Travis County Commissioners Court

July 17, 2012 - Item 18
Agenda

Item number 18 is consider and take appropriate action regarding 1115 Medicaid Waiver including potential participation.
And we indicate there it may be taken into executive session under the consultation with attorney exception.
And chairman, I thought it would be good to put this back on because one is that the program does seem to change periodically, and there is an approaching deadline of some sort.
So sherri.
Ms. Fleming.

>> Good morning, judge Biscoe, Commissioners, sherri fleming, county executive for health and human services and veterans services.
And yes, the train is on the track and moving down the road with the 1115 waiver and so we thought it would be a good idea to come before you today and talk about your intentions, but also to let you know what's been going on since the last time we spoke about this, which was on June 28th, I believe.
We have a brief presentation to sort of center us back to key components of the waiver process so we'll try to go through that quickly so you can get to key discussion points.
Just by way of background, in December 2011 the centers for medicare and medicaid services, often referred to as c.m.s., approved a waiver a process received in 1115 of the social security act.
The Texas proposal to expand medicaid managed care is predicted to save the state $300 million to improve access to care for millions and to dramatically increase the quality of the care delivered.
The waiver is approved through September 30th of 2016, and one question that comes up is is this related to the affordable care act.
This waiver is on a separate track from that.
So Texas has -- Texas and our governor have been making some decisions relative to the affordable care act that we're not prepared to talk about today, but the waiver will continue as a project for the state.
In terms of time lines, July 3rd through July 19th we have been a part of the region's planning around the review and selection of projects from categories 1 and 2, which we'll talk about what those are in just a few minutes, heading toward a plan, a regional health care plan for our region, region 7.
That will contain a full list of delivery systems, reform, incentive pavement projects.
And this is one of the new terms we've learned and this is really our incentive, if you will, for considering participation in this project.
So project costing and project planning has been a big major part of our discussion so far.
On July 20th at the end of this week, proposed projects are due into central health.
Central health has been designated by the state as the administrative lead on this project or the anchor so they are responsible for pulling together the regional health care partnership as well as the region's plan for how we will access the 1115 waiver resources.
On July 4th, draft projects will be available for review on a website that has been set up or will be set up by central health.
July 27th and the 30th there will be public hearings related to those projects, and then by Friday, August 3rd, the final project plans are due to central helath.
Other dates, a regional planning project by the state and we'll talk about that later on.
In September the regional health partnership's four-year plans are due to state, to the health and human services commission.
By September 30th, the health and human services commission will be reviewing all of the region's plans -- all of the regional health care partnership plans.
October 15th the regional health care partnership plan changes will be due back to the health and human services commission.
And then that process will continue up until the submission to the federal government or c.m.s.
There will be an opportunity for -- for some dialogue in between there with a final decision due back to the regional health care partnership sometime in February, it says February 1st here.
So those are the key dates that are guiding the work in our region.
So --

>> Where did these dates come from?

>> These dates are coming from the health and human services commission.

>> The state.

>> So the state, the state of Texas health and human services commission is guiding the work around the waiver.

>> Including July 20th?

>> The July 20th date is a date set by central health in order to be able to meet the health and human services deadlines.
So our -- our regional health care partnership plans the or projects must go to our anchor so they can then prepare the plan for submission.

>> We think that regional partners will be able to meet that deadline?

>> We believe that they will.
And I know central health has been working with -- with our county as well as the other counties who are part of our region to ensure that projects are identified to be submitted.
Now, there will be a great deal of work I can manual that will go on once those projects are committed.
They provided a tool that counties and performing providers in the system can use to structure their presentations.
These proposals are probably not as detailed as you might imagine.
There was sort of a template, I think that we were -- that the projects are able to follow so that the information can get to central health as quickly as possible.
There will be time to flesh out much of the detail of the projects during this review period.

>> There's a state committee meeting right now.
Scheduled to start at 10:00.
And 11:15, medicaid waiver is supposed to be on their short agenda.
But we have no reason to believe these dates may change as a result of that meeting?
Meeting.

>> We don't.
But anything can happen and has in the last six months that we've been discussing this.
So I don't know that I can be as definitive as you would like, but these are the dates that we're working with right now until we hear something further.

>> And by the way, we do have several representatives there.
Commissioner Davis.

>> Yes, thank you, judge.
And I know, I think this came before the court in a work session, I believe part of it did.
But let me say this.
Explain to the public what we are really doing here as far as this initiative.
Of course, the human health -- hhs commission at the state level, of course, is focusing this type of expansion as far as coverage as far as a regional situation, but -- but at the end of the day when we look at this, it's actually federal matching dollars that are being -- being focused down here to the local level.
There are other participants in this particular regional setting that we are looking at here.
Could you tell me what those other regional partners are in this proposed situation here on this particular proposed waiver?

