitlists.

Increasing functional capacity of both the new ASH and the care continuum requires referring people needing care to the most appropriate and least restrictive setting possible so that the hospital and each different housing option is used at the top of its capabilities; i.e., for the hospital, it is used only for individuals needing inpatient-level services. Distributing available resources efficiently across a continuum can lead to a broader array of residential services than can be achieved if every situation and individual is simply placed in the most expensive environment, namely the hospital. For the ASH region, there are three considerations to address. First, local communities need more and broader housing options in their communities that can be used in lieu of ASH. Second, once a person’s clinical condition has improved so that inpatient care is no longer necessary, there must be clear and straightforward processes available to refer people into the right setting. Third, to make these plans work, the financing of these services needs to be structured to incentivize and reward best practices, based on value, i.e., providing the highest quality, most appropriate services at the right price. To work towards these goals during the next biennium, three strategies are presented, and if implemented, we believe will increase the functional capacity of the new ASH and the care continuum throughout the service area, thereby: 1) offering solutions to the growing waitlist for state hospital beds, 2) referring people in the hospital who are appropriate for alternative care venues, and 3) supporting care for people in the least restrictive setting necessary. To begin, we therefore recommend rapidly developing and implementing increased housing options for people who no longer need (or never required) state hospital level care, but are not yet well enough for standard community outpatient services.

Phase I Recommendation

During Phase I, we recommended increasing residential care and supported housing capacity to enhance the continuum of care and optimize the use of a new hospital. The initial ASH Redesign report presented three different options for the campus, see Table 3. Of these three, Option B was preferred, namely, to build a 216 – 240 adult bed hospital with a 48 – 72 bed residential facility. The latter would have established a step-down option on the ASH campus and better focused the hospital on acute care. With the combination of a hospital and residential facility, the campus would have immediately increased the functional bed capacity by 70 or more beds and initiated creation of a model care continuum on the campus. However, Option A was selected, namely building a 240 adult bed acute/sub-acute hospital only. This option was selected in part because of funding limitations to support operations of a larger hospital as well as multiple other commitments statewide for inpatient hospital facilities construction and repair. Nonetheless, although the total physical bed capacity will only marginally expand on the ASH campus, we propose to work toward increasing the functional capacity by establishing a stronger care continuum, like that illustrated in Figure 6.

Currently, there are limited housing options for the large region supported by ASH, particularly in rural counties. The ASH Redesign Phase I identified seven LMHAs offering some form of residential treatment and housing options, involving only 18 of the 38 primary counties served. The diverse landscape of the ASH region creates an unbalanced ecosystem. Urban counties tend to have opportunities for more infrastructure and interlocal support than rural counties. Additional housing option initiatives must therefore consider both urban and rural housing needs. 

Housing options with various levels of clinical care and wrap-around social supports provide alternative venues to continue a person’s recovery following (or in lieu of) inpatient care while integrating the individual back into the community. The care provided within each setting will vary on a person’s level of need. Services needed include individual and group therapy, access to case management, peer services, medical care, and even transportation and employment services. Together, these wrap-around services provide better support for the transition from acute and crisis care to long-term recovery in the community. Many people get stuck in the intervening crisis loop of the continuum of care, returning to multiple emergency rooms, jail cells or extended hospital stays (Figure 6). Increase in community housing options throughout an expanded residential care continuum will decrease people stuck in this loop. The previous ASH Redesign report found that in the ASH service area during the years 2015 – 2016 a total of $163,000,000 was spent on emergency rooms for unmet mental health and substance use needs rather than a person receiving care elsewhere in their community. Providing additional residential treatment and housing options following discharge from the hospital will transition people back into their community for care and support (or at times in lieu of the hospital) more smoothly. A person returning to their community with appropriate housing and wrap-around services can be managed more cost effectively than the expenses of trying to provide care in less appropriate settings (e.g. emergency departments or jail), thereby allowing limited resources to serve more people.

Housing on Campus and in Continuum

A key strategy to increase the functional capacity of the new ASH, is to discharge people who no longer need hospital level care to a more appropriate and less restrictive setting. These settings, then, need to be built and funded. For example, discharging one person who has been at ASH for a year and is ready for a less restrictive setting would allow four people to be served under the current typical 75-day length of stay. This improvement would provide long-stay individuals with a more appropriate care setting and more independence, while also opening capacity for people needing intensive inpatient care. Doing so would help to reduce the current waitlists for people trying to enter the statewide hospital system. Establishing a variety of housing options on and off campus could also be used to transition people from the acute hospital until they are ready to return to their homes and outpatient care (when available) or alternative less expensive and more appropriate residential settings; doing so would consequently serve both rural and urban regions of the ASH service area.

