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Section F, Part I. Aims and Objectives

I. Introduction

This section describes the strategic aims to be established by the administration of the MHMRA of Harris County—which, for the purposes of this discussion, includes the members of the board of trustees, the executive director, various deputy directors, and key staff. For each aim listed below, at least one objective and an associated indicator will be specified.

In addition to aims, objectives, and indicators, for each case a relative schedule for completion of objectives, or for review of indicators to assess progress toward completion, has also been proposed. This timeline is intended to be a rough guide for the responsible individuals or groups whose efforts will implement this strategic plan.

This presentation of aims, objectives, and indicators draws upon the discussion of outstanding issues presented in the previous section of this plan. In some cases, an issue has been transformed directly into one or more aims. In other cases, issues have been translated into objectives. Several aims and objectives are introduced, however, because they derive from the basic strategic needs of the MHMRA, as to many large institutions, rather than from specific issues.

a. Methodology

As employed in this strategic plan, terms are defined as follows:

• Aims are the specific conditions to be created or to be achieved.
• Objectives are the specific tasks to be performed in service of an aim.
• Indicators gauge the organization’s progress toward the achievement of an aim or objective.

Put another way, objectives are the means to reach the end of an aim. An indicator might register success in achieving an important milestone, or it might simply mark the initial collection of data about an objective. Indicators range from the board of trustee’s acceptance of a list of budget priorities submitted by a particular division, to the observed reduction in the average number of days that consumers spent on a waiting list for services.

b. Note on the Enumeration of Aims and Objectives

Some issues may, upon reflection, result in more than one possible aim or objective. For example, as described below, confronting the pressures of the high demand for mental health services leads quite logically to the establishment of aims related to the reduction of that demand. One of the objectives described is that the authority develops a better capacity to assist eligible consumers to identify alternative organizations, such as those in the private sector, that could provide comparable services.

Alternative objectives could have been named. One way to reduce demand for services would be to make services less attractive, perhaps by lowering quality, arbitrarily raising prices, or increasing bureaucratic barriers to access—this last a practice that has been called rationing by harassing. One indicator of the “success” of these efforts would be the drop off of new applications for service.

Such objectives and indicators would indicate a flawed understanding of the source and nature of the “demand.” For MHMRA, the demand for services arises from the genuine needs of the priority population. Simply discouraging applications for assistance would not reduce the need for mental health services, and would, in fact, contravene the basic mission of the authority, which is, after all, to ensure the provision of services to and support to members of the priority population within Harris County.

The information in this section is presented with the key understanding that the authority was created and continues to exist in order to increase the number of persons in Harris County’s priority population consumers who are able to achieve stability, recover function, and, if clinically possible, exit the system. The catalogue submitted below is the result of a search for useful aims, objectives, and indicators, where “useful” is defined simply as having the potential to assist in the successful fulfillment of that founding mission.

II. AIMS RELATED TO THE STATE BUDGET CRISIS

AIM II.A. Prepare to Meet Threat of Current Deficits.

Discussion: The statewide budget pinch is especially acute for Harris County MHMRA, because the authority had already been experiencing deficits in FY 2003. Thus, despite an increasing demand for its services, funding for MHMRA can be expected to contract, with the impact being felt almost immediately.

Although the extent of the required cutbacks is not yet clear, the authority’s management can act now, either to identify targets for cuts or to identify areas that must be shielded from cuts in order to maintain contractually mandated services to the priority population.

Objective II.A.1. Board examines the authority’s immediate budget priorities.

Progress indicator: Board directs that each MHMRA division is to examine costs and benefits of all services currently delivered to consumers and to recommend priorities for imminent budget cutbacks or retention.

Schedule for Review: Begin immediately upon acceptance of strategic plan.

Progress indicator: Deputies report recommendations for priorities and opportunities for savings.

Schedule for Review: One week from acceptance.

Progress indicator: Executive director compiles a master list of priorities by division that accurately accounts for costs, benefits, and correlation of specific programs currently offered to statutory requirements for services.

Schedule for Review: One week from acceptance.

Progress indicator: Board weighs the costs and benefits and establishes priorities for imminent budget cuts.

Schedule for Review: Two weeks from acceptance.

Progress indicator: Executive director communicates the priorities, as well as impacts, to staff and community.

