A wave of deep budget cuts to mental health services is sweeping through resource- scarce states. The mental health field has never been awash in money, but now, as demand soars, billions of dollars in cuts are threatening to shutter facilities, prolong waiting times to get services, and purge countless people from support systems across the country.
In Texas, more than 4.3 million residents, including 1.2 million children, live with some form of mental health disorder. And, according to the Texas Medical Association, Texas ranks 49th in the nation for the amount it spends per person on mental health care. Texas also has an estimated $27 billion deficit so the potential for harm in this legislative session is very high.
In the midst of all this, the Hogg Foundation for Mental Health has established itself as a strong policy player in the mental health field in Texas.
Founded in 1940 by the children of Texas Governor James S. Hogg, and housed within the Division of Diversity and Community Engagement at The University of Texas at Austin, the foundation has a masterfully developed strategy for impacting the mental health system in Texas. Not only does the Hogg Foundation tackle research, but also funds policy advocacy and, itself, engages in legislative education. Within that framework is a deep undercurrent that places a high value on consumer involvement in policy development and service delivery.
Almost from the beginning Hogg has been involved with helping shape policy. In the mid 1950s, the foundation was instrumental in working with policy makers, mental health experts and advocates to draft the first mental health code in the state. But at other times the foundation stepped back from policy and focused energy on funding local services.
In the past decade the foundation has once again stepped up to the policy plate. “We realized we had a strong focus on small service grants but we looked at the need in the state for improved services and realized that with our funds – we’re a medium-sized foundation – we had nowhere near enough money to bring services up to the level we wanted,” says Dr. Lynda Frost, Hogg Foundation’s director of planning and programs. “And so we began a process of getting more heavily involved in policy work.”
Hogg evolved to focus more on policy and moved away from an open grants process, replacing it with grants that were more strategic and often linked to policy objectives. They also began to do more research and direct funding of policy work.
Among other policy initiatives, the foundation is focusing on educating lawmakers about the risks of defunding mental health programs around the state – the most critical issue facing mental health providers right now, says Colleen Horton, program officer at Hogg. Horton often is invited by legislative committees to testify on policy issues related to mental health. “If you don’t spend it [money] on mental health services, you’ll spend it on criminal justice or homelessness or higher costs for hospitals and ER rooms,” Horton said. “The foundation is well-situated to offer recommendations on ways to spend the money more effectively and efficiently.”
Another issue Hogg has brought to lawmakers’ attention is outpatient competency restoration. Under the U.S. Constitution, a person with mental illness who is charged with a crime and deemed to be incompetent cannot be tried without successfully going through the process of restoration. Typically, this is done in a state mental health hospital costing the state about $400 a day. Hogg is educating lawmakers about the outpatient restoration process, an alternative that would save the state much-needed funds by treating people in the community instead of a state hospital.
“We’ve been talking to a lot of folks on the house appropriations and senate finance committees about the value of expanding several successful state pilot programs that offer outpatient competency restoration because, in addition to the cost savings, the human outcomes are more positive than putting somebody in a state psychiatric hospital,” says Horton. Typically, Horton says, the current system leads to offenders with mental illness cycling back and forth between jail and the hospital.
Aside from these critical pressing issues that Hogg is addressing in real time, the foundation has deeply invested in recent years in a collaborative care model of service delivery – a model that integrates quality mental health care services into physical health care settings.
The collaborative approach to mental health care provides improved access and quality of care for Texans’ mental and physical health, says Dr. Octavio N. Martinez, Jr., executive director of the Hogg Foundation. “When you really have an integrated system, a collaborative care of approaching folks’ illnesses from a physical and mental standpoint, you’ll see decreased ER visits, you’ll see decreased hospital stays. You’ll see also an increase in quality of life.”
About five years ago Hogg decided to fund a multi-million dollar grant program that enabled seven sites to use a collaborative care model, with the goal of identifying and overcoming barriers to integrating mental health care with traditional physical health care in Texas. Under this model, people receive a mental health screening during routine visits to primary health physicians. The physician oversees any needed mental health treatment, with the help of a care manager who follows up frequently with the person being treated, tracks information about the person’s condition in a registry, and consults with a psychiatrist regularly.
