A Crisis in Care

Bill Kelly has seen DSHS’ inefficiency firsthand as public policy director at Mental Health America of Greater Houston. He said health professionals he’s spoken to have trouble understanding how to bill or coordinate services with the huge state agency.

“It’s a $6.5 billion department, and there’s a lot of red tape to fight through,” he said. “In talking to contractors like hospitals and smaller providers, [the feedback MHA of Houston directors receive] is that the process becomes onerous and that it’s almost too hard to deal with.”

DSHS’ addiction to red tape is a major factor in many problems noted in the report. Not enough staff at the state hospital? That’s due in part to a bureaucracy in which basic personnel actions can take more than a year — so long that applicants sometimes just gave up. And the sunset staffers found that, far too often, DSHS tends to substitute the filling out of forms for any actual showing that patients are being helped.

Sherry Cusumano, board president of the National Alliance on Mental Illness office in Dallas, said the recommendation to measure outcomes validates a concern she has long held.

DSHS “measures a whole lot of things, but they have yet to measure outcomes,” she said. “What impact is your intervention having? It’s difficult to do, but it has to be done. If [patients] are not experiencing remission, then our tax dollars aren’t being used effectively. I’m not trying to paint villains, but the system is difficult to deal with, and the people we serve need a much more cohesive effort.”

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The report’s overarching theme is of an overburdened agency that bounces from one emergency to another, frequently moving on to a new crisis before the last one is truly dealt with.

“The sheer scope and complexity of DSHS’ many responsibilities poses challenges to its management and focus,” the sunset staffers wrote. Their report questions the wisdom of the 2003 consolidation and repeatedly mentions the possibility of disbanding the agency.

The failure of DSHS to begin dealing with mental health disorders and substance abuse as two parts of the same picture has been a longstanding problem.

Garnett said that when State Health Services was formed, the medical community was re-evaluating how mental health disorders and substance abuse should be treated. While health professionals began treating the two conditions together, DSHS never adapted to the new approach, she said.

“Now hopefully we’ll see legislative guidance to bring those two pieces together,” she said.

There’s an additional aspect of the review process that has to be finished before the sunset commission can make final recommendations on the future of DSHS. As unlikely as it may seem, there is yet another bureaucracy above DSHS — the Health and Human Services Commission, which oversees the health services agency plus the departments of Aging and Disability Services, Assistive and Rehabilitative Services, and Family and Protective Services. The sunset staff review of the Health and Human Services Commission was released on Oct. 2.

Ken Levine, director of the Sunset Advisory Commission, said public hearings and staff testimony on the HHSC report are scheduled for Nov. 12 and 13, and the sunset commission is due to vote on the recommendations on Dec. 10.

As with the DSHS report, the Health and Human Services sunset review concludes that the 2003 consolidation of agencies is the “obvious starting point” for the health system’s current woes. The report’s first recommendation calls for consolidating all the far-flung elements of the state health system into one agency.

Part of the basic problem, the report said, is the “incompleteness of [the] setup” of the Texas health system that was done in 2003. That led to vague lines of accountability and overlapping services, all of which needs to be fixed, the reviewers said. The fact that Health and Human Services oversees this immense system while also managing the state’s Medicaid program only adds to these problems, they concluded.

The current fragmented health system has led to the “five system agencies developing about 100 websites and maintaining 28 separate hotlines. The system’s piecemeal approach to developing these resources requires users to navigate an increasingly complex network of information, frustrating even savvy stakeholders familiar with the system,” the report said.

Nelson said the sunset review on the Health and Human Services Commission will help her evaluate whether DSHS “should continue in its current form, a modified form, or not at all.”

Cusumano acknowledged that she has already seen DSHS officials responding positively to the sunset review findings.

“But we’ll see where the rubber meets the road,” she said.

Back in Arlington, Julie Belindo said she is glad she moved back to Texas to be near her family. She knows that her sister may never improve, but she still believes that a nursing home is not the ideal situation for a person like Angela, who needs psychiatric care.

“If this is her fate, and if this is the best she will ever improve, then there should be something more” for Angela and others like her, Belindo said.