What's Inside

Section D. Organizational Profile
I. Introduction

This section sets out the institutional context and reality of publicly funded mental health services in Texas. Factors relative to the regulation of the public mental health system, and especially the role of the Texas Department of Mental Health and Mental Retardation (TDMHMR) will be discussed.

In addition, the history and current organization of the Mental Health and Mental Retardation Authority (MHMRA) of Harris County will be described. This section will conclude with a brief assessment of the current institutional health of the MHMRA organization.

Texas has long been one of the fastest growing states in the nation. Between 1960 and 2000, for example, Texas enjoyed the fifth greatest rate of population increase in the country. Between the 1990 and 2000 U.S. Census, the Texas population grew 22.8 percent, to 20,851,820.

Over the next five years, the state’s population is expected to increase by 1.7 million, an increase of approximately eight percent. As the population grows, it can be expected that demands for services will also increase. By FY 2007, the state’s priority populations (a term defined below) eligible for mental retardation services and mental health services are each expected to increase by six percent.

Texas Department of Mental Health and Mental Retardation Strategic Plan for Fiscal Years 2003-2007; Appendix E: Workforce Plan.

A. Mental Health Facts

Mental illness, as the term indicates, is a medical condition. In 2000, there were nearly three million Texans—around one in seven—living with some form of mental illness. Consider the following facts:

• More than 666,000 Texas children, from birth through age seventeen years old, can be identified as either having or being at risk of developing an emotional disturbance.
• Over 200,000 children ages six to eighteen have serious emotional disturbance, and more than half of these are estimated to need MHMR services.
• Some 670,000 Texans—one in 30—experience depression, manic-depressive disorders, or other depressive disorders.
• Nearly 200,000 Texans—one in one hundred—experience schizophrenia disorders
• Approximately 30,000 new cases of schizophrenia disorder occur each year.
• As many as two out of ten Texans will have at least one episode of major depression during their lifetimes.

The annual direct costs of mental illness to both the private and public sectors in Texas are estimated to be nearly $4.8 billion. The indirect costs of mental illness, such as reduced productivity or even lost employment, criminal activity, and reliance on social programs, are estimated to increase the annual cost of mental disorders to more than $11 billion.

TDMHMR Office of Program Statistics and Planning, January 2001. “Synthetic Estimate of Need for Mental Health Services,” Holzer, et al. This estimate was first made in 1986.
“U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of

B. Mental Retardation Facts

Mental retardation typically is a lifelong condition that can be found in men and women of all ages, cultures, and economic conditions. Mental retardation is a condition that can begin at birth or emerge during early childhood. Thus, although they can occur in the same person, mental retardation and mental illness are not the same conditions. Unlike mental illness, for example, mental retardation is associated with limitations on intellectual and functional skills that are manifest prior to age eighteen.

It has been estimated that approximately three percent of the population has mental retardation. In 2001, some 565,000 Texans had some form of mental retardation. More than 22,000 had severe or profound retardation.

The same year, nearly 33,000 students enrolled in the school system had mental retardation. More than 11,000 of these students had multiple disabilities.

Mental Health, 1999. Updated by TDMHMR Office of Program Statistics and Planning, 2-28-97. “The Economic Burden of Mental Illness,” Rice, Kelman and Miller, Hospital and Community Psychiatry, December 1993, Vol. 43, No. 12. Updated by the Source: Office of Program Statistics and Planning, 2-28-97.
Mental retardation (MR) is defined as “significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and originating during the developmental period.” See 25 Texas Admin. Code § 406.202.
Among the several possible measures of MR is categorization according to the measure of an intellectual quotient (IQ): Mild retardation (IQ 55 to 70); Moderate (IQ 40 to 54); Severe (IQ 25 to 39); and Profound (IQ below 25). Another classification scheme, used in Texas in most Medicaid-funded programs, is based on the intensity of supports needed by the individual.
TDMHMR Office of Program Statistics & Planning, December 2000.

II. The Mental Health and Mental Retardation System

A. The Texas Department of Mental Health and Mental Retardation (TDMHMR)

The Texas legislature created the TDMHMR in 1965, with the passage of the Texas Mental Health and Mental Retardation Act. It is now one of thirteen agencies under the oversight of the state Health and Human Services (HHS) Commission.

The policy making body of TDMHMR is the nine-member board appointed by the governor (with the advice and consent of the state Senate) for overlapping six-year terms. The head of TDMHMR is the commissioner, who is appointed by the HHS commissioner with the concurrence of the board and the approval of the governor. At least one member of the board must be a consumer of mental health and mental retardation services, or a family member of a consumer.

Many organizations offer services to persons with mental illness and mental retardation. They may employ doctors, psychologists, social workers, case managers, and therapists. Those organizations are providers. Other organizations may develop policy, monitor quality, and fund the purchase of services. Such an institution is an authority. TDMHMR functions as both an authority and as a provider.

TDMHMR Strategic Plan for Fiscal Years 2003-2007; App. E: Workforce Plan.

FIGURE 1: Texas MHMR System Current Organization
Figure 1 is available only as an Adobe PDF Click here to view image.

As the state authority charged with oversight of local authorities across the state (described below), TDMHMR is responsible for overall planning, policy development, and resource allocation for the delivery of required services. As a provider, TDMHMR serves consumers through various state mental health facilities, state mental retardation facilities, community centers, and the TDMHMR headquarters.