Quality research showing that the model works had been done, says Frost. But Frost and the rest of the foundation knew that funders and legislators would be skeptical about its local application and would first want to see the model working in Texas. They hoped, too, that these pilot programs would have a multiplier effect. “We hoped that through this process we would have sites that would essentially become advocates for integrated health care and would change their cultures of care. They would change their service delivery models and they would have caught the fever; talk to colleagues about it, talk to funders and policy makers about it, and be able to carry the message in a way that we as a foundation cannot do as well as the folks on the front lines,” Frost says.
As a result of these pilot programs and strategic meetings with key mental health officials and lawmakers, the Texas Legislature passed a law in 2009 creating a legislative workgroup operated by the Texas Health and Human Services Commission. The workgrouppresented a policy report back to the legislature with recommendations for expanding integrated health care in Texas.
This is a perfect example of how Hogg is able to directly impact the quality of mental health care, not only on the front lines, but also from its position as a key policy player in the state.
But Hogg isn’t intent on focusing solely on Texas. As the field of mental health scrambles to find a foothold as health reform moves forward, the foundation is watching for opportunities to expand the inclusion of mental health in federal health policy decisions affecting Texas. During the run-up to the health reform law Frost spearheaded the drafting and circulation of a position paper on health care reform that 16 foundations from across the country signed on to.
“So, even apart from the impact we hoped it would have on the health care reform process, we were hoping it would encourage foundations to make more of a commitment to policy work,” says Frost. “And, I think that it turned out to do that for some of the signatories. People had to take the position paper to their boards and the boards had lots of questions. I talked with some folks who were concerned that this was lobbying, wondering can we do this? What would it mean for us to sign? And, so, I think it opened up some really healthy and productive discussions internally.”
So how is the Hogg Foundation – a self-described mid-sized foundation – able to effect change the way they do, from policy and advocacy to ground-level practice? What makes Hogg so different from its peers in the foundation world?
One reason may be the unique positioning of the foundation at the University of Texas at Austin, a major research university. “All of our program officers have professional expertise in mental health. Some of us have faculty appointments and teach at the university. So, we bring, I think, a different perspective to our work,” says Frost. “We really work in partnership with researchers and academicians to try to bring research to practice and improve the quality of services in the field.”
Another way that Hogg has been able to change the way mental health care is thought about in Texas may be that they not only talk the talk, but they also walk the walk. The foundation is committed to funding peer support and creating a consumer-led mental health system. Peer support is when someone who self-identifies as having a mental illness is trained to help other mental health consumers navigate the system and work toward recovery and wellness.
Hogg has co-funded a certification program where people can get specialized training to become peer support specialists and help others define their goals for recovery. “So, peer support services are not focused on symptomology or medication, but instead focus on leading a rewarding life, making social connections, and providing a living model of how somebody with a serious mental health condition can become self-directed, achieve recovery and wellness, and live a productive, active life in their community,” says Frost.
The foundation has taken the concept a step further by looking at their own operations as a starting point for improvement. “We had no self-identified mental health consumers [on staff] and we thought, well, that seems a little backwards,” says Frost. “If our mandate is to improve mental health in Texas and figure out the best way to do it, we need people at the table to help us do that. And, we thought, well, we really need people involved in our day-to-day business who bring that perspective every day. So, we changed our staffing. We hired two program officers who we also call consumer and family liaisons. And we appointed two consumers to our national advisory council.”
The foundation has been able to use this kind of commitment, along with their knowledge base and respect in Texas as a neutral convener and facilitator, to bring people together to think through better ways of delivering mental health services – especially concerning policy work. The foundation stands out as an example of what is possible – and advisable – in the world of mental health funding.
But Frost and Martinez are optimistic that they have strong allies in their quest for a more efficient and higher-quality mental health system. Frost has seen the interest of other foundations pick up in recent years. “Five years ago I would have said, yeah, it’s kind of rare. They [foundations] would say, well, it’s really complex or it’s really hard to sell to our boards and there were other issues with really compelling needs, like oral health, that were less controversial. But, more and more of the health conversion foundations are realizing we can’t do health if we don’t do mental health. If we ignored it, it’s really affecting everything else we do. We really do have to address it.”