00. Executive Summary
Stephen Strakowski discusses options in a workshop with Steering Committee members David Lakey (second from left) and David Evans (right) and systems designers from the Design Institute for Health.
Austin State Hospital Brain Health System Redesign Executive Summary
Texans deserve the best mental (brain) health care available. In response to this goal, the 85th Legislature invested $300 million to initiate and plan several public hospital expansions and replacements to advance the mental health care of its citizens. The Legislature expressed its intent to complete expansion and replacement of the hospitals over a three biennia period. Additionally, the Legislature encouraged academic/public partnerships in these plans. After decades of deferred maintenance, the outmoded Austin State Hospital (ASH) must be replaced. Austin State Hospital was specifically referenced in the Cannon Report as needing replacement with planning funds toward this end allocated in the 85th Session. Consequently, the Health and Human Services Commission (HHSC) approached Dell Medical School (DMS) of the University of Texas at Austin to lead the redesign of ASH and the delivery of mental health services in the ASH Service Area. Dell Medical School organized a regional Steering Committee and planning cascade, engaging stakeholders from throughout the ASH Service Area to complete this task. The core principle leading planning was “People first.”
ASH serves 38 counties for adults and 75 counties for youth. In FY18, ASH operated 252 beds, including a 30-bed child and adolescent unit (CAPS). At times, capacity at ASH has been reduced due to workforce shortages, a problem that affects the entire Service Area and state. ASH is always full. The structure and workflow of the hospital are better designed for longer-term subacute care rather than either short-term acute stabilization or residential care. Nonetheless, approximately 70 individuals essentially live at ASH. Consequently, these 70 beds are ‘off-line’ for new admissions, resulting in 95 individuals each day waiting to be accepted into ASH, usually from jails. Increasingly, ASH is occupied by individuals mandated to the hospital by courts for competency restoration, waiting to stand trial. Competency restoration procedures are overly complex and conflate clinical need for treatment with inability to participate in legal decision-making. Waitlists in jails delay initiation of treatment and timely resolution of legal charges. A typical inpatient competency restoration at ASH costs more than $75,000 and lasts longer than ideally recommended. Less expensive, more effective, alternatives are available, if gaps and processes in care can be addressed. Indeed, underfunded gaps in mental health care in the ASH Service Area cost Texas over $150 million annually, with much of this cost in the legal system. Better allocation of these dollars would gain efficiencies and make care more effective.
“The core principle leading planning was ‘People first.’”
Within the ASH Service Area, more than 20 community hospitals treat over 12,000 people annually. These hospitals typically have up to 150 beds available daily to provide acute stabilization in lieu of an admission to ASH. These facilities are better designed than ASH for short-term admissions. The 12 regional Local Mental Health Authorities (LMHAs) buy private beds in these facilities to manage people needing care. These LMHAs also serve over 80,000 adults and 50,000 youth annually in outpatient and crisis programs. Despite providing these services, the existing systems cannot address the epidemiological need. Currently, nearly 600,000 residents in the Service Area will experience a need for mental health services. Additionally, the Service Area population is rapidly growing and mental disorders directly scale with the population. Simply building a few more hospital beds will not manage this growth.
With this information in mind, we developed a care continuum (the ASH Brain Health System Redesign). This continuum served as a substrate to frame recommendations for the 86th Legislative session and beyond. These recommendations are:
Transform the Austin State Hospital (ASH) Campus
1. Replace the existing outmoded adult hospital with a new state-of-the-art facility.
a. Appropriate at least $285M to replace the hospital during the 86th Legislative session..
b. Identify funding to update and maintain the ASH Child and Adolescent units.
c. Have HHSC fund a team to relocate long-stay individuals to better placements.
2. Improve ASH operations.
c. Develop a plan to transfer management of ASH operations to an academic partner.
d. Increase ASH operating budget to offer locally competitive employee salaries.
3. Change the ASH reporting structure.
e. Move ASH governance and fiduciary oversight to an independent hospital board.
4. Initiate a brain health platform on the ASH campus and beyond.
f. Have HHSC release an RFI to identify partners to build a mental health care continuum.
g. Have HHSC fund a campus oversight team to lead campus development.
Optimize the Use of Community Psychiatric Beds in the Region
1. Expand the community psychiatric bed-purchasing program (CPB).
a. Increase CPB funding to LMHAs by at least 10% (~$1.7 million for 200-250 annual admissions).
2. Expand CPB to provide short-term competency restorations.
b. Fund a pilot program to expand CPB programs for short-term competency restorations.
Redesign Competency Restoration Programs and Processes
1. Establish consistent competency standards and assessments across all courts.
a. Ask the Judicial Commission on Mental Health (JCMH) to convene a workgroup to develop statewide competency standards, assessments and workflows.
2. Establish a formal 60-day inpatient competency restoration limit.
b. Change 46B statutes to set time expectations and a formal 60-day cap on competency restoration processes to disentangle clinical care and legal decision-making.
3. Create a regional competency restoration team to work across venues.
c. Fund a regional competency restoration team to work across venues.
Increase Residential Care and Supported Housing Capacity
1. Foster better use of the HCBS-AMH 1915(i) State Plan Amendment program.
a. Have HHSC fund a regional work group to eliminate perceived and real barriers to better use of HCBS-AMH 1915(i) funding to expand supported housing.
2. Finance expansion of evidence-based residential care and supported housing.
b. Have HHSC develop a comprehensive plan for expanding residential care, supported housing, and home health capacity in the state (including ASH Service Area).
One perpetual belief 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. However, mental health expenses occur regardless of the systems we do or do not provide to address them; with well-designed care systems, these costs can be quantified and designated to improve care as efficiently and effectively as possible. More importantly, an established continuum of care is specifically designed to decrease the human suffering associated with these illnesses. We believe that investment in new public psychiatric hospitals is a great step in the evolution of how we care for Texans. Doing so can lead Texas to the forefront of public mental health as a national leader in how best to advance brain health.