>> Yes.
There are six counties that are part of our regional health care partnership.
They are bastrop, caldwell, fayette, hays, lee and travis.
And there will also be other members of the regional health care partnership, those providers who will be actually performing services, hospital representatives will also be a part of the planning partnership, but the counties are the six that I have named.

>> Okay.
And I guess part of my question and I need to get, I guess maybe the health care folks to answer that, the district, kind of relate to them, but is that the -- this is all about new money.
The money -- if I'm understanding correctly, it's not talking about the money that we have already set aside for the services we provide at this point, but the federal dollars that will be coming down will be new -- will be based and contingent on the new money that you invest into this situation.
So if you invest in new money, there has to be a way to -- to acquire this new money.
And at this point an example if you -- I think an example of that if we put in a million dollars, they will give us -- you know, they will give us, well, $1.4 for every dollar that we invest of new money.
So it would be about $2.4 million.
So my question, though, is in Travis County, if we're going to allow the hospital district to be the overseer of all of these things, the question then becomes will it require additional staffing, will there have to be -- what will the -- what will the -- how will the new revenue be generated to offset -- to make sure you draw down this $1.4 per every dolphin new money that we invest, and what impact will there be to overall budget.
Now, the hospital district can also levy tax increases.
I don't know if this is part of the equation.
I know Travis County can also, but this is a governing -- this is a body that can also levy, in fact they do now when you get your tax bill, you see the hospital district on your tax bill.
So my question, though, is with this new money and the responsibility of Travis County's hospital district, looking into and overseeing and administering the -- I guess the overseer for the other counties that you mentioned, then what impact would that be for the hospital districts as far as getting revenue for new money and also the staffing that's going to be required -- and I'm saying may because I don't know.
These are the questions unfolding, of additional staff that may be needed to carry out this project, this program.
So I need to get some answers for somebody.

>> Well, we can request that information from the health care district.
We're talking about the staffing at the health care district and whether or not -- and what administrative costs they are incurring in acting this this role and we can pose that question and have posed that question on your behalf to the -- to central health.
As soon as we get it, we will provide it to the full court.

>> Yeah, because I think the public need to know what we're getting into, and not only that, and there are a couple of categories we have as far as the services that we'll be really looking at as far as funding, but will there be a tax increase wit.
But the bottom line all the ramifications of this have not been fleshed out, in my mind to, get to tend I'm trying to get to.
Of course, I'm laying it out the way it been presented to me.
So I need to get that answer if I possibly can from those folks.

>> We'll provide it as soon as we get it, absolutely.

>> I would appreciate that very much.
Thank you.

>> So that's a good question, what is the -- how can the county participate and what is the incentive to do so.
The county is designated as an entity that can make an intergovernmental transfer.
And that intergovernmental transfer would entitle us to matching dollars from the federal government at the rate of $1.40 per dollar that we transfer.
Now, the -- many of our partners have the unique position of being both an i.g.t., internationaller governmental transfer entity, but also a performing provider which means they are able to directly receive their incentive payments back from the federal government.
We are not in that unique position so we would have to align ourselves with a performing provider that -- of our choosing in order to reap the benefits -- to designate who would receive our incentive pavements on our behalf.
And so that's -- that's -- we send our money up.
We get the $1.40 match, and then we would designate the performing provider who would receive the matching fund based on our intergovernmental transfer.
How frequently would we do that.
Performing providers receive incentive payments for milestones that are achieved from their projects.
Once a project is identified and our regional health care plan is approved, then the payments may be made as frequently as a semiannual basis.
But the performing providers are responsible for reporting the metrics on those projects.
Those reports are distributed to the i.g.t.
Entity, which Travis County can be one, and the anchor entity.
The health and human services commission then determines the amount of funding based on the progress of the project.
So as a potential i.g.t.
Entity, what would be our responsibility?
They would like us to estimate our i.g.t.
Capacity for the next four years.
Estimating your capacity doesn't lock you into a particular number but it gives the -- it gives the plan and our anchor and the state an idea of what we believe we will be able to contribute toward our projects over the next four -- the remaining four years of the waiver.
Your participation is optional.
You do not have to do an intergovernmental transfer or fund a project if you choose not to.
Your responsibility is also to determine the use of your funding.
So you identify the funding and decide where you want to put it.
You can select projects from the regional health care partnership plan and then work with the performing provider to establish the metrics consistent with the state's identified metrics for -- for whatever particular project we're talking about.
You can request and receive input from key stakeholders and from the public.
So you might want to -- once you determine the level of participation, you might want to hold a public hearing to focus on which projects or which resources you want to dedicate to this project.
Certainly you would be expected to have a participant in the government structure and of course you would have to make your intergovernmental transfer.
The responsibilities of the performing providers are to participate in the regional health care partnership in order to receive the waiver funding.
Coordinate with the i.g.t.
Providers to provide either the uncompensated care or regional health care projects as basis of receiving the sponsor payments.
And we haven't talked about uncompensated care because those projects really have to do with hospitals and there's a part of this that focuses on hospitals and a and d a part that allows us to -- the performing providers must meet performing metrics as basis of the funding payments and provide those metrics to the i.g.t.
Entity, the anchor entity and the health and human services commission.
So what is important for us to talk about and maybe blank.

