V. Caveats and Conclusions

With these changes, the ASH campus and its Service Area will be positioned to lead mental health care transformation throughout its region and serve as a model for Texas. However, these changes alone will not sufficiently prevent the proposed expansions from being quickly overwhelmed due to a number of factors within the region that will continue to increase demand for mental health services.

As reviewed in the “Epidemiologic Considerations” section of the review of the ASH Service Area, despite the large numbers of people already receiving care, there is a large unmet need for both inpatient and outpatient services. From an inpatient perspective, several groups nationally completed studies to determine the ideal number of psychiatric beds per a given population. Although these studies have a relatively wide range, in a recent review of studies (Appendix 19), the Treatment Advocacy Center suggested a best estimate of 39 psychiatric beds/100,000 adult residents could sufficiently meet inpatient needs in a typical state model of care. The ASH Service Area includes 3.7M people; based upon this metric, then, the ASH Service Area needs 1443 psychiatric beds. Currently the total number of psychiatric beds summing both ASH and private facilities totals approximately 1,000, or 443 beds below the predicted need. Obviously, increasing ASH by 30 or even 60 beds will not adequately address this need. Additional beds and hospital replacements are also being added in Rusk, Kerrville, San Antonio and Harris County, but none of these increases will sufficiently fulfill the need of each of the respective service areas. Consequently, based upon this work, even with increased numbers of psychiatric beds provided with state hospital replacements, additional pent-up demand is looming that will quickly overwhelm these new hospitals once the current status quo is disrupted by the addition of more beds.

Of note, studies like the one referenced here are based on existing mental health care continua. By providing more effective and efficient outpatient and other services, the need for psychiatric beds can be decreased. To manage this potential problem we recommend, first, continue to add replacement state hospital beds as planned at ASH and other facilities around the state, AND develop other incentives to attract more private psychiatric companies into Texas and community solutions (e.g. tax- and land-credits, continuing the SB292 and HB13 programs, and improving the HCBS-AMH 1915(i) State Plan Amendment program), AND continue to build out the care continuum, starting with the recommendations in this report for the ASH Service Area. In the absence of these changes, the new replacement hospitals will be overwhelmed within a few years and the current investment will have not been optimized.

A second consideration is that Central Texas includes some of the fastest growing cities in the country and recent estimates predict that the ASH Service Area population will increase 13% by 2025 and 23% by 2030. Rates of psychiatric illnesses are predictable across any large population, so increases in the numbers of people needing psychiatric care will directly scale with increases in population. Consequently, within the ASH Service Area, demand for brain health services will increase steadily. Again, continuing to build out the care continuum is critical to stay ahead of this growth. To gain the maximum benefit from the planned hospital investments, over the next several biennia we recommend that the state continue to find ways to increase the continuum of mental health care, especially prior to acute crises, legal entanglements and need for hospitalization. Expanding residential care and supported housing, as previously discussed, is perhaps most immediately relevant for optimizing the hospital investment. However, other services needing expansion include short-term crisis and residential programs, Assertive Community Treatment (ACT) and Forensic (ACT) programs, coordinated specialty care for first-episodes of psychosis, intensive outpatient and partial hospitalization program, drug and alcohol use treatment programs, community-based program to support individuals with intellectual and developmental disabilities, peer-support programs, and routine ambulatory care and prevention. Greater investment in programs earlier in the course of illness severity are generally less expensive per person and decrease the need for expensive, resource intensive programs later. 

Finally, one of the perpetual beliefs about paying for mental health care is that it is ‘too expensive’; inherent in this notion is the myth that if we do not pay for mental health care, there are no costs. As described in the “Financing” section of this report, mental health costs occur regardless of the systems we do or do not provide to address them. However, with well-designed care systems these costs can be quantified and the spend can be optimally designed to improve care as efficiently and effectively as possible. In the absence of such a system, costs simply distribute across functions: from sheriffs transporting people for hours in their squad cars to people sitting for days in emergency departments at the highest room rate possible to people languishing in a state hospital awaiting competency restoration. Even more costs accumulate from unmanaged mental illnesses that include lost days at work, problems in schools, and increased use of other medical services. These costs are difficult to understand and quantify, additionally they then become virtually impossible to manage in the absence of a designed system of care. More importantly, an established continuum of care is specifically designed to decrease the human suffering associated with the illnesses, whereas the absence of such a system haphazardly spends the money, but does little to optimize an individual’s recovery. We believe that investment in new public psychiatric hospitals is a great next step in the evolution of how we care for Texas citizens. Doing so can lead Texas to the forefront of public mental health becoming a national leader in how best to advance brain health. We hope this report helps support the decisions necessary to make this happen.