Category1ProjectNarrative

BluebonnetTrailsCommunityServices– 126844305.1.1

ProjectArea, OptionandTitle:1.12.2 – Expand thenumber of community based settings wherebehavioral health servicesmaybedeliveredin underservedareas

RHPProjectIdentificationNumber: 126844305.1.1

Performing ProviderName:Bluebonnet TrailsCommunity Mental Health and Mental RetardationCenterdba/Bluebonnet TrailsCommunity Services

Performing ProviderTPI#:126844305

ProjectSummary:

  • Provider Description: Bluebonnet Trails Community Services (BTCS) is the state designated Local Mental Health Authority (LMHA) for Burnet and Williamson Counties in RHP 8 and six adjacent Counties in three other RHPs. Burnet and Williamson Counties comprise 25% of the land mass but 54% of the population. Williamson County has nearly 50% of the population at
  • 422,679.BTCS providesbehavioral health, intellectual and developmentaldisabilitiesand earlychildhoodservicestoover10,000poor,under and uninsuredindividualsin multiple locations throughout thesetwocounties.
  • Intervention:BTCS proposestoprovide outpatient behavioral health servicestolow income and rural areasinWilliamson and surrounding rural counties through a program internally known to BTCS as Expanded Access in order toprovide servicestoa group of patients that arecurrentlyineligiblefor services.BTCS will provide servicestoall behavioral health diagnostic groups including substance use disorders.
  • ProjectStatus:This is anewprojectopening during DY2inanewlocation and in anarea of Williamson County that doesnothavea clinicfor behavioral health services.
  • ProjectNeed:This projectaddressesRHP8Community NeedsAssessmentneeds:CN.2.1 Limitedaccesstobehavioralhealthservicestorural,poorandunderanduninsuredpopulations(meds,casemanagement,counseling,diagnoses)inWilliamsonCounty;and CN.2.13–LimitedaccesstoadultbehavioralhealthservicesinWilliamsonCounty.
  • TargetPopulation:Thetargetpopulation is all diagnostic categoriesof behavioral health disordersin thisrural area.Weanticipateserving1,000newpatients.Of those servedby BTCS in FY2012,an averageof 43%of theadults wereMedicaid‐eligible; 76%of youth wereeligiblefor CHIPorMedicaid and 73%of BTCS clients arebelow thefederalpoverty level.Weestimatethatapproximately 70%of thosebenefitting fromthisprojectwill be poor, underoruninsured.
  • Category1or 2ExpectedProjectBenefitfor Patients:The projectwill seektoserve 1,500adultsand youth in DY4and2,000inDY5 and todoso closertotheir home communities.Weexpect this locationwill reducebarrierstoaccess, improve adherencetoappointments and satisfaction with access.
  • Category3Outcomes:IT‐10.1.b.ii RAND Short Form 12 (SF-12v2) Health Survey

Rationale: Our goal is to improve the overall scores on the RAND Short Form 12 (SF-12v2) Health Survey and demonstrate a 5% improvement over baseline in DY4 and a 10% improvement over baseline in DY5. We selected this particular outcome because the SF-12 is an overall health survey and want to show improvement in overall health.

  • Baseline Information: The baselinerateestablished inDY3 was 33.12. Our baseline measurement period established in DY3 was 03/01/2014-08/31/2014.
  • Collaboration:TexasA&MHealth Science Center(TAMHSC)had a Pass1allocation it could not use,since TAMHSC did not haveproviders in RHP8.TAMHSC allowed its allocation to beusedby local healthdepartmentsand local mental health authorities (public entities)which had muchsmaller provider allocationsin Pass1,so theseentities could havemorebroad, transformative andregionalprojects.TAMHSC hasnot playeda role in theseprojects,otherthan therole of anchor. Therearenoimpermissible provider‐relateddonationsinvolved.This usageof theTAMHSC allocation ensured theseproviders, whocould self‐fund therequired IGT,could participate in thewaiver.BTCS and community leadersin easternWilliamson County consider this tobea transformative projectbecausetherearenobehavioral health servicesin this area orin this community.

The residentshavelowerincomes and higher Medicaid percentagesthan the westernpartof theCounty but currentlyhavenoaccess.