>> [one moment, please, for change in captioners]

>> That's a brief overview of what they do.
It has become a very important project in our community.
We do have david evans and don hadley here from Austin Travis County integral care who could answer any questions about that program for sure.
But the interest of our partners is that we would consider an investment that would allow for the expansion of this program as a part of the 1115 waiver process.
If the court were to indicate their intention to invest a million dollars in this project, for example, I believe the estimated project costs right now is $2.1 million.
So if you were to indicate your intention to invest a million dollars, then that program would be submitted to our regional health plan.
We would go through the various dates and reviews that we talked about at the beginning and once our plan is approved that project would move forward in our community.
Once the necessary metrics are are met we would be able to either as Travis County transfer those dollars to the state which would then transfer them to the federal government or we would be able to send those funds directly to Austin-Travis County integral care so that they could transfer to the state and then on to the federal government.
We would anticipate that that million dollars would generate an incentive payment from the federal government related to the 1115 waiver of about $1.4 million, which would pay for the balance of the program.
So that's pretty much how it works.

>> So we believe that the -- an expansion of mcot would qualify as a transform asianal project?

>> Yes, we do.

>> And does the stayed make the call on that or the health care district?

>> The regional health plan -- sorry.
The regional health plan, planning protocol, which is the part of the project that can be undertaken, was created by the state.
And it models what was allowed in california and their 1115 program.

>> But the people that actually apply the state criteria would be located where?
At the state level or health care district?

>> The plan first has to be approved by the health and human services commission and then it will have to be approved by cms at the federal level.
I wasn't a math major, so that makes the numbers easy for me.

>> [laughter].

>> Tell it like it is, sherri.

>> Tell it like it is.

>> [laughter].

>> Mr. Evans?

>> Judge, Commissioners' court, appreciate your taking up an extraordinary opportunity under this 1115 waiver.
I've listened to sherri fleming's presentation and my name is david evans with atcic.
I've also brought don handily, our director of behavioral health services.
I just want to compliment sherri and her staff for being in all the planning meetings and really inviting in the kind of partnership that it will take to make this work.
As we were coming up your question was the definition of the transformational, just take one step back with all the uncompensated care under programs like disproportionate share and more recently upper payment limit that went away on September 15th it really advantaged hospitals and uncompensated care.
The transformation is an opportunity to build all of the preventive wellness, early interventions, access, the kind of health care delivery system in the community that hopefully will in the future see less reliance on our hospitals is a more expensive and late in the stage of disease management.
But dawn, you've operated directly the crisis -- the mobile crisis outreach team and see where there could be benefits from expanding that service along the lines that sherri fleming outlined.

>> That's correct.
And part of the reason mcot does fit under the district categories is category 2.
It's under expanding the crisis services, so that is what mcot is a crisis service.
The idea that we're looking at here is expanding it to not only diversion for hospitals, but also a diversion for jail.
So there's a way for us to catch that up front before individuals are even in the system, are even booked in the system, and we can provide those services that wrap around them to prevent them from getting in the system.
So that was just the idea around suspending mcot in that area because it has been so successful and is successful working in community.
It fits nicely with the number 7 of the 10 and 10 of senator watson's plan under mental health initiatives.
It's one of the things that came up as priority in the crisis stabilization type services.
This is one of those services.
We think by utilizing this and expanding it to the jail diversion, expanding it to the emergency department so that individuals are not sitting in the emergency departments for 24 to 48 hours waiting for a hospital bed because the system is so backed up, but if we can come around it from this direction that we can help divert that need for that inpatient bed day to begin with and then help to begin to connect these individuals to resources in the community that we currently have going on.