The TDMHMR system includes thirteen mental retardation components for individuals with mental retardation in the priority population. Eleven state schools provide campus-based mental retardation services (State Schools are located in Abilene, Austin, Brenham, Corpus Christi, Denton, Lubbock, Lufkin, Mexia, Richmond, San Angelo (Carlsbad) and San Antonio). The El Paso and Rio Grande (Harlingen) State Centers also provide residential services to individuals with mental retardation.

State hospitals are located in Austin, Big Spring, Kerrville, Rusk, San Antonio, Terrell, Vernon (North Texas State Hospital-Vernon Campus), Waco (Waco Center for Youth) and Wichita Falls (North Texas State Hospital-Wichita Falls Campus). Administrative operations of the two hospitals in Vernon and Wichita Falls have been combined.

TDMHMR Strategic Plan for Fiscal Years 2003-2007; App. E: Workforce Plan.
TDMHMR Strategic Plan for Fiscal Years 2003-2007 (May 2002).

B. TDMHMR Oversight of Local Authorities

The Texas MHMR Act of 1965 authorized local agencies to assume responsibility for local administration of MHMR services, albeit with TDMHMR help and oversight. The Act established a working partnership among local authorities, the state (represented by the TDMHMR), and the federal government, which provided more than fifty percent of the funds being spent at the time to establish mental health service centers. During the 1970s, however, federal funding became scarce. In 1975, Texas legislators responded to the growing financial and administrative difficulties at state centers by creating a special Management Audit Section (MAS) within TDMHMR.

TDMHMR has contracted with more than forty local authorities to ensure that required services will be provided to members of the priority population. TDMHMR retains oversight of programs and services delivered through these state contracts with local authorities. This oversight function also includes ensuring local authority compliance with state and federal law. TDMHMR fulfills its oversight responsibility through the following methods:

• monitoring data related to service delivery
• promulgating rules for compliance and fiscal functioning
• interviewing individuals and families receiving services
• interviewing providers and administrators of services
• reviewing records and administrative documentation

“The Texas Council of Community MHMR Centers, Inc., A Retrospective: 1976-2001”, The Curriculor, Volume 25, Number 3 (Summer 2001).

C. Functions and Responsibilities of a Local Authority

Each county in Texas has a designated local authority that either provides services directly or facilitates service delivery through a network of local providers. Community centers are political subdivisions of the state, which are locally governed components of the MHMR system. Each community mental health and mental retardation center is required to obtain funds through local resources to match a portion of the General Revenue funds appropriated by the legislature.

Local authorities have primary responsibility for providing mental health and mental retardation services to members of the priority population (defined below) who reside in their county or counties. Services provided range from round-the-clock crisis care to ongoing assistance, such as facilitating consumer employment, housing, or in-home support.

Under state law and TDMHMR regulations, local authorities are expected to execute the following basic responsibilities and functions:

• Planning: Planning identifies needs and budget priorities, defines performance targets, and monitors whether targets are being met.
• Policy Development: Policy includes rules and regulations, standards, performance expectations, best practices and practice guidelines.
• Resource Development: Resources can be obtained from sources other than the state.
• Resource Allocation: Allocation describes how dollars are to be spent.
• Oversight: Oversight ensures that implemented policies, standards, and programs are appropriate for stated goals.
• Network Development: Network here refers to the system of providers that is formed by a local authority so consumers have meaningful choices.
• Consumer Empowerment: Empowerment is ensuring that consumers gain a sense of authority and personal control.

A local authority’s board of trustees—composed of business, professional, and community leaders appointed by local government authorities—volunteer their time to oversee the local center. A board must establish policies and procedures that will enable their organizations to successfully pursue these responsibilities and functions.

D. Potential Changes to State Mental Health System.

Some of this information may be rendered obsolete in the future, because public institutions in Texas are in flux. State support and regulation of the mental health system may change significantly as the Texas legislature considers not only budget cuts, but a major reorganization of the health and human services divisions. One possible outcome of the state government reorganization is presented below.

TDMHMR Strategic Plan for Fiscal Years 2003-2007 (May 2002).
Karen F. Hale to Sandy Skelton, “FY 03 Immediate Spending Reductions.” Memo (24 January 2003). Carole Keeton Strayhorn, “Limited Government, Unlimited Opportunity.” Window on State Government Memo (January 2003).

FIGURE 2: Texas MHMR System Proposed Reorganization
Figure 2 is available only as an Adobe PDF Click here to view image.


III. The MHMRA of Harris County

In November 1965, the Harris County Commissioners’ Court responded to the passage of the Texas MHMR Act by creating the Harris County Mental Health and Mental Retardation Center (MHMRC). The staff grew to number more than 150 by the early 1970s. The Commissioners’ Court changed the agency’s name to MHMRA of Harris County in February 1973. That same year, mental retardation services were organized into a separate department.

The original mission of the MHMRC was to provide mental health services to adults. Also in 1973, however, the MHMRA obtained a grant to create the Early Childhood Intervention (ECI) Program, the first program of its kind in Texas. ECI was created to assist children who exhibited an atypical delay in development, or who had a medical condition that had the potential to lead to a developmental problem. ECI grew to include a variety of special services, such as speech, physical, or other therapy, in-home education, or rehabilitation.

The ECI program was the first of several children’s services MHMRA established during the 1970s. The Children’s Mental Health Services group was expanded in 1978, for example, to provide expert advice to the juvenile courts. Starting in 1981, MHMRA collaborated with Harris County’s Juvenile Probation Department to perform psychiatric evaluations of more than 600 juveniles charged with criminal offenses. Despite budget cuts during the 1980s, MHMRA was able to expand several of its key programs, including children’s and crisis services. The 1990s saw the introduction of medical, counseling, and training programs for the homeless.

