Travis County Commissioners Court
November 6, 2007
Item 23
>> 23 is to receive an update from Austin Travis County mental health mashs center regarding Travis County's allocation of psychiatric beds at Austin state hospital and related issues.
>> judge, Commissioners, my name is david evans, the executive director of the Austin Travis County mhmr center. I’m here this afternoon with dr. Jim van norman, the medical director. We would rather be talking about some of the national recognition we've been receiving about our clinics or the excitement around the new safe schools grant with aisd, but our board has taken policy direction regarding the limited number of beds that Travis County is alot lotted through the state department of health services contract. And with that new policy dr. Van norman is going to discuss what these limitations may mean.
>> thank you for your time. I wanted to walk through with you the situation with regard to the state mental health resources and then what's brought us to the point of having to come up with a more drastic management plan. The department of state health services allocates general revenue on a per capita basis across the state to each of the local mental health authorities. Austin Travis County mhmr's allocation for use for citizens in Austin and Travis County is #- $8.4 million. And this results in basically a daily census at the state hospital of about 63 people and this is a combination of both folks there on a civil commitments as well as criminal commitments sent to the hospital for restoration of competency or not guilty by reason of insanity. Regionally locally we've got additional services for inpatient services. Austin Travis County mhmr has put in $519,000 to add extra inpatient resources at seton shoal creek so we believe that the total inpatient resources for use in Travis County and Austin is 72. Nine beds at seton shoal creek and 63 beds at the Austin state hospital. Now, we have in the previous two years, in fiscal year '06 and '07 exceeded the use that have allocation n 2006 we were about three and a half million dollars over the allocation. And in fy 2007 we used about two and a half million dollars beyond the allocation. Our philosophy up until this point has been to match the need with the resources and we have been able to work with the department of state health services not to charge for the use of those inpatient resources. We believe that in a sense they've been a good partner with us because they've been willing to forebear charging and pulling resources out of the community while we began to develop our crisis response and improved resources such as the mobile crisis outreach team, the integrated behavioral health, beds at seton shoal creek, looking at transitional housing opportunities. Unfortunately, the state has said in fiscal year 2008 they can no longer afford to not charge fows the use of those resources beyond the allocation. They have said this is a limited resource. For Travis County residents, Austin residents there's $8.4 million of state mental health hospital resources once you reach that cap, we're going to have to start charging the local community mental health center for use of those resources. As we've looked at what we can do to respond, there's a couple of changes in the system that have happened in this fiscal year. First the state decided to begin to count those forensic beds against our allocation. Previously they had exempted those put under the 46 b statute not competent to stantd trial or not guilty by reason of inantiwere not counted against our allocation. In this fiscal year the state decided to add those folks back into our count, our bed day charges and counts. They did increase the allocation, but based on our historic usage in fy '07, we had about $900,000 more usage out of the forensic patients than they increased our allocation. So even though there's more in the allocation for state hospital in fy '08, it doesn't begin to meet the historic use when you count in the forensic patients. Development development
>> [one moment, please, for change in captioners]
>> > they would take them tho a local emergency department to be manage managed while we continued to go down to the hospital census and allow admission.
>> so is the Travis County jail defined as an emergency department.
>> it is not. It is not. We defined only the emergency departments. Hospital emergency rooms. You.
>> so have seton, st. David's and other appropriate hospitals had a chance to respond?
>> we've talked with them and continued to talk with them. We've fwhn communication with Travis County sheriff's office and the police department and I’ll go tomorrow with trish young from the health care district and the judge to meet with the medical advisory committee to give them information.
>> so you will need to come back to visit with us after you run the traps and gotten formal responses from the emergency room.
>> the past few years we've had our delegation on correspondence between ourselves and the state department of health services. Last year the delegation, each member signed a letter requesting that the state not collect on any utilization. We requested relief by reallocating dollars of the rural areas of the state that are under spending. In some cases sheriff's department is won't in the rural areas transport even within the is the if it's too great of a dance. It's our anecdotal belief that many people choose to stay in Travis County when a person is up for discharge even though the state hospital sefbz a 38 county region on a frequent basis people choose to continue to live after they've been discharged in Travis County. So we've heard no to our regional office request, we've heard no to a reallocation of state dollars. We've requested technical assistance if there's anything that we're missing within this allocation and we're working closely with our delegation to see if we can't reach any other resolution on this. The thing that jim articulated well is that we've always tried to make the best clinical decision and so if there was any bed available that was allocated within the 37 county region, we would utilize that bed, but with in September receiving a letter from the state that Travis County on a clinical need model use an additional $314,000. I think our board saw that over the course of a year that there was no local tax base to cover that kind of cost.
>> what happens to those underutilized funds? Do they go back to the fund balance for the state?
>> I think the state make the case that their overall cost after hospital system somehow absorbs within that statewide system and so because this is all a virtual fund, there's no real dollars, there's never any dollar that returns to -- that stays in a county if it hasn't been utilize understand a state hospital. And so in that regard even though we're charged frawf this model, on the flip side the case makes the case that there's no excess dollars to redistribute.