Schedule for Review: One week from Board action.

Objective II.A.2. Board weighs costs and benefits of current services and establishes the authority’s immediate budget priorities.

Progress indicator: Board directs that each MHMRA division is to examine costs and benefits of all services currently delivered to consumers and to recommend priorities for imminent budget cutbacks or retention.

AIM II.B. Prepare to Meet Threat of Imminent Budget Contraction.

Discussion: The MHMRA leadership can work to ameliorate the effect of present or future cuts in two additional ways. First, the authority can begin looking toward the potential for securing external funding from public and private sources. Second, the authority can gather evidence of the impact of historical inequities in the funding of local authorities across the state.

Objective II.B.1. Board establishes the authority’s long-range institutional priorities.

Progress indicator: Deputies report recommendations for priorities and opportunities for savings.

Schedule for Review: One month from acceptance.

Progress indicator: Board compiles lists of priorities, accurate factual data on costs and benefits of cuts, to be retained for discussions regarding possible future cuts.

Schedule for Review: Two months from acceptance.
Progress indicator: Increase accuracy and timeliness of available financial and operational information. Board establishes IT infrastructure and date processing improvements as a clear priority.
Schedule for Review: Begin immediately upon acceptance of strategic plan.

Objective II.B.2. Develop database of sources for grants and other alternative funding (Note: A compilation of such potential funding sources appears in the appendices).

Progress indicator: Board directs each MHMRA division to propose grants funding for their own programs.

Schedule for Review: One week from acceptance.

Progress indicator: Executive director designates a deputy to develop a procedure to facilitate and monitor the submission of grant proposals.

Schedule for Review: Six months from acceptance.

Progress indicator: Deputy directors report success in the search for and securing of outside funding.

Schedule for Review: Within 1 year of acceptance.

AIM II.C. Control High Costs of Pharmacy Services.

Discussion: Appropriate medications, including the New Generation medications, should to be made available to those consumers who could most benefit from them. Yet, the authority must develop criteria and protocols that review the adequacy of older (although still costly) alternative medications.

Objective II.C.1. Establish a mechanism to account for future increases in costs, while maintaining budget flexibility and quality patient care.

Progress indicator: Executive Director instructs deputies to closely monitor changes in cost structure of medications.

Schedule for Review: Begin immediately upon acceptance of strategic plan.

III. AIMS RELATED TO MANAGEMENT PRACTICES

AIM III.A. Reduce Inefficiency and Redundancy.

Discussion: The organizational structure of MHMRA must become efficient and effective in order to address current and potential fiscal realities. Management ranks must be thinned. The remaining administrators must be made more accountable for setting goals and meeting standards for organizational outcomes.

Objective III.A.1. Reorganize management infrastructure in light of the authority’s institutional and budget priorities.

Progress indicator: Board directs Executive director to examine the current administration of each division and to recommend positions either for cutback or retention.

Schedule for Review: Begin immediately upon acceptance of strategic plan.

Progress indicator: Executive director compiles a list of personnel actions and administrative changes that cut overhead costs and program redundancy significantly.

Schedule for Review: One month from acceptance.

Progress indicator: Board reviews and approves Executive director’s recommendations.

Schedule for Review: Six weeks from acceptance.

Progress indicator: Executive director announces personnel actions and administrative changes, directs deputies in each division to develop implementation.

Schedule for Review: Two months from acceptance.

Progress indicator: Deputies implement decisions.

Schedule for Review: Three months from acceptance.

Progress indicator: Executive director reports evidence of efficiencies gained to Board.

Schedule for Review: Six months from acceptance.

Objective III.A.2. Identify and Reduce Inefficient Facilities

Progress indicator: Board directs Executive director to examine the budget and overhead committed to the maintenance of physical plant and to recommend facilities either for cutback or retention.

Schedule for Review: Begin immediately upon acceptance of strategic plan.

Progress indicator: Executive director compiles a list of candidates for reductions of facilities.

Schedule for Review: One month from acceptance.

AIM III.B. Increase ability to identify and to adopt evidence-based best practices and state-of-the-art procedures.

Discussion: The authority is poised—by necessity, it is true—to emerge from current budget woes as a leaner and more focused agency. Some services will have to be cut, and others will be cut down.