MHMRA of Harris County, Local Plan for FY 2002-2003 (August 2001).

A. MHMRA of Harris County’s Priority Population

MHMRA of Harris County is charged to provide or facilitate the provision of services to persons with mental disabilities, regardless of their ability to pay. Even so, the Texas MHMR Act and follow-on legislation established specific criteria to define the “priority population” for which state mental health-mental retardation dollars may be used.

The priority population as defined by state regulations includes adults diagnosed with severe and persistent mental illness, children with serious emotional disturbances, and persons of all ages diagnosed with moderate to severe mental retardation. Nearly 560,000 Texans meet one or more of these descriptions.

The priority population for Harris County encompasses the following:

• 55,000 adults with mental illness.
• 6,500 individuals with mental retardation.
• 54,000 children with serious emotional disturbance.

However, the disturbing truth is that in Harris County thousands of individuals with mental illness or mental retardation are either un-served or under-served.

For example, in FY 2002, due to resource limitations, MHMRA was able to serve only 16,315 adults with outpatient services. This means that approximately 40,000 adults in the priority population need services but are not receiving them.

Also, the total number of consumers who received MR services was less than half of the estimated 15,800 in Harris County who could be classified as mentally retarded (i.e., with IQ scores of 70 or below with adaptive behavior delays).

Finally, only about one in seven of the 54,000 eligible emotionally disturbed children are served by MHMRA. Some of these children, however, may be able to access services through other health and human service organizations.

B. Basic MHMR Services to the Priority Population

The authority’s divisions—including Adult Mental Health, Child and Adolescent Services, Mental Retardation, and the NeuroPsychiatric Center (NPC), which are each described below—provide services and supports to residents of Harris County, regardless of race, ethnicity, or citizenship status, in several MHMRA clinics throughout the Greater Houston area.

Consumers can obtain medication at the clinics, as well as receive limited housing support and rehabilitation programs. Emergency psychiatric services are available at the NPC. With the introduction of medical services and counseling in the jails and schools, training programs for the homeless, as well as other support for the emerging indigent population, the authority provides or supports some services in over fifty sites across Harris County.

Leslie Gerber, Beyond Crisis: Adult Mental Health Service Needs in Harris County, A Report of the Mental Health Association of Greater Houston (October 2002).
MHMRA of Harris County, Local Plan for FY 2002-2003 (August 2001).

1. Adult Mental Health Division (AMH)

The AMH Division provides comprehensive services to adults with a diagnosis of severe and persistent mental illness. The division also provides support to family members. Adults suffering from bipolar disorder, schizophrenia, major depression or schizo-affective disorder are eligible for services. Any person experiencing a psychiatric crisis and requiring immediate attention may access the crisis stabilization services at the NeuroPsychiatric Center (NPC, described below).

a. Required versus Optional Services

1. Required Programs or Services. The following activities are either required specifically by the performance contract with TDMHMR or are otherwise indicated as best practices by the professional community.

• Outpatient services through clinics.
• Intake assessment.
• Treatment planning.
• Medication administration.
• Medication monitoring.
• Medication training.
• Pharmacological management.
• Cases coordination.
• Service coordination.
• Forensic/Inpatient services at Harris County Jail.
• Forensic New Start (for former inmates).
• Mental Health services for homeless.
• Treatment training.
• Rehabilitation services.
• Respite services.
• Skills training.
• Supported employment.
• Supported housing.
• Assertive Community Treatment (ACT).

2. Optional Programs or Services. The following activities are not required by the TDMHMR performance contract but have been made available because the authority has decided that they contribute value to the priority community.

• Outreach.
• Consumer peer support.
• Counseling and psychotherapy.
• Supported employment (with maintenance).

3. Potential Programs or Services. The following services are not currently delivered by the authority but may contribute value to the priority community.

• Family training.
• Skills maintenance.
• Acute day treatment.
• In-home crisis intervention.
• Treatment training (residences).
• Adult foster care.
• Personal care (homes or assisted living).

b. Examples of Basic Services for AMH consumers

MHMRA offers adult consumers psychiatric services such as evaluation, diagnosis, medication administration and monitoring, laboratory and pharmacy services, and physician certification to receive rehabilitative services. Examples of these services are:

• Group and individual counseling provided by licensed professional staff. Such treatment is time limited, however, focused on specific problem resolution for a maximum of 12 weeks.
• Skills training to support an individual’s independent living and community integration. Such training includes work-related, educational, socialization, and symptom management.
• Supported employment and education. This program assists and supports the adult consumer to prepare them for entry into college classes and/or vocational training opportunities.
• Substance abuse treatment. Up to 8 hours of programming per week designed to educate, support, and monitor consumers as they work through the steps of sobriety. Drug screens are required.
• Housing supports for adult consumers who qualify for federally supported housing subsidies.
• Transitional residential services. These programs provide 24-hour specialized living environments in which treatment and training are offered. Short-term treatment focuses on developing the skills and resources necessary to live in the integrated community setting.

c. Examples of Special Services for AMH consumers

The AMH Division operates specially funded programs designed to meet the needs of homeless adults who experience mental illness as well as adult offenders who are in the criminal justice system. Among these special programs and services are the following:

• “New Start” is an intensive case management and rehabilitative program that provides 24-hour, seven day per week accessibility to services. Care of the client is managed through a collaborative effort with the courts, probation/parole officers and the jails.
• Homeless programs provide clinic-based assessments and services to aid integration into the community. Medication management, skills training, counseling services, symptom management, supported housing and supported employment are offered.
• Jail-based treatment to individuals with a diagnosis of mental illness. After screening and evaluation, services provided for inmates within the Harris County jail system include medication management and crisis intervention.

d. Summary

The AMH division directs treatment toward stabilization in the home, the workplace, and the community. The division is assigned a service target through its Performance Contract with TDMHMR, which calls for 8,830 unduplicated adult consumers who meet the priority population criteria to be served each month. In fact, despite the ongoing budget and other resource limitations, the AMH division serves many more than this number each month.