ProjectDescription:

Expansion ofServices

BTCS is theLMHA for Burnetand Williamson Countiesin RHP8and for sixadjacent Countiesin threeotherRHPs.BTCSproposestoexpand outpatient behavioral healthservicestolow income and rural areasineasternWilliamson County and beyond as there are no residency restrictions in this project; and toexpand servicestoa largergroup of patients than arecurrentlyeligiblefor BTCS services.Expanded Access services, anchored at the Taylor Clinic, willbe comprised of a behavioral health teamincluding psychiatrists, AdvancedPracticeNurses (APNs),CaseManagers(CMs), Substance AbuseCounselors, Behavioral Analysts(tosupport carefor Autistic and otherIDD patients),PeerSupportSpecialists, RegisteredNursesand business support staff. The teamwill beresponsible for diagnosis andmedication management,counseling, psychosocial rehabilitation,casemanagementand benefits assistance providedtoadults and youth seekingtreatment.Thisteamwill be primarily located in a clinic in Taylor,Texasestablished and renovatedthrough a grantfromtheSt. David’s Foundation.

Thisbehavioral health teamhas thepotential to servean additional 1,000people a year. The team will provide a full rangeof behavioral health servicesbased on a philosophyof wellness and recoveryand will be supportedwith a certifiedPeerSupportSpecialist tohelp with personal recoveryefforts.The location of theclinic addressestransportation and socio‐economic limitations and challengesby establishing a full servicebehavioral health clinicin the cityof Taylor.Itaddresseseligibilitylimitations by providingcaretoall persons,regardlessof diagnosis and by adopting thepracticeof openaccessfor intakeand scheduling.Forpersons requiring higher levelsof medical expertise,and toensureeasyaccesstomedical services,the clinic will belinked by telemedicine toour locations with additional physicians.

“Mental disordersarecommon in theUnitedStates,and in a givenyearapproximately one quarterof adults arediagnosable forone ormoredisorders”(Kessler RC,Chiu WT, Demler O, Walters EE. Prevalence, severity,and comorbidityof twelve‐month DSM‐IV disorders inthe National Comorbidity SurveyReplication(NCS‐R).Archives of General Psychiatry, 2005 Jun; 62(6):617‐27). Only 36%of those witha disorder arereceivingtreatmentand only 13%of themarereceivingminimally adequate treatment(NIMHStatistics; (Wang PS, LaneM, OlfsonM, PincusHA, Wells KB, Kessler RC. Twelve month use ofmental healthservices inthe United States.Archives ofGeneral Psychiatry. 2005Jun; 62(6):629‐640). BTCS contracts with theDepartmentof StateHealth Services(DSHS) toprovide specialty behavioral health servicestoadultswith SeriousMental Illnesses (SMI) and childrenwith SevereEmotional Disturbance (SED),which DSHSidentifiesas the“priority population”.The DSHS contractwith BTCS restrictstheuse of generalrevenuefor ongoingservicestoindividuals within limited diagnosticgroups.Thecontractdoesnot restrictBTCS fromusing non‐general revenuesources of funds (such as those available through this waiver)toserveother individuals. However,thesecontractrestrictions,effectivelylimitour ability tocarefor all those in needin our communities.DSRIPallowsus tobroaden our scope of servicebeyond the restrictive“priority population” without violating our ability toperformunder thecontract with theStateof Texas. Theseindividualswhodonot qualify for servicesfunded through the DSHS contractarereferredout.Unfortunately,those in povertyand those whoareuninsured or underinsuredcannot accesscaredespite being referredtoit,especially since allcareis outside their local area.Wewill expand accesstocareby establishingthisbehavioral health clinic in a low income,rural areaand opening accesstoall.The teamis committed toproviding caretothisareaand tothebroaderpopulationof personswith behavioral health needs.

Wepropose toservetheareaaround Taylor,Texasand toopen theclinictoall behavioral health diagnoses.According to2010Census data,easternWilliamson County has a poverty rateof 19.5% which ishigher than thestateaverageof 16.5%.Bycontrast westernWilliamson County, theRound Rockand Georgetownarea,havepovertyratesofonly 5.5%.Serviceshavetended to bealigned around themoreaffluent partof theCounty.Thisfull serviceclinic with a responsiveteamintegratedintothecommunitywill address thisdisparity.