MHMRA should take this opportunity to implement improved services and methods of service delivery, by investigating evidence-based practices, by developing state-of-the-art procedures and therapies, and by adopting more advanced technology. This may seem an unattainable aim in an era of increasing demand and diminishing resources, but it is exactly at times such as these that services and programs based on the latest advances in treatment ought to be investigated.

Despite looming budget cuts, MHMRA will no doubt continue to operate under statutory and contractual constraints that give it responsibility for providing basic services. Yet, the authority’s board of trustees and administrators will retain the local power to determine how the services that remain are to be provided. The authority should announce a commitment to become the recognized innovator of the mental health system.

Objective III.B.1. Examine Local Authority Model

Progress indicator: Board directs Executive Director to examine potential for increasing efficiency and service by transitioning to a local authority model.

Schedule for Review: Immediately upon acceptance of strategic plan.

Progress indicator: Executive Director identifies core functions suitable for retention and non-core service functions that are candidates for outsourcing.

Schedule for Review: One month from acceptance of strategic plan.

Progress indicator: Executive Director reports on potential for collaboration between public and private providers.

Schedule for Review: Two months from acceptance of strategic plan.

Objective III.B.2. Build a Reputation for Innovation.

Progress indicator: Board establishes innovation as a priority throughout MHMRA.

Schedule for Review: Immediately upon acceptance of strategic plan.

Progress indicator: Board appoints a committee or Executive director designates a deputy to examine opportunities for innovation throughout MHMRA.

Schedule for Review: One month from acceptance.

Progress indicator: The committee or deputy completes study of opportunities for innovation and presents proposals for implementation.
Schedule for Review: Six weeks from acceptance.

Objective III.B.3. Develop Procedures to Implement Innovation.

Progress indicator: Executive director designates a deputy to develop a mechanism enabling divisions to identify and to implement innovations from within.

Schedule for Review: Two months from acceptance.

Progress indicator: Board approves implementation of innovation program throughout MHMRA.

Schedule for Review: Two months from acceptance.

Progress indicator: Deputies within each division institute procedures to solicit and reward innovation.

Schedule for Review: Three months from acceptance.

Progress indicator: Designated deputies report progress of efforts and assess measurable impacts on services.

Schedule for Review: Six months from acceptance.

Progress indicator: Public and private providers of services begin to adopt innovations pioneered by MHMRA. Evidence of imitation, up to and including requests for expert advice, accumulate.

Schedule for Review: Within 1 year of acceptance.

AIM III.C. Reduce rate of personnel turnover.

Discussion: Quality service depends on the retention of qualified staff. During these challenging times, MHMRA must decide not merely who can be cut, but who must be retained. Staff satisfaction, and retention, can both be increased by persuading employees that worthwhile priorities are being set and implemented. Priorities must begin with a demonstration of the authority’s renewed commitment to maintaining quality service delivery and expanding opportunities for staff development during the very unsettled environment brought about by the state’s current budget crisis.

Objective III.C.1. Increase staff and management quality, satisfaction, and capacity to serve.

Progress indicator: Executive director designates a deputy within each division investigate reasons for and to assess impact of staff turnover.

Schedule for Review: Begin immediately upon acceptance of strategic plan.

Objective III.C.2. Personnel turnover, especially among critical staff, is significantly reduced.

Progress indicator: Executive director designates a deputy within each division to identify critical staff to be retained and to suggest means of ensuring retention.

Schedule for Review: Within three months from acceptance.

AIM III.D. Increase cultural diversity among staff to accommodate diversity in consumer population.

Discussion: Bureaucratic processes, if compounded by language and cultural barriers, may lead to frustration among consumers and families. Training in culturally appropriate customer service would lead to more effective delivery of services.

Objective III.D.1. Identify areas where diversity among staff will accommodate diversity in consumer population.

Progress indicator: Executive director designates a deputy within each division to identify extent to which cultural and language deficiencies among staff raise barriers to consumer access to services.

Schedule for Review: Begin immediately upon acceptance of strategic plan.

Progress indicator: Designated deputy proposes appropriate means (e.g., training, transfers, new hires) to increase diversity among key personnel.

Schedule for Review: Within three months from acceptance.

AIM III.E. Institute staff training and orientation.

Objective III.C.3. Develop training program to broaden staff’s knowledge of services across the authority (that is, not only within home division or office).