2. Child and Adolescent Division (CAS)

To be eligible for CAS services, a person must be a Harris County resident between birth and eighteen years of age. In addition, the child or adolescent must:

• Have a formal mental health diagnosis, or be enrolled in an early childhood intervention program.
• Be classified as seriously emotionally disturbed, or be at risk for out-of-home placement, or be at risk for removal from a preferred day care setting.

a. Required versus Optional Services

1. Required Programs or Services. The following activities are either required specifically by the performance contract with TDMHMR or are otherwise indicated as best practices by the professional community.

• Outpatient services through clinics.
• Intake assessment.
• Case coordination.
• Service coordination.
• Treatment planning.
• Skills training.
• Medication administration.
• Medication monitoring.
• Medication training.
• Pharmacological management.
• Provision of medication.
• Intensive crisis (residential).
• Inpatient services.
• Juvenile Justice system supports.

2. Optional Programs or Services. The following activities are not required by the TDMHMR performance contract but have been made available because the authority has decided that they contribute value to the priority community.

• Counseling and Psychotherapy.
• School-based services.

3. Potential Programs or Services. The following services are not currently delivered by the authority but may contribute value to the priority community.

• Outreach.
• Wraparound planning.
• Family training.
• Day treatment.
• Flexible community supports.
• In-home crisis intervention.
• Acute day treatment.
• 24-hour residential treatment.
• Other residential.

b. Basic Services for CAS consumers

MHMRA services to CAS consumers can include screening and assessment, substance abuse counseling, psychiatric services, skills training groups, service coordination, family preservation, and linkage to community resources.

Examples of CAS services are:

• Children and adolescents (aged 3 to 17 years, 9 months) who are suspected of having mental retardation, autism, or pervasive developmental disorders are evaluated by the Children’s Determination of Mental Retardation Unit.
• Family resource centers provide clinic and community-based mental health services to children and families. Services include assessment, medication, service coordination, and counseling.
• School-based programs offer therapeutic services in an educational setting. Services are provided through the Houston, Aldine, Alief, Cypress-Fairbanks, Deer Park, Galena Park, Klein, Spring Branch, and Humble school districts, and Juvenile Justice Alternative Education.
• Child and Adolescent Psychiatric Emergency Services (CAPES) provides intervention for children and adolescents through a mobile crisis unit. Services include assessment, intensive crisis resolution, and community linkage for continuing care.

c. Special Services for CAS consumers’ families

MHMRA offers CAS families a variety of services and support. Services can include screening and assessment, substance abuse counseling, psychiatric services, skills training groups, service coordination, family preservation, and linkage to external community resources.

Examples of CAS family services are:

• Various programs provide respite and flexible funding to assist families to overcome barriers to mental health treatment and to be able to access appropriate therapeutic services for their children.
• Family preservation service referrals by juvenile probation agencies, Children’s Protective Services, or MHMRA.
• Early intervention programs give comprehensive family services for children aged up to six years. Services include family intervention, home visitation, teacher consultation, service coordination, and linkage to community resources.

d. CAS consumers in the criminal justice system

The CAS Division operates a number of programs within juvenile justice facilities, in cooperation with the Harris County Juvenile Probation Department. Services can include assessment, substance abuse counseling, psychiatric services, skills training groups, service coordination, family preservation, and linkage to community resources. Examples of CAS juvenile justice programs are:

• First Time Offender (FTO) services help children and adolescents aged seven to seventeen who have serious emotional or behavioral problems and have committed a misdemeanor or delinquent act for the first time. Such services can improve behavior, increase family stability, and help reduce the possibility of future criminal activity.
• The Juvenile Forensic Unit is located at the Harris County Juvenile Probation Department (HCJPD). The unit provides psychological, psychiatric, and family assessments to children between the ages of ten and seventeen years old who are referred by the Harris County juvenile court system. The evaluations address treatment and placement needs as well as issues of competency.
• The Burnett-Bayland Reception Center (BBRC) is a 144-bed secure assessment and treatment facility. It is operated by the Harris County Juvenile Probation Department, but combines the services of various agencies serving the needs of juveniles.
• The Psychiatric Stabilization Unit of MHMRA and the Specialized General Program Units at BBRC provide clinical oversight, psychiatric evaluation, case consultation, medication, and individual and group therapy to young persons experiencing psychiatric distress.
• The Harris County Juvenile Probation Department’s Delta 3 Boot Camp, Youth Village, and Juvenile Detention Center provide residents assessments, psychiatric evaluations, medication services, group skills training, and therapy.

e. Summary

The MHMRA CAS Division provides services to young people and their families. Children and adolescents with serious emotional disturbances or behavioral problems, as well as those with dual diagnoses of emotional disturbance and mental retardation, may qualify. The staff provides services in MHMRA clinics as well as in homes, schools, and other community locations, including facilities within the Harris County juvenile justice system.