>> It makes a lot of sense to me, especially sitting on that group that we were attending.
And I guess those meetings are still going on.
But how difficult it is to address the issue that people with mental health issues have and the families.
And so it was great to take that vote to fund that mobility van.
And then on top of that to hear from people in community who have utilized the service and basically saying that we saved people's lives.
We actually save some people's lives.
And so -- and as much as we've struggled to try to find, you know, the funding that is required, if this is a way that we can further expand those services that we know are needed, not only at the adult level, but I wish we could address more of the children's level as well.

>> [overlapping speakers] that is incredibly needed.
So this would be terrific.

>> We are able to even actually go into the school on school campuses.
So if a child is in crisis at school, we can intervene at that point as well.

>> We've been talking about this issue really for the 18 years I've been here.
It's just like one of those things where we're finally seeing the light of maybe some funding being available.
And I think we ought to take it.

>> One of the unique opportunities that we've had over this past year that we just started this year with our mcot services is participate in training.
So we're doing some co-training with a.p.d.
With all of their officers that we want to extend that to the county cit officers and all of their officers.
So we do all the cadets.
We do the cit and we do all the mho officers.
That has made a tremendous different, already even in the short amount of time, just in how you interact when you meet that individual in the community who is in crisis and then using those skills together and working in tandem, and that's really just building the relationships with the police department as well and helping to divert so we can move in.
They feel comfortable with it.
It's a place they can take them and feel like we have that warm handoff there and that the client is safe or the consumer is safe and really focusing that intervention on care versus incarceration, whether that's in a hospital inpatient locked unit or if that's in jail.

>> Do we know exactly how many folks we have served -- and I supported that program in the past.
And of course I'm not abandoning, but what I'm trying to do is focus on the cost element, especially with new money.
And of course how would we pay for some of the things that are coming up and going into the budget cycle?
I just need to get a better handle.
That's why I asked the hospital district if -- who is also a taxing jurisdiction, because we have two categories here of what we can expand, but of course there is -- there has to be a cutoff point somewhere that -- because we can't do it all.
But we can do our best, I think, at what we do.
And of course, what my concern is, the services that have been -- I know what we do, we look at our performance and what we get the mileage out of investment that we make, must not that we invest.
What kind of mileage do we get out of that?
That's still very critical.
And I hear what you're saying.
I support that program.
But what I'm after is the overall fiscal impact on the upcoming budget, how much can we absolve in this as far as matching funds because it's all new money.
It's not old money that we're talking about.
We're talking about brand new money.
And that means to me that it has to come from a source, what source will it come from?
So these are some very legitimate questions as far as continuing to provide service.
And it's not a shell option from the state, from the health and human services commission, but it's something that is discretionary.
We can or we cannot.
But at the end of the day if there's money available to enhance, expand programs, my goodness, we should look at it very seriously.
But for how much for each service.
You know, for how much for yours?
Sherri did a million dollars.
She said that's about the best way for her to do a match.
It doesn't have to be a million dollars.
It could be less, more, I don't really know, but there has to be somewhere in the services that we're considering expanding with new dollars coming from some source.
How do we put a lasso around it and how could we have it where you could still provide good service to community, additional service to the community, but then not break the bank?
So this is what I'm trying to get to.
And I really do need the hospital district to talk to me about some of these things because again, they are also a -- a jurisdiction that deal with revenue and they also have taxing authority, just as this Commissioners' court body does.
So how we generate this revenue is going to be the crux of the matter to make sure that the new dollars that we spend is matched appropriately by the federal dollars that are coming down.
So I hope everybody get my drift.

>> So if I may, whatever the court's pleasure is today, let me maybe lay out a couple of options.
The first option would be first and foremost is it the court's interest to participate in the 1115 waiver as an intergovernmental transfer entity.
So that would be your first decision.
Your next decision might be to --

>> Tell the public what that means.

>> What that would mean is that you would have an intention to identify resources that you would apply to a project yet to be identified that would qualify for potential incentive payments under the 1115 waiver process.
And those resources would be primarily new resources for expanding and transformational programming.
That's what that would mean.
The second option would be to identify a dollar amount.
If you so choose to, that you would either earmark for a future expenditure.
I mean, there's certainly contracts and things that have to occur.
Or -- and designate a particular project that you have interest in.
Or you may indicate an amount of money that you would want to invest, but not indicate a project.
As I mentioned to you July 20th is the deadline for projects to go to central health.
Central health will be reviewing those projects and those projects will then go up for public comment.
There may be other projects on the menu of recommended projects that you might have interest in investing in.
So it is certainly your option to identify resources that indicate a project or the way for that menu of projects to review.
That's your option.
Let's see.
I think I got them all.
Certainly as an i.g.t.
Entity, that would make you a partner in the regional health care partnership, but of course there would be also a document coming forward from legal for them to advise you on and for you ultimately to approve.
And we just received the revision on that on Monday so that's why we're not prepared to discuss that with you today.