ASH provides care to individuals with a primary diagnosis of a serious mental illness. However, in addition to serious mental illness, ASH commonly serves people with co-occurring substance use disorders, intellectual or developmental disabilities, and other health conditions. Therefore, as housing on the ASH campus is developed, ideally it would need to support services for these common comorbid conditions.

There is sufficient space on the ASH campus to create housing options as part of building a brain (mental) health campus. During Phase I, HHSC posted a request for information (RFI) to solicit interested partners to join the campus, either by building on the land or renovating one of the existing buildings. Although the community expressed interest, HHSC and the planning process was not yet able to pursue partnerships at that time.

Consequently, HHSC will be issuing a new RFI during this next phase of planning to identify partners who can join the campus and potentially operate housing facilities. Figure 7 illustrates potential locations for these partnerships. The campus will aim to be a diverse setting of mental health services operated in combination of government, local, non-profit and private organizations. The long-term goal remains to expand partnerships on campus to create a model brain-health care continuum that supports expanded services throughout the ASH service area.

Table 4 identifies potential approaches to these partnerships. A phased approach will create organization to the campus and limit disruptions of daily operations.

Several different housing types are recommended to improve the functional capacity of ASH. To begin, creating alternatives for counties that most commonly use the hospital would create the largest impact toward increasing functional capacity. If successful, doing so would improve access for the entire ASH service area. Currently, Travis County is the highest user of ASH with an average of 32% bed-day occupancy from FY14 – FY20. By increasing alternative treatment options for Travis County patients, we would create capacity for the rest of the region. Alternatively, and additionally, these housing options do not necessarily need to reside on the ASH campus, but could be located near the next highest county utilizers. Counties within Bluebonnet Trails, Heart of Texas and Central Counties LMHA service areas all averaged bed-day use of 10% annually from FY14 – FY20 and represent good starting points for this approach.

Funding Collaborations

To build housing options, multiple funding models will be explored by the ASH Redesign team. Over the next two years of the redesign, a subcommittee will focus on developing a list of available funding models to create the needed housing continuum. This timeline aligns with opening the new ASH. The subcommittee will engage other groups working on housing options for people with mental illness, substance abuse, intellectual disabilities, and other brain health care needs to align efforts. As an example of this approach, New York developed a database for organizations in need of funding to build or operate supported housing. The extensive list developed by The Network of NY is updated and maintained with the most recent available funding (the Network). A similar funding matrix for Texas would streamline work and collaborations to build a housing infrastructure.

Models to Build Upon

Recent additions to the care continuum in Travis County include the Terrace at Oak Springs, a permanent supported housing complex that opened in 2019 and is operated by Integral Care (the Travis County LMHA). A braided funding mechanism was used to build this facility to support both capitalization and operations. This example can inform how the region might establish more, similar opportunities.

During 2020, in partnership with HHSC, Bluebonnet Trails developed one of two pilot sites in Texas for a State Hospital Step-Down Program. Partnering with all state hospitals, this pilot project supports the transition of people with complicated cases from state hospitals across Texas to a community-based setting. The pilot uses a regional collaboration approach (rather than simply a local focus) to expand housing options across counties. Both programs are models for replication throughout the ASH service area if proven successful.

HCBS-AMH Program

In addition to expanding available housing for people transitioning from ASH, the current Home and Community-Based Services Adult Mental Health (HCBS-AMH) 1915(i) Medicaid Program presents an opportunity to increase the functional capacity of ASH. The HCBS-AMH program provides home and community services for adults with serious mental illness to maintain their recovery in their community. A person must meet Medicaid eligibility and also one of three criteria to qualify for waiver services. These are:

• Long-term psychiatric hospitalization – three or more cumulative years in an inpatient psychiatric hospital within a five-year span.

• Jail diversion – four arrests and two psychiatric crises within a three-year span.

• Emergency room diversion – fifteen or more emergency room visits for any reason and two psychiatric crises within a three-year span.

ASH uses the HCBS-AMH program as a discharge option for people that meet these eligibility criteria, although its capacity is somewhat limited within the restrictive criteria. The ASH Redesign team will continue to work with HHSC to optimize and expand the use of the HCBS-AMH program.