>> so there's no actual pie that is sliced up somewhere. It's a virtual pie that's constantly shrinking.
>> we're having a legislative item work session discussion on Thursday at 1:30, day after tomorrow.
>> I’d be happy to be a resource to the court for that discussion.
>> two points I think, one is what kind of language we think would be appropriate to address the situation. Not necessarily just the unexpended state dollars that would deal with the root causes, and the other point would be of strategy whereby we contact other counties in a similar position that we are and ascertain their interest in trying to prepare for a discussion with the legislature once they get back to town. This has been a problem for several years. Our population keeps increasing. Unfortunately the number of mental health clients also, but the state funding to local levels is decreasing, right? The delegation may have some of the facts, but if we need to update them, Thursday would be a step in the right direction for preparation for the next legislative session. And in my view it seems to me that on some of these big items that must affect other counties in addition to putting together what we think is the appropriate strategy, we ought to be out trying to get partners for the legislative session so they can get their delegations to do the same thing. But time is good in that if can you drop by at about 1:30, 1:45 day after tomorrow in this courtroom, we'll be having that discussion for one hour.
>> thank you for that invitation.
>> let me make sure I understand something. Is it that we have more people coming into the system and we have a lack of money there or truly that there is less money coming from the state? Which one is it.
>> it's actually both. There's less money to cover what's being charged against our allocation and there are more people coming in.
>> because just reading last Thursday's article in the paper, I mean, just trying to figure out the math, in a 2.3 million from Travis County health care district it, got you eight mental be, which comes out to about $287,000 a bed. And then the next sentence, mhmr kicked in another $519,000 for an additional bed, so there's a difference between a 519,000-dollar bed and a 287,000-dollar bed. How do you get those numbers -- that's a more detailed question. But when you're reading this article, you're really kind of trying to follow the math. And it's very confusing.
>> that additional bed, though stharks at shoal creek?
>> it's at shoal creek. And it really is between nine and 10 beds, but when we're talking in public it was hard to say it's nine or 10, 9.4 beds. The raim rait is the same for both the health district funding and the Austin Travis County mhmr funding. So it will swing slightly between nine and 10 beds.
>> and also those beds, my understanding is the shoal creek beds are for voluntary commitment as opposed to the Austin state hospital beds, which are both for voluntary and involuntary commitments.
>> initially that's how we started with using the beds. Then we found that in our crisis respite service called the inn, be which is attached to the psych emergency service, we could manage 99.9 percent of those voluntary patients at a much less expensive level of care. We work with judge herman and trish young in particular with the health care district, worked with judge herman at the probate court to consider the beds funded by the health care district as publicly funded beds and the court has agreed to waive filing fees on the publicly funded beds, so shoal creek was then willing to accept the involuntary patients. At this point we try to use it for the most at risk involuntary folks or those we can't manage in a crisis respite seght.
>> that's good news. Thank you for that.
>> even if we try to increase the number of clients served with the amount of money available today, what do you think the financial shortfall is for us to meet the need?
>> when the health care district was being formed several years ago, we were being asked for an analysis and asked for a study group that asked at this time if we did a systems mapping and filled all of the gaps to have a model balance system between inpatient, outpatient housing, all the needs that we were about $12 million short. And then I think that we've made gains since then of a little over four million dollars. So I don't know if that gives us a sense for the size of the issue, but as dr. Van norman mentioned, we still have some focus needs and outpatient services. We can through our utilization manage vment a good idea of how many additional inpatient beds and we're missing that crisis stabilization unit, that first place that public safety would bring individuals.
>> we made some gain, but it's still a big issue. But in the end you're looking at us squeezing more out of the state. And then determining where the gaps are. And really the city, the county, health care district, mhmr, the hospitals, any other partners we can find trying to help us meet the need, right?
>> right.
>> [one moment, please, for change in captioners]
>> ... When they are in any kind of medical crisis including a mental crisis, and I was rather shocked by the statements in the newspaper to that regard.
>> we've noted it many times and other folks have pointed out too that we're the only major urban area with a health care district that has -- has had no publicly psychiatric in-patient beds and no psychiatric emergency service. In harris county, houston, in san antonio, dallas, fort worth, they've all got psychiatric emergency services affiliated with the general public hospital to respond. And this has helped to raise the awareness that they've got to increase and improve their capacity and capability to deal with psychiatric illness. That even if we come up with the ideal solution, there's nothing to prevent someone and in fact the law encourages people to go to the emergency room if they are having a psychiatric crisis. So the emergency departments are going to have to increase their capacity to deal with psychiatric I will innocence the emergency department setting. I couldn't agree with you more.
>> I do get concerned that -- while it's true the state is
>> [inaudible] and pretty much any arena you can name, I do have some sympathy for them in this regard that the state hospital has essentially been subsidizing the ability of private hospitals in the Travis County area to have the luxury to not take psychiatric emergency patients. And that luxury should probably -- well, it clearly can no longer be afforded.
>> right. Agreed.
>> thank you very much.
>> thank you.
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Last Modified:
Wednesday, November 7, 2007, 18:30 AM