Progress indicator: Executive director designates a deputy within each division to identify knowledge base that should be included in training.

Schedule for Review: Within one month from acceptance.

Progress indicator: Deputies report compiled findings, which become the basis for training and orientation.

Schedule for Review: Within two months from acceptance.

Progress indicator: Authority contracts to create training materials.

Schedule for Review: Within three months from acceptance.

Progress indicator: All staff, including volunteers, undergo initial and periodic reinforcement of orientation.

Schedule for Review: Within six months from acceptance.

IV. AIMS RELATED TO INSURANCE COVERAGE

AIM IV.A. Reduce demand for MHMRA services.

Discussion: The authority expends resources beyond its legal obligations and usually beyond its budget. As just one example, MHMRA is obligated under a TDMHMR performance contract to serve 8830 unduplicated adult clients per month, but actually serves many more than this number. Similar conditions in the other MHMRA divisions compound the burden.

Under conditions of economic distress, delivery of public services will be over burdened and subject to the constraints imposed by state and county budgets. The result is akin to de facto rationing of services. Hence, some current or potential MHMRA consumers may benefit by seeking mental health services from a comparable public or private organization.

Some current or potential MHMRA consumers may meet the priority population criteria but also qualify for coverage under public or private insurance. Services and supports for these consumers would be available from private providers. The authority would forgo some reimbursement revenues but potentially would reap administrative savings and improve services by concentrating on a smaller clientele.

The private sector usually does not focus many resources on serving the special needs of the thousands of uninsured, poor, or indigent Harris County residents living with serious mental illness. The authority will continue to meet its obligation to provide services to the residents of Harris County who meet the criteria of definition of the priority population but cannot or do not elect to transfer to an outside organization.

Objective IV.A.1. Examine the costs and benefits to be expected from establishing a tighter institutional focus on serving the indigent, the severely mentally disabled, or similar “hard” cases unlikely to receive services and supports from the private sector.

Progress indicator: Board of Trustees appoints a committee to examine the issue of tightening the authority’s service focus to a core constituency of the priority population.

Schedule for Review: Within three months from acceptance.

Progress indicator: The committee completes its study and presents findings and proposals.

Schedule for Review: Within six months from acceptance.

Objective IV.A.2. Develop a triage, or “gatekeeping,” function at the eligibility center that can rapidly identify current or potential MHMRA consumers who have or are eligible for third-party insurance, Medicaid or other public coverage, or who can pay cash for services.

Progress indicator: Executive director designates a deputy to manage the database and staff that will administer the eligibility “gate.”

Schedule for Review: Within three months from acceptance.

Objective IV.A.3. Develop a database of organizations, especially in the private sector, which provide services comparable to those provided by MHMRA.

Progress indicator: Deputy director designated above establishes database and staff to manage the database.

Schedule for Review: Within three months from acceptance.
Objective IV.A.4. Develop a mechanism to transfer current or potential MHMRA consumers identified above to the qualified providers, perhaps under a standing contract.
Progress indicator: Procedure for transfer is established.
Schedule for Review: Within three months from acceptance.

AIM IV.B. Increase Participation in Federal Health Care Programs.

Discussion: MHMRA can receive reimbursement for services delivered to consumers who are enrolled in SSI or Medicaid, the federal disability insurance programs. Even prior to the current budget shortfalls were revealed, the Legislature had announced expectations that state agencies such as MHMRA must work to increase the numbers of uninsured consumers accessing these federally funded and state matched insurance programs.

Unfortunately, the state’s administrative rules make it difficult to gain coverage for potential clients. As a result, far too many of the authority’s eligible consumers still are not enrolled in the programs. MHMRA previously established an outreach program to help people with mental illness register to gain their benefits. It must now redouble its efforts to aggressively seek enrollment.

Objective IV.B.1. Establish rates at which potentially reimbursable services are delivered to eligible but never enrolled consumers.

Progress indicator: Board of Trustees directs each MHMRA division to examine its own level of enrollment.

Schedule for Review: Within one month from acceptance.

Progress indicator: Executive director designates a deputy within each division to compile and report data.
Schedule for Review: Within three months from acceptance.

Objective IV.B.2. Establish program to increase enrollment of eligible consumers in reimbursable disability programs.