>> Is it true that so far the only project that you've been able to come up with is the mcot project?

>> Well, there's a long list of behavioral health projects and various partners who are taking on a variety of pieces.
And so because we already are investing in the mcot project this seemed to make sense for this to be the project that we would consider.
We certainly can consider other projects now and in the future.

>> From the integral care perspective with the mcot expansion expansion be the most logical one for Travis County to assist with?

>> I think so.
And I think it builds on the previous work, judge, that you've been part of, which has been that stakeholder planning.
And I think that my understanding is that the county's interest also around public safety issues.
As an example I walked in on the tail end of a decision around some additional purchases in that area.
Hopefully at an intercept with central booking, being able to do additional and joint community policing, but different standards to interact with folks within the community.
And then the alternative arrangements for individuals prior to hospitalization I think all create not only public safety for the general public, but then also for the individual who is experiencing a psychiatric crisis.
So it's a long-winded answer, yes, I think it does have a nice fit from Travis County's interests.

>> Let's say we indicate that we would like to invest an additional one million dollars.
And let's say that during our budget process we're able to realize 750,000.
So are we held to the one million dollars or are we held to whatever we invest as long as we understand for every dollar we put in we get $1.40 back.

>> You are held to what you actually invest.

>> What is that, sherri?

>> You would be held to what you actually invest.
You make an investment, an i.g.t.
Estimate, which we have heard through this process can either increase or decrease without penalty.

>> Well then, we can put our hands on 300,000.
Because it's in the mental health reserve.
Right?

>> Yes.

>> That amount is still there.

>> Yes, it is.

>> We have been -- we have learned through our budget process that we do have quite a bit of one-time money generally.
The problem is with that one-time money you can only spend it one time.
And during the next budget process you kind of have to generate the same amount again.
So rather than ongoing, it's just one time.
However, some of these pilot initiatives I guess really require a little opportunity to see what impact they have anyway.
And if the other counties of Texas are as confused as I am or we are, then it seems to me that there would be other changes that we can expect to occur over the next few months.
I mean, I don't see any way to avoid that really.
So I guess spending one-time money this time doesn't bother me any.
The other thing is that I'm -- I assume that today, the July 20th deadline is a serious deadline.

>> It is a serious deadline.

>> And if we miss it you're looking at next year?

>> No, not necessarily.
But I think in terms of planning -- and because we have a responsibility and our anchor has a responsibility to look at the menu of projects that are submitted, and there is a review of those projects in terms of okay, are these projects that together will transform the system within your community?
And so, you know, if Travis County is not indicating its intention to provide some funding for this project, then we sort of have to go back to the drawing board with the other partners to determine the priority of this project and then the other potential funders in light of the other projects that are proposed.
So that's a long-winded answer to say --

>> Finally for me, if we commit one million dollars, then we have reason to expect another 1.4 million to come back.

>> Yes.

>> So that's a total of 2.4 million we would have to work with.

>> Yes.

>> And if our project is rejected, then we're not obligated to put up the million dollars.

>> Correct.

>> So we can back off of that commitment if things don't turn out as we wish.

>> Right.

>> And then what happens at the state level?
In this community, because there were a lot of stakeholders around that table who decided that this was something that was needed for Travis County.
Will we hear from all the stakeholders that the stakeholders of this community recommend this project?
Is that something that is done as well to the people making the decision at the state?

>> I believe so, yes.
But of course for Travis County there's the coordination between the hospitals and the health care district and Travis County and the city of Austin and all of that.
So I think it has great merit in terms of our collaboration on all of the projects that will potentially move forward.

>> Because it was a great collaboration and the hospital district was at the table.

>> And it would be health care projects as well.

>> So there are a lot of stakeholders at that table.

>> You know, individually on central health side and on our side we've actually begun some of those public hearings about what are some of the ideas around some of these projects.
And then once all of the projects come together they'll roll that back out.
So we were able to get input from community already around some of these ideas and what some of the needs were.
And these are some of the projects that are getting the support already at this level.

>> And a part of our plan will also be a community needs assessment.
There's been tremendous work not only by central health, but with the work by the city, all of that information has informed the community needs that will be reflected in a -- in our plan.

>> So your project has to be backed up by the needs assessment.
And there are particular metrics to answer your question, about getting that incentive because basically it's a bonus.
It's an incentive for meeting the metric and they are in this project in what you are expected to give as your outcome measures.
So that part is very controlled and very -- and we know it is and those are the goals that we're shooting for in order to get that incentive payment back.

