The Mental Health and Mental Retardation Authority of Harris County

Last month in this column, I focused on the efforts of the Community Coalition in Austin and the results of the Equity Task Force report reflecting that Texas ranks 43rd per capita in spending for mental health services and 41st per capital in spending for mental retardation services. Over the past weeks, I have had the opportunity to show and watch the video called “Texas Can Do Better” prepared by the Community Coalition, a group of organizations that have set aside their individual differences to create a united front in approaching the Texas Legislature to achieve the national per capita average in funding for Texas over the next three biennium sessions. As I have watched the video (and I encourage each reader to please see this video and the people who volunteered to tell their individual “stories”*), I was struck with how it captures the essence of what the public mental health and mental retardation system is all about. It’s about our consumers and their families – it is so about them.

As I watched, I began to ask myself – what if this coalition is successful? What if the consumers, families, advocates, concerned professionals, providers – really all concerned people – lock arms together and convince the Texas Legislature to do what is “right”? What if they actually get the Legislature to fund the services and supports of the public mental health and mental retardation at the national average? The thought – funding at the national average (just the average per capita of all states spending) would be truly awesome. Having been so poor, so limited in services for so long, I began to speculate – what would it be like?

As I began to speculate on such a system, it dawned on me that we could and should then be able to define a package of benefits that appropriately blends the services and supports for certified “safety net” consumers that are clinically justified (tied to the severity of his/her condition) over time. Over time – over his/her life. Not programs that people are plugged in – not silos of care. A true package of benefits that adjusts across the person’s lifetime – adjusts across the multiple transition periods in the person’s life.

Hold on now, you say, what is this? What transitions? Stop and think about it – we serve people who, by and large, have lifelong conditions. In truth, the public MHMR “safety net” should be focused on the most impaired with first priority to serve the uninsured who meet the criteria for being covered by this state-funded “insurance” package. These conditions are, generally speaking, based upon our current knowledge and technology, lifelong conditions – not acute episodes that are “cured” through our interventions. Persons with mental retardation don’t get “fixed” and become of average intelligence. These conditions may result from genetic anomalies, illness while in utero (prior to birth), trauma to the brain at an early age, and/or environmental factors while in utero or at an early age (i.e., significant exposure to lead-based paint) – they don’t go “away”! However, the impact may be substantially reduced such that the person more closely attains his/her potential.

To do so, to ensure that the investment of our ever-improving clinical interventions enable that person – each person – to maximize what he/she is capable in terms of independence, integration, and participation in community life – we must tie the resources to the person who qualifies across his/her lifetime. We must be attentive to and address those critical transition periods over that lifetime – whether the person has a diagnosis of mental retardation or mental illness.

Let me be clearer – starting with the earliest of our interventions, Early Childhood Intervention (ECI), services and training are available for children from birth through three years of age who have physical/medical indications of a potential, or a demonstrated developmental delay in their early milestone acquisitions, behaviors which evidence serious emotional disturbance. The importance and demonstrated impact of the ECI services is to reduce the extent of the developmental lag, attain closer to average age-appropriate functioning, and, often, prepare the child (and parents) for “handing off” to public education at age three. This, then, becomes the first of the transition periods. In the months leading up to the third birthday, staff should be working with the family and child to move into the new system and provider network under the auspices of the local independent school district. Is there sufficient “overlap” between and communication among the providers (the existing, ECI, and the new, ISD) to ensure a smooth transition and minimize the potential for “slippage” in the child’s progress, the home bound program, and reduce the likelihood of program modifications which may not be warranted or necessary but appear so due to inadequate communication between providers and family? Paper can only convey so much – verbal communication is generally more effective.

Transition is the movement from one state of development – treatment – services – to another, the transfer from one provider/organization to another. The “pieces” we have today are so woefully under-resourced that we often do not have the time, energy, or people to undertake the very activities that ensure a successful “handing off” or continuance of care (continuity of care is, truly, more than a paper, contract requirements – it is the glue to maintain the clinical progress to date and more likely ensure successful integration at the next stage of care). Case in point: we now do a tremendous amount of work on the Children’s Mental Health side of the house in a “best practice” called Early Intervention. Working with three through six year olds in day care facilities who are at risk or have been “expelled” from their day care due to their “emotional problems” and the behaviors they manifest. This valuable program works with some of the most “at risk” children at a very early age. Relatively new in its implementation, these children may be some of the most at risk for school behavioral and academic problems and, not too far down the road, juvenile justice involvement – let alone more deeply penetrating into the intensive emergency and inpatient MHMR services. And, if the families become exhausted, is not Children’s Protective Services a possible next step? Do we now invest and will the “new and enriched” system adequately address the transition period for these children and families from day care to public education?

Speaking about public education – covering the “services” until the child’s 18th birthday (or 21st if in special education), what is truly the role of and coverage provided by and through the public education system vs. that of the MHMR system? Essential clarification and definition is needed. Many of these children will need and clinically justify continued clinical services and/or supports through the public MHMR system (i.e., children qualifying for HCS wraparound services remaining in the familial home environmental and local school) while enrolled in public education. And, certainly, many of these children will need (both children with mental retardation and/or serious emotional disturbance) to be handed off (maybe handed back) to the public MHMR provider network as they age out of public education. This, then, the next major transition due to the age and complexity of their clinical, personal, social, and familial issues needs to be adequate in time and staff resources to (here it comes again) ensure a successful transfer with – to the degree possible – minimal disruption and loss in progress of the child and his/her family. The “systems” must communicate, share resources, and move the individual through “graduated” steps that are tailored to his/her condition. Lack of information for planning/capacity purposes, lack of available resources to “pick up” the child before graduation is so counterproductive and traumatic. What sense does it make (programmatic, humanistic, or business) to spend years of effort and countless thousand of dollars on special public education services to assist the person toward more fully reaching his/her potential to, upon “graduation,” be placed on a waiting list for MHMR services and sit in front of a television set all day – virtually deteriorating and losing ground?

Transitions come in all shapes and sizes throughout a lifetime: leaving the familial home to a supported living environment or place of ones own; moving from sheltered vocational to supported employment to integrated job placement; moving from intensive clinical services to graduated, stepped down care – each a transition – each an opportunity to maintain or lose the progress accomplished. And, most recently, we have become increasingly aware of the transition needs of our priority consumers as they move into seniorhood – they reach the age of “retirement.” Having the appropriate, age-adjusted services and supports needed to address the aging of our population and the changes in their neurochemical and physical status that will inevitably occur – needs to be included in the new benefit package and design.

Much work is ahead of us to attain the confidence of the Texas Legislature that the additional funding to reach the national per capita average will be utilized in a responsible and accountable fashion on behalf of the state’s priority population consumers and their families. The new benefit package and delivery system – when funded adequately, must reduce, if not eliminate, the program "silos" and be responsive to the person across time. Again, these are not conditions that "go away". They may become minimal in their impact and the person reach a level of integration and participation that requires much more limited interventions – but the condition is there and the "safety net" must be responsive if there is a "worsening" of the condition. What sense does it make to "disengage" and wait until the person "crashes", then requiring some of the most expensive and intensive interventions? Too often today we are like fire fighters with too few personnel and equipment for the number of fires – so we jump from one to the other without fully extinguishing the blaze and removing the cause of the fire. When it flares back up, we act surprised – and it often takes out several of the "houses" around it before we can get back to it again. Let’s do this "right" – let’s really make the new system – people first.