GoalsandRelationshiptoRegionalGoals:

The goal of theexpansion is toadd anewclinic location in an underservedareaof Williamson County,Taylor,Texasand toofferservicestoa broaderpopulation than theone servedunder contractwith DSHS.With thisexpansion weexpecttoimprovebehavioral health outcomesfor persons in this areawhonow havelimitedaccesstobehavioral health services.The challenges facing individualsin themorerural areaof Williamson County arethat therearenobehavioral health practitioners in thearea.To receiveservicespeoplemust travelintoRound RockorAustin and Travis County.For thosewhoarepoor and uninsured, thedilemmais exacerbated becausethereis nopublictransportation and evenif transportation can beacquiredand paid for,theycould betreatedonly if theyareeligiblefor DSHS services.Substance abuse treatment is limitedand frequentlyunavailable eventhough thedisorder is prevalentamong those requesting services.Thisprojectallowsus toopen accesstopersonsoutside thenarrowscope of eligible youth and adults througha clinic easilyaccessibletotheseindividuals.

ProjectGoals:

(1) Establish a behavioral health clinicin easternWilliamson County; (2)develop a robust behavioral health teamon site and supportedby telemedicine;(3) provide behavioralhealth carethat ismulti‐disciplinary, recoveryorientedand comprehensive;and (4) provide behavioral health caretoall those in needregardlessof income,insurance status ordiagnosis.

ThisProjectmeetsthefollowingRegionalGoals:

  • Improving accesstotimely,high quality careforresidents,including those with multiple needs;and
  • Increasing coordinationof prevention and carefor residents,including those with behavioral ormental health needs.

Expanded Accesswill offera solution focused,multi‐facetedapproach ofcaretoinclude wraparound servicesandtransition planning for effectivefunctioning in their home communities and care that is local. Weexpectthevarietyofservicesavailable,responsiveness ofthedesign, staffing, location, timely access, clear communication with providers and culturally competent providers toimprovebehavioral health functioning outcomesand significantly improve satisfaction.This projectbuilds on theexpertiseand resourcesof BTCS related servicesfor the patients with SMI. Patients utilizing Expanded Access will alsohave accesstocrisis intervention and respiteif neededas well as housing andemploymentsupports.

Challenges:

The primarychallenges for thisproject are toestablish a location that servesall persons in needof behavioral health servicesratherthan just those in thepriority population and for BTCS tobe acceptedinthat role by thecommunity and referringproviders.CurrentlyBTCS is known as the provider ofcarefor those with SMI diagnosesand wehavenot acceptedpatients with other diagnoses. Asa result, manypeoplein needroutinelyaccessotherproviders as a first option whenseekingbehavioral health assessmentand treatment.Wecan besuccessful witha comprehensiverangeof servicesfor youth and adults with abehavioral health teamthatis accessible,responsive and integratedintothecommunity.

5‐YearExpectedOutcome for ProviderandPatients:

BTCS expectstoseea greaternumber of people servedin Williamson County and surrounding rural counties with a broader range of diagnoses and conditions.Weexpecttoseea growing levelof satisfaction relatedto accessing carequickly, improvedcommunication with clinicians, information provided to patients ontreatmentand self‐help resources,increasedculturalcompetencyand perceived improvementin functioning.The expectedoutcomesarearesult of and relatedtoproject goals statedabove,including theability toservean additional 1,000persons moreperyear.

StartingPoint/Baseline:

Currentlynoclinic existsin easternWilliamson County and servicesarenot provided outside theDSHS guidelinesfor priority population atany BTCS location.Therefore,thebaseline for thenumber of patients atthat location and thenumber of patients not in thepriority population is 0in DY2.FromDecember2011throughAugust2012,weservedapproximately 175personsfromeasternWilliamson County attheBTCS location in Round Rock.All of those servedhad diagnoseswithin thepriority population guidelinesand all otherswereprecluded fromserviceand referredelsewhere.

Rationale:

CommunityNeedAddressed:

  • CommunityNeedArea:CN.2‐ Limitedaccesstoprimarycare
  • SpecificCommunity Need:

oCN.2.1‐ Limitedaccesstobehavioral health servicestorural,poor and under &un‐uninsuredpopulations(meds,casemanagement,counseling, diagnoses)in Williamson County.

oCN.2.13– Limited accesstoadult behavioralhealth servicesin Williamson County.

