A Crisis in Care

Texas’ massive health services agency, which oversees the state’s psychiatric hospitals and many other aspects of healthcare, is failing to do its job. Its  aging hospitals are in crisis and short of staff, and patients are falling through the cracks in a system that values paperwork over actually helping people.

Those are some of the key findings by the staff of the Sunset Advisory Commission in its examination of Texas’ Department of State Health Services. The report left open the possibility that the commission could recommend a pervasive restructuring or dismembering of the agency.

Based on the review, there is a potential for “sweeping changes” across the state healthcare system, State Sen. Jane Nelson said in an e-mailed statement. The Republican from Flower Mound chairs the sunset commission and also the Senate Finance Committee. She said she will work with Senate and House colleagues to draft a package of bills to address the report’s findings when the Texas Legislature convenes in January.

Sunset commission staffers acknow-ledged the size of the job facing DSHS, which is responsible for more than 200 programs, but summarized the agency as a “jack of all trades and a master of none.” They noted, for instance, that the supply of psychiatric beds in Texas decreased by 19 percent over the last 12 years while the state’s population grew by 25 percent. The report said the vast majority of Texas counties are suffering a drought of a different kind than usual: They have been federally designated as having a shortage of mental healthcare professionals, to the point that, even when hospital beds were available in many cases, patients could not be admitted because there were not enough doctors, nurses, and other workers to take care of them.

From a base in Big Spring, for instance, West Texas Centers provides state mental health services across 23 counties. In only one county is there a psychiatrist to whom troubled residents can turn. For the rest, West Texas Centers and its 15 mental health clinics are often the first and last resort, providing care via a 24-hour hotline, nursing staff at the clinics, and access to psychiatrists through televised meetings. Even with clinics spread throughout the region, patients routinely drive an hour and a half to reach care.

“It’s a lot of territory,” CEO Shelly Smith said. “We don’t have public transportation; patients may not be able to afford to travel 100 miles to far-off places [for treatment], so we try to push the services out to the folks.” In the rural areas her clinics serve, “There are no other psychiatric resources around except us,” she said. “So it always falls back to us. We run pretty much on a shoestring budget in terms of staffing.”

The DSHS review wasn’t comprehensive, but sunset staffers found many problems nonetheless, including with the agency’s overall direction. DSHS directors, the report said, spend so much time putting out fires that the agency lacks strategic leadership.

DSHS, created in 2003 by merging four other agencies, still hasn’t managed to accomplish the tasks that were set for it back then, reviewers concluded. More than a decade after that consolidation, the department still hasn’t managed to mesh the initial assessment and referral process for mental health and substance abuse patients, the report said.

Nor has the agency addressed many other longstanding concerns, “despite clear and repeated direction” from the Texas Legislature and others, the sunset staff found — and despite a major infusion of cash into the agency by the legislature last year. Audit findings dating back to 2009, detailing the need to improve the security of the state’s vital-records system, still haven’t been addressed.

The report also reflects something that patients, their families, and healthcare professionals have been saying for years: DSHS tends to get bogged down in bureaucracy and “meaningless outputs” rather than focusing on delivering care to those who need it.

The report, released in May, has drawn little news media coverage. A few weeks ago, most of the critical recommendations of the report were endorsed, some in amended form, by the Sunset Advisory Commission itself, made up of Texas House and Senate members.

Then on Friday, another related sunset staff report was issued that could spell the end of DSHS as it is currently organized. The latest review, covering the rest of the health bureaucracy in Texas, called for even broader changes, affecting every aspect of healthcare, from rehabilitation services to mental health to child protective services.

“The time of reckoning for the difficult problems facing the health and human services system has arrived,” the new report concludes.

Bill Kelly of Houston, with the advocacy group Mental Health America, said he believes many people have become complacent about mental healthcare in Texas.

“The system is in crisis,” he said. “Like a lot of social services in this state, we haven’t invested properly [in mental health]. The infrastructure in [DSHS] clearly needs to change. This won’t be a one-bill solution.”

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