Progress indicator: Executive director designates a deputy to develop and administer the focused enrollment campaign.

Schedule for Review: Within two months from acceptance.

Progress indicator: The designated deputy reports an increase in the rate of consumer enrollment in these disability programs.

Schedule for Review: Within six months from acceptance.

AIM IV.C. Increase Percentage of Consumers Enrolled in Third Party Insurance Programs.

Discussion: Many Texans either lack private insurance or are under-insured with regard to mental illness. Harris County has the second highest rate (30 percent) in Texas of residents who lack insurance. It is estimated that 54 percent of MHMRA consumers are uninsured, and over 80 percent are unemployed. Unfortunately, where a consumer has third party insurance, public agencies often expect insurance payments to cover the total costs of service. That is, unless a reason exists to justify the application of public funds to supplement third party coverage, the state contribution is reduced. Nonetheless, MHMRA ought to commit to raising the rates of coverage among its consumers.

Objective IV.C.1. Establish rates at which services are delivered to consumers who are eligible for but are not taking advantage of third-party insurance coverage.

Progress indicator: Board of Trustees directs each MHMRA division to investigate its own rate of service delivery to the insurance eligible.

Schedule for Review: Within one month from acceptance.

Progress indicator: Executive director designates a deputy within each division to compile and report data.

Schedule for Review: Within two months from acceptance.

Objective IV.C.2. Establish program to increase coverage of eligible consumers by third-party insurance.

Progress indicator: Executive director designates a deputy to develop and administer focused coverage campaign.

Schedule for Review: Within one month from acceptance.

Progress indicator: The designated deputy reports an increase in the rate of consumer coverage under third-party insurance.

Schedule for Review: Within two months from acceptance.

AIM IV.D. Establish more effective partnerships with private providers and other supporting agencies.

Discussion: MHMRA must ensure that it can refer consumers to partnered and contracted providers with appropriate credentials. To the extent possible, MHMRA services should be designed to complement rather than compete with services delivered by its partners. Of course, overlap of basic programs is to be expected.

Peer support, family education, and crisis alternatives are examples of important services that contribute to recovery, and yet these are not widely offered by the private sector. Other scarce but much-needed services include assistance with the development or rehabilitation of functional skills. These may include wraparound supports for education, employment, socialization, housing, and financial planning.

Partnerships may invite some level of risk because potential partners, whether public, private, volunteer, or community-based, are also facing pressures. As a consequence of economic conditions, all services may not be available in the future at the same level as they have been in the past. As an example, approximately 500 private psychiatric hospital beds have been eliminated in Harris County over the past several years, thereby increasing pressure on the public system.

Objective IV.D.1. Identify programs and resources made available by other organizations that serve the same consumers as MHMRA.

Progress indicator: Executive director designates a deputy to establish criteria for partnership and to compile a database of qualified providers.

Schedule for Review: Within three months from acceptance.

Progress indicator: Deputy designated above establishes the procedural mechanism to manage the partnerships, perhaps under a standing contract.

Schedule for Review: Within six months from acceptance.

Progress indicator: Significant numbers of consumers are transferred to partnerships.

Schedule for Review: Within nine months from acceptance.

Progress indicator: Develop a procedural mechanism to monitor the suitability of maintaining partnerships with private providers.

Schedule for Review: Within one year from acceptance.

V. AIMS AND OBJECTIVES FOR MHMRA PROGRAMS

This section describes the strategic goals to be established by the administration of particular divisions within MHMRA of Harris County—which, for the purposes of this discussion, deputy directors, and other key staff. The methodology repeats the presentation employed in the previous section, except that the objectives are not presented in detail.

Given the budget constraints on the authority, few if any newly introduced programs or services are likely to move MHMRA closer to its goals. Related infrastructure (such as new facilities and staff) would be costly to establish. For that reason, what follows will most often describe aims related to long-term expansion of services. Of course, the services and programs that are cut now might be added to this catalogue.

When the budget cloud lifts, it would be appropriate to revisit the improvements that constitute longer-term aims of the authority and consider them in greater detail.

AIM V.A. Increase opportunities for volunteers.

Discussion: Volunteers are a critical resource. They may deliver many services to clients, contribute to support programs, or assist in the governance and leadership of the MHMRA. Especially during this time of reorganizing, the activity of volunteers would be a major indicator of the community’s investment in MHMRA, and vice versa.