3. The NeuroPsychiatric Center (NPC)

The NPC is a MHMRA-owned, 24 hour per day psychiatric emergency clinic staffed with staff psychiatrists, registered psychiatric nurses, and other mental health professionals. This unique facility opened in October 1999 in a refurbished section of Ben Taub Hospital. Originally designed to accommodate 600 patient visits per month, the NPC currently averages approximately 1,100 monthly visits.

a. Required versus Optional Services

1. Required Programs or Services. The following activities are either required specifically by the performance contract with TDMHMR or are otherwise indicated as best practices by the professional community.

• Psychiatric Emergency Services (PES).
• Crisis Stabilization Unit (CSU, residential within NPC).
• Crisis hotline.
• Inpatient Harris County Psychiatric Center (HCPC).
• Psychiatric Crisis and Emergency Administration.

2. Optional Programs or Services. The following activities are not required by the TDMHMR performance contract but have been made available because the authority has decided that they contribute value to the priority community.

• Outreach/mobile crisis.

Leslie Gerber, Beyond Crisis: Adult Mental Health Service Needs in Harris County, A Report of the Mental Health Association of Greater Houston (October 2002).

b. Examples of NPC crisis stabilization services

People suffering from a mental health crisis may arrive at the NPC voluntarily, perhaps accompanied by friends or family, or may arrive involuntarily in the custody of law enforcement personnel. In either case, patients can be extremely agitated and dangerous to themselves or others. Therefore, for safety reasons, some are treated immediately with medication. After evaluation, those in true crisis receive services at the NPC. Others are given referrals to community organizations or outpatient clinic appointments.

The Crisis Stabilization Unit (CSU) of NPC, on the second floor of the facility, is available for voluntarily admitted patients in crisis who need time to stabilize their psychiatric condition. The staff may place such people in the 23-hour observation unit or place them in the 8-bed CSU where they can remain up to five days. These placements are for people who can become stable without being hospitalized. Indigent patients involuntarily brought to the NPC are transferred under court order to the Harris County Psychiatric Center (HCPC) if they warrant the more intensive inpatient level of care. Both facilities habitually operate near or at their designed capacity.

c. Examples of Law Enforcement use of NPC services

In the past, many people suffering from a mental health crisis were placed in jail, where their psychological condition might worsen, prior to receiving medical evaluation. Now, police officers bring many of these individuals for treatment at the NPC. The Crisis Intervention Team (CIT), established by the Houston Police Department in late 1999, has trained approximately 25 percent of its officers to recognize and to react appropriately to mental health symptoms. HPD officers also learn techniques to defuse tense situations that might be aggravated if traditional police tactics were used.

According to a recent review of the county’s adult mental health system, about a third of the persons brought to the NPC by CIT have never been in the MHMRA system. Thus, cooperation between mental health and law enforcement professionals has not only reduced the number of offenders with mental illness in the Harris County jail, it has allowed many persons with mental illness to receive systematically provided, clinically appropriate treatment for the first time.

d. Summary

The goal of the NPC is to allow a crisis to subside, to provide timely treatment, and, if clinically possible, to avoid client hospitalization. The staff assesses, stabilizes, and triages the patients to the appropriate level of care (i.e., inpatient care for complex psychiatric conditions, outpatient care if the condition meets priority population).

Leslie Gerber, Beyond Crisis: Adult Mental Health Service Needs in Harris County, A Report of the Mental Health Association of Greater Houston (October 2002).
Leslie Gerber, Beyond Crisis: Adult Mental Health Service Needs in Harris County, A Report of the Mental Health Association of Greater Houston (October 2002).

4. Mental Retardation Division (MR)

The MR Division provides services and support to persons who are determined, after a formal assessment, to have MR, pervasive developmental disabilities, or autism. According to state regulations, the priority population for MR services consists of individuals who meet one or more of the following descriptions:

• Persons with mental retardation as defined by the Texas Health and Safety Code.
• Persons with pervasive development disorders, including autism, as defined in the current edition of the Diagnostic and Statistical Manual (DSM).
• Persons who are eligible for MR services under Medicaid.
• Nursing facility residents who are eligible for specialized MR services under the federal Social Security Act.
• Children who are deemed eligible for services from the Early Childhood Intervention Interagency Council.

After being certified as eligible, an individual and his or her family meet with a service coordinator regarding consumer needs, types of services available, and choice of providers. Although some MR services are available immediately, other services are in such demand that persons needing care are placed on a waiting list. Most often, service availability is limited due to funding constraints.

a. Required versus Optional Services

1. Required Programs or Services. The following activities are either required specifically by the performance contract with TDMHMR or are otherwise indicated as best practices by the professional community.

• Service coordination.
• Respite services.
• Supported employment.
• In-home and family support.

2. Optional Programs or Services. The following activities are not required by the TDMHMR performance contract but have been made available because the authority has decided that they contribute value to the priority community.

• Vocational training.
• Site-based habilitation.
• Residential living.
• Specialized therapies.
• Supported home living.
• Liaison with HCPC.
• Linkage with community programs (ARC, etc.)

3. Potential Programs or Services. The following services are not currently delivered by the authority but may contribute value to the priority community.