Aprojecttoexpand thecapacitytoprovide behavioral healthservicestoadults withSMIand children/youth with SED in thisrural underservedareaas wellas toindividualswithdiagnoses outside thepriority population of DSHS is vital toimproved behavioral health outcomesin Williamson County.Afull servicebehavioralhealth clinic integratedintothisrural community will provide a wide rangeof careand serveas a hub for communityinvolvement undertakenby an accessible and responsiveteamof professionals.The teamwill provide physician and physician extenderdiagnosis, assessmentand treatment,medicationservices,brief,solution focused counseling services,outpatient substance abuse servicesand community education and provider consultation.

Asstatedabove,BTCS doesnot currentlyprovide behavioralhealth caretoall persons, only to those in thepriority population.Wealsodo notprovide substance abuse treatmentas partof thebehavioral health servicearray.Both servicesareidentifiedneeds inthisarea.One critical disparity identifiedfor RHP8is scarcityof behavioral health servicesthroughouttheregion,especially inrural areas.Asstatedin theRHPPlanning Protocol document, Texasranks50th in percapita funding for statementalhealth authority(DSHS)servicesandsupports for people with serious and persistent mental illness and substance use disorders.Medically indigent individualswhoarenot eligible for Medicaid havenoguaranteeof accesstoneededservices and mayfaceextendedwaiting periods.Additionally, Texasrankshighest among statesin the number of uninsuredindividualspercapita.One in four Texans lackhealthinsurance.People with behavioral health disordersaredisproportionately affected.Positivehealthcareoutcomes arecontingent on theability of thepatient toobtain both routine examinations and healthcare servicesas soon aspossibleaftera specific needfor carehas beenidentified.However,many residents areunable toaccesseitherroutine servicesorneededcarein a timelymanner because theylacktransportation, arein poverty,lackinsurance coverageorbecausetheyare unable toschedule an appointment due toworkscheduling conflicts.

BTCS assessedthepatient data in its Anasazi EHR and foundthat 175people accessedservices by travelingtotheBTCS clinic in Round Rock.This is farlowerthan prevalencestatistics indicate individualsin theareahavea needfor services.Community leadersin Taylor identified thisas a needand assistedBTCS toapply for a granttoplanand initiatesucha clinic.Thisclinic increasescapacityand accesstothesespecialty services.Weexpecttodecreasethenumber of cancellationsand no showsas comparedtoour currentoperations in otherclinics.In DY5,we expecttodemonstrateimprovedsatisfaction with accessas a result of thislocal, integrated service.With theassistance of PeerSupportSpecialists, weexpecttoimprovefunctional status by assisting individuals to usetransitional housing and employmentsupports which arecurrently only available in thelargerurban areasormetropolitanareaof Round Rockand Georgetown. CertifiedPeerSupportSpecialists will provide thetraining and supports in coordination with Qualified MentalHealthProfessionals.Weexpecttocreatean expanded model of carethat goesbeyond theDSHS priority population andmeetsthecomprehensiveneeds of individualsin their own communities.

CoreProjectComponents:

Although 1.12.2doesnothaverequired corecomponents listedwith it,it is in thesameProject Option as1.12.1and those required corecomponents wereusedas a guide for ourown components.Wehavereviewedthecomponents, modifiedthemand will address themas below:

a)Evaluateexisting locations of behavioral healthclinics and toidentifybarriersto access including, transportation, operatinghours,admission criteriaand acceptable payment.If anyof thesebarriersis asignificant issue in careaccess,developand implement improvements.Patientscurrentlyaccessing careattheRound Rockclinicin west Williamson County will beofferedtheopportunity touse theclinic in Taylor.Personsrequesting servicesfromBTCS but whoarenot in thepriority populationestablishedby DSHS willbeofferedservicesattheTaylor clinicregardlessof residencyorhome address.Operating hoursoutside theusual business hourswill be available through Expanded Access.