AIM V.B. Decrease Barriers to Access.

Discussion: Current marketing materials are optimistic and tend to oversell the availability of timely services. A more honest approach would recognize that tightening entry criteria, bureaucratic procedures, and waiting lists often result in denials or delays in access.

AIM V.C. Orientation for Consumers and Families.

Discussion: Successful orientation must include not only available services but also the steps necessary to access services. MHMRA should begin by archiving materials developed by other advocacy organizations. Orientation to the delivery systems of MHMRA is needed especially for aging population of consumers and caregivers.

AIM V.D. Increase Availability of Day Programs.

Discussion: Outpatient care should include programs to provide shelter for recovering persons during or after a crisis as well as transition after hospitalization. Few day or outpatient programs currently exist for persons with mental illness and, where available, they are usually restricted to customers eligible for Medicaid.

AIM V.E. Increase Availability of Residential Services.

Discussion: Living and functioning in the community continues to be one of the crucial problems for MHMRA consumers. Development of a countywide plan for supported housing programs would meet service needs ranging from in-home support to independent living.

AIM V.F. Increase Availability of Respite Programs.

Discussion: Respite provides time and sometimes a place for a consumer or family members to rest and recover after lengthy care, a crisis episode, or hospitalization. It would be helpful for MHMRA to collaborate with Harris County task forces and also to attempt to convince the private sector to develop more of this capacity.

AIM V.G. Availability of Job Skill Development.

Discussion: To increase the economic and financial independence of recovering consumers, MHMRA must build relationships with the private sector and local educational institutions. The challenge is to overcome the lingering stigma of mental illness, including fear of relapse. This discourages partnership with or other support by businesses. This may indicate a need to help partners recognize early signs and symptoms or relapse.

AIM V.H. Increase Availability of Transportation.

Discussion: Harris County is a large and diverse geographic area that has urban, suburban, and rural aspects. It is served by few transportation alternatives relative to the high number of residents in the priority population. The absence of readily available, affordable, and flexible transportation options for consumers may lead to cancellations or no-shows, which may contribute to relapse. Cost of new transportation programs would have to be weighed against cost to establish and operate additional satellite sites.

AIM V.I. Changes in CHIP enrollment criteria.

Discussion: Because some children on CHIP in the past could have been served privately, requirements for eligibility will be tightened. Also, CAS will be required to rely on earned revenues, and those CAS consumers with third party coverage (e.g., Medicaid) must be primarily supported by third party sources.

AIM V.J. Crisis Services for Children and Adolescents.

Discussion: There is an ongoing need to deliver authorized services appropriate to a child’s condition. For example, there is a gap in the state’s recognizing and hence in MHMRA’s serving the specialized needs of children or adolescents with dual diagnoses (i.e., Mental Illness as well as Mental Retardation conditions).

AIM V.K. Psychosocial Services for adult consumers.

Discussion: The AMH Division recently identified its priorities as including improved psychotherapy, day treatment, counseling, and in-home and family support. Community clinics lack funds to provide supportive and rehabilitative services that would keep indigent clients out of public crisis centers, hospitals, or jails. Effective programs would assist recovery by persons with co-occurring chemical dependency and mental illness.

AIM V.L. Increased utilization of PACs.

Discussion: PACs function as recipients of information or as consumer advocates rather than as understanding their role as advocates for MHMRA to funding bodies. Information provided to them tends to direct activities to a narrow band of issues consistent with consumer expectations. Thus, outcomes are limited and potential political leverage is lost. This pattern has chronically limited the range of impact the Authority might have to influence fiscal decisions by policy-making bodies.

AIM V.M. Consumer Rights Protections

Discussion: Changes in MHMRA services must not lead to reduced commitment to protecting consumer rights. The Authority’s efforts to bring services within budget realities must take into account statutory mandates and contract compliance issues.

AIM V.N. Improve ODHR standards and procedures

Discussion: ODHR lacks clear metrics for employee performance, and lacks consistent procedures for documenting and reviewing performance issues. Performance issues cannot be addressed and corrected without standards and procedures.

VI. Summary of Institutional Aims

This section described the strategic aims to be established by the administration of the MHMRA of Harris County. These are summarized in the following chart.