• Contracted specialized residences.
• Family support services.
• Residential family living.

b. Examples of Basic Services for MR consumers

MHMRA services to MR consumers can include screening and assessment, counseling, skills training, family preservation, home-based education, speech, physical, or occupational therapy, developmental rehabilitation services, assistance in transitioning to the public schools, service coordination, and linkage to community resources. The following are examples of basic MR services:

• Transition services assist consumers approaching 22 years of age to move from receiving services from a school district to receiving services from MHMRA or other community-based program.
• Early Childhood Intervention (ECI) services assist children under the age of three years who have delayed or atypical development, or who have a medical condition that could lead to a development problem. ECI may provide services in a home or day care center.
• Vocational services include traditional skill-building workshops as well as innovative programs to help place MR consumers in jobs. Services may be provided by MHMRA or by a contract provider.
• Day Habilitation accommodates the daytime needs of consumers who lack the skills to participate in vocational training. Services can be provided either by MHMRA or by a contract provider.
• Clinical Services provides clinical support to individuals with a developmental disability with or without another mental health diagnosis. Services include psychiatric counseling for adults and children, day programs for adults and school-age children, and in-home training and support to deal with immediate service needs.

c. Examples of Services for MR consumer families

MHMRA services to MR consumer families can include counseling, skills training, service coordination, family preservation, and linkage to community resources. Examples of MR family services are:

• Home and Community-based Services (HCS) is a Medicaid waiver program that provides a variety of services to meet a person’s needs for residential support, habilitation, dietary and nursing services, counseling, and therapies.
• In-Home and Family Support Grants provide alternative means to fund service. Grants may cover special food and supplies, medical services and equipment, medications, modifications to a home to accommodate special needs, transportation to services, or attendant care for the medically fragile. Eligibility for grant funds is based on family size and income and is also limited due to high demand.
• Respite services provides temporary and short-term care that allows the primary caretaker to revitalize by taking time for their own personal or psychological needs. Respite can be provided in the home or at another site.

d. Summary

Services are provided to residents of Harris County regardless of race, ethnicity, or citizenship status. However, MHMRA can only provide services to individuals who have no other source of funding. Thus, some applicants may be referred to other providers.

FIGURE 3: Current Organization of MHMRA
Figure 3 is available only as an Adobe PDF Click here to view image.

5. Potential Changes to the Mental Health System.
In response to budget and organization concerns, MHMRA has made plans to reorganize its reporting structure. The result is presented below. As previously noted, state support and regulation of the mental health system may change as the legislature considers budget cuts and reorganization. The potential for state action may necessitate further changes at the local level.

Karen F. Hale to Sandy Skelton, “FY 03 Immediate Spending Reductions.” Memo (24 January 2003). Carole Keeton Strayhorn, “Limited Government, Unlimited Opportunity.” Window On State Government Memo (January 2003).

FIGURE 4: Proposed Organization of MHMRA
Figure 4 is available only as an Adobe PDF Click here to view image.

D. Additional Interaction with Consumers and Public

1. Planning Advisory Councils (PACs) and Network Advisory Councils (NACs)

The public is encouraged to participate in the MHMRA system through the various PACs and NACs. Through these bodies, consumers, family members, professionals, advocates, providers, and other interested citizens provide MHMRA’s board of trustees and administration with guidance and feedback pertaining to community needs, concerns, and perceptions relating to services and supports delivered by and through the MHMRA and its provider network. MHMRA’s reliance on such advisory councils stretches back 35 years. The earliest, the Catchment Area Ten Advisory Council, first met on 13 September 1966.

Through regularly scheduled meetings and various sub-committees, four independent PACs address adult mental health, child/adolescent mental health, mental retardation, and medical issues. By contrast, the NAC focuses upon operational issues. As required by TDMHMR, at least 50 percent of the NAC is composed of consumers, family members, and advocates.

MHMRA of Harris County, Local Plan for FY 2002-2003 (August 2001).

2. Department of Public Affairs

The Public Affairs department represents the MHMRA to the press and public, and generates interest in and support of MHMRA’s public service mission. The department promotes the authority in print and broadcast media, and maintains the website, www.mhmraofharriscounty.org, which includes MHMRA news, program descriptions, and an event calendar.

The Public Affairs department publishes the MHMRA newspaper, Interface, and provides staff with assistance with publications, press releases, and event announcements. Finally, the department coordinates a Speakers Bureau that provides subject matter experts for presentations on issues concerning mental health and mental retardation.

3. Volunteer Services

Volunteers are a critical resource to the community and to the MHMRA. Volunteers may deliver services to consumers, contribute to support programs, and assist in the governance and leadership of the organization. Volunteer Services Councils also work to develop potential resources, increasing the community’s investment in the MHMRA with in-kind donations, technical support, and professional services.

F. Services through related public facilities

Although private, non-profit groups also serve adults, children, and families, many such organizations are not able to provide the medications and complex services needed by people with serious mental illness. Uninsured MHMR consumers and indigent people with mental illness who have neither private insurance nor federal disability coverage are examples of individuals who are supported primarily through publicly funded institutions such as the MHMRA.

Thus, the availability of key mental health services depends largely on allocations from local, state, and federal government agencies. Such a mixture of funding sources causes support for services to ebb and flow. Inadequate state or federal funding, for example, cannot always be offset by proportionately higher allocations from the Harris County Commissioners Court to MHMRA and related public agencies.

In addition to the MHMRA, public resources for mental health care include hospitalization at the Harris County Psychiatric Center or the Rusk State Hospital, outpatient, inpatient, and crisis services through the Harris County Hospital District, and mental health support to the Harris County jail. Through informal or contractual relationships with MHMRA, these providers collectively offer a partial continuum of care for residents of Harris County.