>> So would we be expected to continue this program for four years or is the determination made on an annual basis each year?

>> Well, I think that certainly the health and human services commission has an appreciation for the fact that you budget annually.
And that you are bound by the budget that you approve each year.
So I believe there's recognition of that.
That's why the i.g.t.
Capacity is an estimate.

>> We do need to estimate the i.g.t.
Capacity for all four years to go to the regional health care plan.

>> Of course, once you align with the project, then the idea would be to continue that project for the four years, yes.

>> And if we get into the project and need to make an adjustment in year three we can make an adjustment to the project if ear not seeing what we need to see.

>> I guess david, when we first got into this supportive mode, supporting the service that you guys provide now, integral care and what we're look at today as being the one that we need to really look at seriously to go forward, it's going to probably come to the attention of the public and they say okay, well, Commissioner Davis, you seem like you want to continue to support that particular service.
It's a mental challenge and how it affects so many various family members, individuals, jails, the whole nine yards.
So it appears that you want to support it.
The question may also come is this: what have they done thus far with the money that you have already invested into them?
Why should we expand it?
And of course, will there be -- and I know there will be -- in this particular array of events that will happen, there will be an opportunity for the public to -- public hearing and stuff like that to people say what they need to say, I guess.
The question is what can you provide I guess to me, I guess, and anybody else that want it, of the actual service improvements that have been made by providing the service?
In other words, the actual value of the investment as far as what we've done as far as the incarceration rates, da, da, getting in touch with the family members, just the whole challenges that you have dealing with a person that has mental challenges?
So is that information readily available to the public or how would I get my hands on it?

>> We can provide for you a year by year, since the beginning, the number of calls, the disposition of the calls, how long we took to respond to the call, whether it was children, adults, whether or not the cit or the sheriff's office was involved in those.
So we can put together that data.
To use another term to answer your question in a second way, use the question what's the value of the project?
And that's to me a different question.
And right now health economists are trying to address this whole waiver, and then what's the value or the economic impact in which there should be some offset from law enforcement, from jail time, from emergency room use?
The transformation part is -- on the back end of this what the value is overall or an economic impact on our community.
It's a much more detailed question, and we've done that for some parts of our service, but each one of those projects will have to have a value assigned to it and that work is being done right now.

>> Okay.
That would be good to have because as we go through this, that question more than likely will probably come up.
I don't know if it will be, but it will be good for us to know -- to lay that out publicly and let the public know what we're getting into here and those things that I just mentioned, those attributes.
That's basically what I'm looking toward doing.
Anyway, that's all I have.

>> We can work with your office because we would really welcome the opportunity not just to talk about numbers, but to talk about what this kind of service means and to better educate on the very nature of mental illness.

>> All right.
Thank you.

>> Mr. Reeferseed?

>> Thank you.
I just wanted to echo Commissioner Davis.
You're really right on track with some of the questions that I was on.
And also you, sir, judge Biscoe, your question has already answered some of my concerns.
But just generally speaking I would want to say I'm here representing parents, my general concern.
And the thing that got me up here actually was somebody said it's modeled on california, modeled on california.
That's insane!
They've got this governor and former governor, present governor, who is pro guard sill, pro abortions, without parents even hearing about it.
So that's what I'm worried about.

>> Is this relevant to the mobile crisis unit investment?

>> That's what I'm asking.
If we say we're modeled on california, the health nightmare of the state of california is something -- I'm just saying as a citizen of Texas, we don't want to import into Texas the california nightmare.
It's a nightmare what's happening there and people are leaving california.
They're coming here.
I mean, it's not a mistake.
And I don't know, it just made -- it sounded so great.
Free money.
What could be wrong with free money.
There's no such thing as free money.
This is taxpayer money.
It comes from you and me and all these schemes are paid by you and me.
It's a big cash cow.
And I hope as a citizen I was hoping to get a copy of or where can we find again, echoing mr. Davis, where can we find this as a citizen?
Where can I find this backup material for citizens on this 1115 waiver?
This sounds like a cash cow.
I'm sorry I'm ignorant.
Didn't have any backup material on this.

>> Mr. Reeferseed --

>> Okay.

>> You can find it right here in my right hand.
It's my backup.

>> And the health and human services commission of Texas has an active website on this issue.
You can also sign up for email alerts on all decisions and information that is newly posted.
So the state of Texas health and human services commission has an active website on this issue.

>> Great.

>> Commissioner Eckhardt?

>> I had a couple of questions with regard to how the thing is going to work administratively because we've got kind of two tracks.
We have the i.g.t., the intergovernmental transfer investment, and then we have the disrip investment coming back down.

>> Yes.

