The Mental Health and Mental Retardation Authority of Harris County

We in the United States are used to standing in line. We wait our turn at the bank drive-in window, at the grocery store checkout stand, at the theatre ticket window, or at the restaurant for our food order. We are even used to sitting in the "waiting room" for our professional appointment. We understand about waiting our turn to get access to something and are usually pleased when we can just step up and go right in, or acquire what we seek, right at the point of wanting or needing it. Sometimes, we find ourselves frustrated when the organization or provider is perceived as being too slow and non-responsive to our needs or time pressures. We in the U.S. have come to "now" - in this hurry up world, we have come to expect rapid, if not immediate attention. And, if we don't get it, we often look around for an alternative to obtain what we want or what we need.

But, what if you are a consumer or need to be a consumer of public mental health or mental retardation services? What if you are placed in line for services or supports and really can't wait - or shouldn't wait due to the nature of your condition? What if the line has no end in sight, the movement is imperceptibly slow? What then?

This is very real today. A significant number of people classified as meeting or appearing to meet the priority population criteria of the Texas Department of Mental Health and Mental Retardation (TDMHMR) are being, or will shortly be, placed onto a waiting list for services with no apparent end in sight. Case in point, in Harris County today, the waiting list for unduplicated persons with mental retardation seeking access to Home and Community-Based Services (HCS) is standing at over 2,600 people, adding approximately 50 people to the list each month. That's correct - 50 families each month reach the painstaking, often gut-wrenching decision that they need help to care for their loved one with mental retardation. Why? How is that decision reached? Well, for some, they have no choice. They are getting older, more feeble, perhaps one parent has passed away, or, one or both are becoming ill, potentially physically incapacitated. For others, the behavioral and/or medical issues along with the level of retardation may reach a level of intensity, which overwhelms the family's ability to care for their loved one. While others, by planning ahead, can see the day when their person with mental retardation will want and need to be as independent as possible, living as much on their own and participating in community life as their condition will permit.

The stories are in truth unique, each one different, but each one just as meaningful to that family. What they each come to realize, at whatever point it is reached, or, perhaps, even forced on them by life's circumstances, is they need help. And, most importantly, our federal government has made a commitment to assist with these extraordinary conditions and the expenses associated with them. HCS is a Federal Title XIX Program, available to all who qualify for the number of "slots" established by the state legislature, which must put up the state match to the federal funds. And, there's the rub. The last session, state match was provided for approximately 300-320 HCS slots -state wide. There are over 10,000 people on the HCS waiting list state wide - over 2,600 in Harris County alone. When that family, for whatever their personal reason or crisis, reaches out and places their loved one on the HCS waiting list, what do we say when they are slot number 10,101 and there are maybe 320 people who will get access to HCS slots in this biennium, fiscal years 2000 and 2001? When, really, do they have hope of meaningful assistance? And, more ominously, what are the consequences of waiting, particularly if the family is already in crisis?

Oh, you say, this is isolated to HCS. Really? Let's stop for a minute and look at the funded capacity for Adult Mental Health outpatient services. MHMRA must, by contract with TDMHMR, serve 8,830 unduplicated consumers each month of the fiscal year. However, the actual State General Revenue (SGR) provided under the contract will permit MHMRA to serve, albeit in a limited fashion, approximately 4,794 consumers each month who are uninsured - truly indigent. The balance of the contract number, approximately 4,039, must have third party coverage (primarily Medicaid). If we do not meet our total target served each month (at least 95%), we will have to give general revenue funds back to TDMHMR. Yet, the funds provided are not sufficient for us to serve the total number required, if they are uninsured, at even a reasonable level of quality and scope of service to assist these individuals with severe and persistent mental illnesses to assume greater independence, self sufficiency, and community integration.

Even worse, under the terms of the Contract with TDMHMR, we must, provide aftercare (outpatient) services to each person being discharged from the state funded public hospitals for the mentally ill, within 7 working days, with no additional revenues above allocation for the fiscal year. Aftercare services for this "at risk" population is both clinically necessary as well as fiscally prudent. MHMRA receives, on the average 245 per month, each month, discharged from these state-funded hospitals. Approximately 50+% of those transfers each month are new consumers to the public system. On top of this, the long awaited NeuroPsychiatric Center (NPC) was opened in October and is beginning to serve many more adults with adult psychiatric illnesses. Many, if not most, will need continuing outpatient/aftercare services, whether they have been admitted to an inpatient unit, or not. In addition, each month we receive transfers into the AMH outpatient system from the state prison and county jail systems - people with severe mental illnesses who need continuing mental health services to maintain their stability and reduce the risk to society of a reoccurrence of their antisocial behavior, whatever their individual offense.

So - and you can see this coming - in short order, MHMRA will be creating waiting lists for uninsured adults in the community who call into our ACCESS Center for outpatient mental health services, appear to meet the criteria for service eligibility (priority population), but aren't in crisis yet. In essence, the lack of responsiveness due to severe resource limitations says to these people with neurochemical disorders of the brain - you are not sick enough yet. If, and when your condition deteriorates such that you will justify the more extensive and expensive services in our armamentarium – then you can get in the door. Is this good policy? Is this clinically or morally appropriate? Is this fiscally sound? A resounding and unequivocal "NO!" on all accounts. But, it is our reality today. More importantly, it is the reality they face along with their families.

There is no quick fix, no easy way out of this box. It falls to us to carefully and thoroughly scrutinize every aspect of our system, ensuring to the degree possible and appropriate that we can deliver efficient and effective services within the limits of the resources provided. We must clearly articulate the funded capacity and its limitations for the uninsured of Texas with significant mental disabilities. We must be clear - what is the "safety net" of Texas (of Harris County) for the mentally disabled who are uninsured? We must deliver those services and supports funded under the benefits package to those eligible consumers who do get access into the system in as consumer friendly and satisfying a way as possible. We must not yield to the pressures of what, at times, may appear to be insurmountable barriers to meeting the justifiable needs of our consumers or people seeking access to the public system, but unable to get in the door.

We must - simply must ensure that our performance data and clinical documentation is truly adequate to reflect both the value of the public system in improving the lives of Texans with mental disabilities and the cost benefit of such services and supports. And, we must maintain clean, well defined waiting lists, even when such waiting lists run contrary to everything we believe in.

If we stay focused and committed even during these most challenging of times, I am confident that the myriad of concerned voices will rise up and join together to impress the Texas Legislature with the extent of need - to overcome true and unequivocal resource deficiencies - that substantial financial attention will be brought to bear to "right" the system. It will occur because these voices in unison will convince the Legislature that it is both the "right thing to do" and economically sound as an investment for Texas.