The state requires MHMRA first to serve persons discharged from the MHMRA’s NPC, the HCPC, the Rusk hospital, or the Harris County jail. Each of these facilities operated near or even beyond their intended capacity, which severely limits the number of new consumers able to enter the system.

Leslie Gerber, Beyond Crisis: Adult Mental Health Service Needs in Harris County, A Report of the Mental Health Association of Greater Houston (October 2002).

1. Harris County Psychiatric Center (HCPC)

The HCPC, operated by The University of Texas Medical School at Houston, is the only freestanding public psychiatric hospital in Harris County. State and county funding for the HCPC has been flat since the facility opened in 1986 with a 250-bed capacity. The HCPC currently operates 203 beds, 143 of them held for indigent patients under contract with MHMRA, although this contract does not cover the costs of indigent care.

To help make up financial deficits, HCPC seeks grant funding and opens some beds to those with private insurance. After discharge, most HCPC consumers are referred for outpatient services to the MHMRA. In order to augment MHMRA’s own limited capacity, however, HCPC has created an outpatient program and a partial hospitalization program.

2. Rusk State Hospital

One of seven state-operated hospitals of its kind, the Rusk State Hospital receives an allocation of patients from TDMHMR. The majority of its patients have schizophrenia or a schizo-affective disorder as at least a part of their diagnosis. The facility serves most of the East Texas region, which includes Harris County. In particular, the Rusk hospital serves Harris County residents sent by the courts to restore their competency prior to trial for misdemeanor offenses.

Leslie Gerber, Beyond Crisis: Adult Mental Health Service Needs in Harris County, A Report of the Mental Health Association of Greater Houston (October 2002).

As at HCPC, the goal at Rusk is stabilization, and the facility does not offer rehabilitative services. As a result of cost increases that have decreased availability, the Rusk facility often is at full capacity and is not open to transfers.

While in the Rusk hospital, patients cannot apply for disability benefits that would provide income to pay for housing. Upon their discharge from Rusk, patients are provided social services through MHMRA, where caseworkers attempt to arrange housing. Unfortunately, despite the help of caseworkers, it is common for patients without families to become homeless. This fact contributes to recidivism.

3. Harris County Jail

It has been estimated that 150,000 people with mental illness are currently housed in Texas jails and prisons. The MHMRA forensic unit evaluates people with mental illness in the Harris County jails. If necessary, prisoners may be moved into the jail’s 96-bed inpatient unit, where they receive treatment to stabilize their condition.

MHMRA services at the jail do not include rehabilitation. The forensic unit also serves patients—internal “outpatients”—in the county’s general prisoner population. The MHMRA’s forensic unit screened more than 9,000 inmates in FY 2000. The goal is to help the patients adjust to the jail setting and, if appropriate, to ensure that they remain on medications while in jail. Finally, the forensic unit helps link patients to the MHMRA community clinics when they are released.

Leslie Gerber, Beyond Crisis: Adult Mental Health Service Needs in Harris County, A Report of the Mental Health Association of Greater Houston (October 2002).

4. Harris County Hospital District (HCHD)

The HCHD offers services based on need, without regard to income, insurance status, or diagnosis. It offers substance abuse services, and is the only component of Harris County’s system able to serve those psychiatric patients who have concomitant medical conditions.

An example of collaborative relationships between public agencies occurred in 1976, when MHMRA contributed one-third of the budget when the HCHD opened its Psychiatric Emergency Center (PEC) at Ben Taub Hospital. In addition to the PEC, HCHD services at Ben Taub include an outpatient clinic, a 12-bed emergency inpatient unit, and a 20-bed long-term inpatient unit within the MHMRA’s NPC that primarily serves consumers with medical conditions rendering them ineligible for HCPC. Since MHMRA has restricted outpatient access, the Ben Taub facilities have been operating at a maximum capacity.

Leslie Gerber, Beyond Crisis: Adult Mental Health Service Needs in Harris County, A Report of the Mental Health Association of Greater Houston (October 2002).
MHMRA of Harris County, Local Plan for FY 2002-2003 (August 2001).
Leslie Gerber, Beyond Crisis: Adult Mental Health Service Needs in Harris County, A Report of the Mental Health Association of Greater Houston (October 2002).

IV. Summary of Current Conditions

As noted above, the 78th Texas legislature is considering a major reorganization of the state health and human services divisions, which will change the operation and reporting structure of MHMRA. Decisions to implement such changes will be driven in large part by the state’s dire budget crisis.

The current legislature faces the task of reducing the multi-billion dollar shortfall in this biennium’s state budget. Gov. Perry has announced a no-new-tax pledge, and has declared that every state-funded program will be scrutinized. Harris County’s greatest task under these circumstances will be to minimize the imminent cuts to its programs, including local mental health care. Unfortunately, even prior to the state’s current crisis, chronic under-funding of both TDMHMR and MHMRA of Harris County contributed to budget inequities.

With more than 19,000 full-time employees and a budget of approximately $1.9 billion for FY 2000-2001, the TDMHMR is now one of Texas’ largest agencies. Yet, a high rank within the bureaucracy does not illustrate the actual priority with lawmakers. Perhaps a better measure of state priorities is the fact that, rather than increasing along with state population, Texas’ budget for mental health services, when adjusted for inflation, has actually declined by six percent since 1981.