>> So using the-million-dollar figure just because it's easy math, if we as an intergovernmental transfer agency make an additional-million-dollar investment in mental health care with our service provider, integral care, it's like being a kidney donor.
We don't get the kidney back, but someone else gets an improved quality of life, the 2.4 comes back down through disrip programs to improve mental health outcomes in our community.

>> All right.

>> So I just wanted to be clear on that that we give the kidney, we don't give the kidney back, but someone else has an improved quality of life.

>> A and just to be clear, there are some entities in our community who actually can transfer funding and get the benefit directly of the incentive payments.

>> That's my next question.

>> Unfortunately counties are not one of them.
Austin-Travis County integral care, however, is an entity that can transfer funds up and also receive directly back the incentive payment.

>> And that's why I want to ask the next question because I absolutely concur that mcot is an already existing proven benefit to our community and expanding its capacity could only be good news.
Plus, we only have until July 20th to submit, so why not use something that we know works and expand it with our kidney.

>> [laughter].
But it leads me to at least two other things that I think will probably be on our plates as the Commissioners' court in the next five years or four years during the life of this program that I'm wondering whether we could -- I'm not saying we need to definitively explore and decide today because again, I think the mcot is the comer, but whether these two other items which are a sobering center, which is essentially rather than a mobile crisis unit, it's a stable -- it's an entity.
Also there's been talk of involuntary outpatient commitment program.
Both of these would be expanded county investment, but undoubtedly integral care would be integrally involved, probably being the service provider.
And then there's a third, which probably isn't squarely on our plates, but may be on the health care district's plate, which is a secure wing at brackenridge.
So I imagine those three things, two of those three may be worthy of exploration for our i.g.t.
Investment over the next four years, and probably all three of them may be something to explore for disrate reason new investment as the money comes back down.
I didn't want to limit us to mcot for the whole four years we might find that our capacity expansion hits a ceiling and then the regional health plan says we're really good at crisis management, we're not so great at chronic stabilization.

>> That's true.
And I think we may also find that there are programs that are producing even greater metrics than we had anticipated.
So we might find with additional resources that we want to further expand.
So I think all of those are in the realm of possibility.
I would add one other thing to your list that we just found out about Monday, which is a potential project from the city of Austin relative to supportive services for permanent supportive housing.

>> Very good addition.

>> And once again, yet another project that we might, you know, at some point in the future, be interested in what our resources might do to increasing that service array.
So yes, and again, we can provide to you -- once the package of projects comes forward, we can provide that to you in any fashion that you would see appropriate, and have you see exactly what projects are on the ground moving for this first year.
But then there will be an opportunity, we believe, to modify projects, eliminate projects.
The question of adding projects seems to be one of those unanswered questions right now.
But you know, we hope that maybe if not adding, mod figure in such a way that we can accommodate the metrics and the information that we're receiving in our service delivery.
Do y'all concur with that?

>> I do.
These are the areas you mentioned are on our radar screen.
To the extent one of the principles has been talked about through the anchor is the principle of trying to maximize this opportunity.
We've been going through what's called a maintenance of efforts scrub in which the state is looking at, how dollars may already be leveraged or accounted for before they ever reach a deposit in our local mhmr center account.
But once we also know the amount, we would have clear for i.g.t., then I think our board is also interested in picking up a number of these expansion projects and working closely with the county and the health care district as a full partner.
So we haven't today reviewed other areas of behavioral health, but we may be picking up as a direct i.g.t.
Entity, but I will say that each of the things that you've mentioned are an act -- are in active discussions?

>> I'm appreciative they're in active discussions, and I'm sure some won't be ripe enough for an i.g.t., but could become ripe for the disrip as it comes down -- sorry to use all those stupid acronyms.

>> (indiscernible) reform incentive payments.

>> The money when it comes down as a larger amount than we put in.

>> And I look forward to and I know we don't have to really go into this today, but I do look forward to some continuing discussions on how we participate in the governing structure of the regional health care plan.
Because I think that will be crucial with regard to the distribution of the disrip money.

>> What do we need to do by the 20th?

>> I make a motion that we indicate our intention to invest one million dollars more into the mcot initiative.
That we authorize staff to prepare the appropriate paperwork, to make that happen.

>> Yay.

>> If we do that we need to work on the budget.
How we make that happen as a budget.
But in terms of meeting the 20th of July deadline, which this motion is intended to do, one million dollars to expand the mcot initiative.

>> Great.
And if I could, the way we would handle that is we would earmark that against allocated reserves.
We're in the process of looking at those reserves right now for the current year and there are a number of those that we don't think we're going to need currently, so we can fit that in in the current year and then roll that into the 2013 preliminary budget.