b)Reviewtheinterventionsimpact on access to behavioral healthservicesand identify “lessons learned,”opportunitiesto scale all orpartof theinterventionsto a broader patient population, and identifykeychallengesassociatedwith expansionof the interventions,includingspecial considerationsfor safety‐netpopulations.Wewill establish a Plan, Do, Study, Act(PDSA)cycleimprovementprocess through theQuality Managementdepartmentof BTCS tocollect and analyze data relatedtothese interventions. That data will includeECHOTMSatisfaction Surveyresults and Electronic Health Record(EHR) datarelatedtofunctioning scalesand frequencyin theuse of higher levelsof caresuchas EmergencyDepartments(EDs) and inpatient psychiatric care.We will assess theresults,makeimprovementsin theoperation of thisClinic, and develop plans toexpand servicesto“non‐prioritypopulation” patients.Wewillholdcommunity planning meetingswith providers,patient advocatesand community leadersin a number of communitiestoassess expansion opportunities.

Howtheprojectrepresentsanewinitiativeorsignificantlyenhancesanexistingdeliverysystemreforminitiative:

BTCS usesthementalhealth block grantfor routine mental health serviceson an outpatient basis.Wewill provide outpatient servicesin thisexpansion projectfor the Taylor, Texasclinicbut those servicesarenot for thesamepopulations.

RelatedCategory3Outcome Measure:

IT‐10.1.b.ii RAND Short Form 12 (SF-12v2) Health Survey

Rationale: Our goal is to improve the overall scores on the RAND Short Form 12 (SF-12v2) Health Survey and demonstrate a 5% improvement over baseline in DY4 and a 10% improvement over baseline in DY5. We selected this particular outcome because the SF-12 is an overall health survey and want to show improvement in overall health.

Baseline Information: The baselinerateestablished inDY3 was 33.12. Our baseline measurement period established in DY3 was 03/01/2014-08/31/2014.

RelationshiptoOtherProjects:

Thisenhancesadditional projects that BTCS is pursuing including:relatedtoCrisis Respite for Personsin BehavioralHealth Crisis (#126844305.1.2);and EmergencyServicesDiversion (#126844305.2.2);in that it providesaccesstocarefollowing those emergencyinterventions. Weexpecttheotherprojects will demonstrateimprovedoutcomesdue toavailability of outpatient and aftercareservicesin thecommunitiesin which people live.Italsosupports the Transitional Housing Guidedby PeerSupport(#126844305.2.1),by supporting peerspecialists in thisrural areaand thereforeoffering theoption ofhousing within thehome community.

RelationshiptoOtherPerforming Providers’ Projects andPlanfor LearningCollaborative:

BTCS will participatein all learning collaboratives organized orsponsored by TexasA&MHealth Science Centerthat arerelevanttoour projects.Webelieveit is important toimproveand adjust thecareprovided.Wewill alsoparticipate with othercommunity centersand behavioral health careproviders as wecontinue todothrough theTexasCouncil of Community Centers. Thisexchange of ideas is important and helps us adjust and refineour programsand approachestobehavioral health care.The Williamson County Mental HealthTask Forcewill be theprimaryconduit forour planning discussions.

ProjectValuation:

Weexpecttoserve1,500adults andyouth in DY4and 2,000patients in DY5and to doso in or closertotheir home communities. The valuation calculated for thisprojectusedcost‐utility analysiswhich measuresprogramcost in dollars and thehealth consequencesin utility‐weightedunits that wereapplied tothefactors existing in thisunderservedarea,including: limitedaccesstoprimarycareand tobehavioral health care,povertyand thelink between chronic health conditionsand chronic behavioralhealth conditions.Thevaluation study was preparedbyprofessors H.Shelton Brown,Ph.D.and A.Hasanat Alamgir,Ph.D. bothof theUT Houston Schoolof PublicHealth andThomasBohman, Ph.D. of theUTAustin Centerfor Social WorkResearchbased on a model that includedquality‐adjusted life‐years(QALYs) and an extensiveliteratureof similar interventions andcost savingsand health outcomesrelatedto those interventions. TheQALYindex incorporatescosts avertedwhenknown (e.g.,emergency room visitsthatareavoided).

Adescription of themethod used,titled ValuingTransformation Projects,has beenposted on theperforming provider websitewhich will belinkedto theMedicaid 1115Transformation Waivertab. A complete write‐upof theprojectwillbeavailableonline.