Matt Schwartz and Roma Khanna, “County seeks to keep status quo: Lobbyists focus on minimizing cuts,” Houston Chronicle (Jan. 13, 2003). “Crying Need,” Houston Chronicle (September 1, 2002).
MHMRA of Harris County, Local Plan for FY 2002-2003 (August 2001), Figure 3.
TDMHMR Strategic Plan for Fiscal Years 2003-2007 (May 2002).
Leslie Gerber, Beyond Crisis: Adult Mental Health Service Needs in Harris County, A Report of the Mental Health Association of Greater Houston (October 2002).

As a result, by the late 1990s, Texas ranked 41st among the fifty states in per capita mental retardation expenditures. Moreover, Texas was 42nd in per capita expenditures for mental health (43rd if the District of Columbia is included).

Harris County is the largest county in Texas (and the third largest county in the nation). It covers around 1700 square miles, and boasts a population of approximately 3.5 million. Moreover, population will almost certainly increase, because Harris County is and is projected to remain one of the fastest growing counties in the state. Therefore, as a consequence of demographics, the MHMRA of Harris County administers one of the largest mental health systems in the nation.

National Association of State Mental Health Program Directors, “FY ‘97 Funding Sources and Expenditures of State Mental Health Agencies.” State of the States in Developmental Disabilities Report, 2000 edition, University of Illinois-Chicago. Texas information from TDMHMR Office of Planning, Research & Evaluation (1998 statistics).
Some 1.8 million persons live within the city limits of Houston, the fourth largest city in the U.S . What is more, the Consolidated Metropolitan Statistical Area (CMSA)—consisting of not only of Harris, but Liberty, Montgomery, Waller, Fort Bend, Brazoria, Galveston, and Chambers Counties as well—covers 8778 square miles and has a population of some 4.5 million. MHMRA of Harris County, FY 2003 Budget Presentation (October 2002).
Other centers, many exercising responsibility for more than one county, are headquartered in Abilene, Amarillo, Austin, Beaumont, Big Spring, Brownwood, Bryan, Cleburne, Conroe, Corpus Christi, Dallas, Denton, Edinburg, El Paso, Fort Worth, Galveston, Greenville, Jacksonville, Kerrville (with a satellite office in San Marcos), Laredo, Longview, Lubbock, Lufkin, Lytle, McKinney, Midland (with a satellite office in Alpine), Plainview, Portland, Rosenberg, Round Rock, San Angelo, San Antonio, Stephenville, Temple, Terrell, Texarkana, Tyler, Victoria, Waco and Wichita Falls. The state has delegated local authority to a community MHMR center in 247 of Texas’ 254 counties. NorthSTAR, a behavioral health service system jointly administered by TDMHMR and the Texas Commission on Alcohol and Drug Abuse, serves the remaining seven counties (these are Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, and Rockwall). TDMHMR Strategic Plan for Fiscal Years 2003-2007 (May 2002).

Yet, as is also true with TDMHMR, MHMRA of Harris County funding has not been a high priority with state legislators. Despite its large and growing priority population, MHMRA has not received a proportionate share of general revenue funds. Based on the statewide per capita expenditures in FY 2002, for example, it has been estimated that the authority was “shorted” more than $33 million.

The authority’s budget situation has been poor for several years, and it will only worsen as the state addresses the huge deficit. Legislators cannot be expected to add new funding for programs and personnel even to a system that remains far below the national median for MHMR services. Indeed, public funding for mental health programs in Harris County can be expected to decline further beginning in FY 2003.

Policymakers must grapple with providing adequate care even as they attempt to control costs. The Management Audit Section of TDMHMR was charged nearly three decades ago with the task of overcoming allegedly poor accounting practices and lax administration at local centers. Although the MAS arguably brought about efficiencies in the general system, much work remains to be accomplished by local authorities, including MHMRA. Clearly, the authority must cut costs immediately, despite the persistent demand for services (a demand that may well be aggravated by the lingering economic slowdown and foreign policy crises).

Dale Lezon, “Mental health care for poor `beyond crisis,’ report finds,” Houston Chronicle (October 8, 2002). MHMRA Ex. Dir. Reports 3/02; Disabled But Able. MHMRA Ex. Dir. Reports 2/02; A Work In Progress.
Margaret Downing, “Reality Check,” Houston Press (July 25, 2002).

V. Conclusion

This section has described the origins and growth of public mental health services in Texas, including a description of the current organization of the MHMRA of Harris County. The fundamental purpose of public mental health systems across the state has been and will no doubt remain serving the diverse needs of the priority population, by providing services and support that are as high quality, efficient, and cost effective as is possible within the resources available. MHMRA has been and must continue to be committed to fulfilling that purpose. At the same time, the authority must be prepared to accommodate the changed conditions.

Budgetary constraints and demographic transformations may necessitate MHMRA’s shifting resources toward or away from current services and supports. The authority may add new services, but it will more likely eliminate services. The question the MHMRA administration must confront is, where can the authority be cut and still maintain viable services?

MHMRA is larger than many public mental health systems, but, unfortunately, it is not unique among them, in several important ways. Systems in many states have been burdened with ineffective programs, redundant services, and stagnant, bloated bureaucracies. Many operational models preclude innovation. Such organizations are spurred to change only by crises, including fiscal pressures. For better or worse, MHMRA finds itself in this situation. The next section of this strategic plan will detail the various issues the authority must confront in these dynamic times.

National Council on Disability, “The Well Being of Our Nation: An Inter-Generational Vision of Effective Mental Health Services and Supports” (September 16, 2002).