>> We authorize staff to make it happen.

>> Great.

>> That's the motion.

>> I think you got all of us seconding it.

>> Any discussion on the motion?

>> Yes, judge.
I want to make sure that there was a lot of good discussion here today on this, and of course I'm in support of this.
I think it's going to go a long way.
But there were also a lot of questions.
I think that the public needs answers to.
I know I need answers to some of the questions that I asked.
So I'm looking forward to get those answers to those questions to me as soon as possible.
I think we need to put our arms around this and provide the public with the necessary answers to I think the very critical questions in this endeavor.
So I'm really looked forward to getting those answers.
Do y'all hear me?

>> Yes.

>> We'll work closely with sherri fleming and provide all those.

>> We can easily provide you what we've done over the past several years.

>> Sherri got silent on me.

>> (indiscernible).
We've not actually done yet, but I think we can look at what we've done and how we expect to see that impact.
And hopefully this moves in the direction that we're anticipating it to go, then there will be less people in jail, less people in the hospital, we'll be spending less money in the most expensive places and be able to build out our community clinic resources and keeping in the -- helping people stay independent.

>> I'm looking forward to getting the information.

>> Commissioner Huber?

>> The question I have, I don't know if there's an answer for today.
As we move forward in this process and the guidelines and rules continue to develop and so on and so forth, do we have any idea of whether or not we will be able to participate in this program within the current framework of county employees from the county standpoint or will we be looking to add employees to support this effort?
And like I said, I'm not sure there's an answer today, but I think we need to know that piece.

>> I don't have an answer.
I think ultimately how we negotiate and the court sides whether or not it chooses to take on the administrative transfer of the resources or we transfer them to Austin Travis County, those decisions I think will impact what will ultimately be the answer to that.
But I just don't know at this point.

>> My recommendation would be that we do the same thing that we do with the current mcot money.
We hand must not over and get out of the way.
It's worked real well.
Mr. Reeferseed, any more comments?

>> I love and respect you more than anyone here.
Here.

>> [laughter].
I have a quo the math, that's all.
The math that you were talking about.
We get a million dollars and then for a project that was for 2.1 million, but then we get another 1.4 million.
What happens to that other 300 million?

>> The potential 300 million is the pot for the whole state.

>> What he means is when you cited the example earlier, you said we were looking for $2.1 million.

>> Right.

>> If we Wednesday a million up and we get 1.4 back, that's $2.4 million.
So his question is what happened to the $300,000?
You thought I wasn't listening to you, mr. Reeferseed?

>> That is a very good question.
We work with our partner to -- once we ensure that that's the amount of resources they have in fact received, then we work with our partner.
I would think among the list of project, current projects, whether or not we would like those funds to be -- we would have interest in those funds being diverted to a different project.

>> We will put that money to did use and will not send it to california.
That's what mr. Reeferseed wants to hear.

>> That's what I needed to hear.
Sorry to be so stupid on this.
You made the point about the one to 140 relationship.
Where does that come from?

>> It's federal matching funds.

>> That's their policy.

>> Yes.
That is part of the 1115 waiver process.

>> Okay.
Great, thanks.

>> All in favor?
That passes by unanimous vote.
Thank y'all very much.

>> Judge, I have one more action, I'm sorry.

>> Took a little longer than I thought.

>> I need one more thing.
We have an invitation from central health to participate in the health and human services submit on August 7th and eighth and you need to designate your representative for that so that we may respond to that invitation.

>> This agenda item is sort of expanding.
We don't have any objection if you do that.

>> Okay.

>> You and whatever staff at hhs that you deem appropriate.

>> Thank you.

The Closed Caption log for this Commissioners Court agenda item is provided by Travis County Internet Services. Since this file is derived from the Closed Captions created during live cablecasts, there are occasional spelling and grammatical errors. This Closed Caption log is not an official record the Commissioners Court Meeting and cannot be relied on for official purposes. For official records please contact the County Clerk at (512) 854-4722.

July 3, 2012: Travis County Launches New Video Playback System

Our new streaming video system uses a single video clip for each session and items are linked to specific locations on that clip. Some browsers and mobile devices do not recognize the location information and display the entire clip. If this happens the "start time" will help you find your item's video within the larger clip.

If you encounter playback issues check out our video playback help page. If you still encounter problems let us know.

On July 3rd, 2012, Travis County began leveraging free resources by posting Commissioners Court meetings on Youtube. Previously every video clip was edited separately and hosted on the county's video server. The old system also required RealPlayer to view the video clips.

The new systems save time and resources -- and that saves taxpayer dollars!