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Texas Money Follows the Person Behavioral Health Pilot
Comprehensive and Coordinated Services
Natalie Maples-Aguilar,MA, LPA, Faculty – Specialist, Department of Psychiatry, UT Health Science Center
Natalie To create the most effective treatment environment for the participant, many agencies work together to make this program a success. The Texas Department of Aging and Disability Services, or DADS, has contracts with relocation specialists who work with the participant while they are in the nursing facility to help them locate suitable housing when they leave.
The Health Maintenance Organizations or HMOs, provide specialized service coordinators to coordinate medical care and they also contract with agencies who provide personal care attendants. The local mental health centers, including the Center for Health Care Services and Austin Travis County Integral Care, have staff providing CAT and substance abuse treatment, and the University of Texas Health Science Center at San Antonio provides CAT therapists and clinical oversight for the CAT program. The ongoing partnership and efforts amongst all of these agencies and dedicated staff have helped our program participants overcome many obstacles and thrive in the community.
Susan Thompson, LCSW, Behavioral Health Case Manager, Amerigroup
Susan My role in the MFP Behavioral Health program is – I feel like I’m a gatekeeper because we have so many components to the behavioral health program. We have the CAT therapist, we have the person on our medical side that goes to the nursing homes and does a medical assessment, and then we have myself but we also have housing, we have the person that receives the documents from the state as well as all of the CAT therapists and the substance abuse therapists so I kind of feel like I’m the gatekeeper.
Right now, we have a format that I think is working really well because once a week we have a conference call and everyone on the team is present on that conference call so we really take the time to discuss what’s going on with everyone with every member that is active with the BH pilot, and we have an opportunity to raise questions, to brainstorm, to see if there’s something that we haven’t tried that might work.
[Marc S. Gold, Special Advisor for Policy and Promoting Independence, Office of the Commissioner, Texas Department of Aging and Disability Services]
Marc We have relocation contractors that help facilitate, provide education for movement of the individual back into the community setting. They help do paperwork, they help with housing navigation, they help provide new supports to set up a brand new type of household. We also provide a whole range of community-based services to support that person to have a successful living opportunity in the community of their choice.
Jennifer N. Coulthurst, LPC, Substance Abuse Counselor, Austin Travis County Integral Care
Jennifer The individuals served by this pilot program have lived oftentimes long, rich and challenging lives. It is crucial to work in collaboration with other agencies because people are dynamic and complex, and having a team helps the individual get the best care and creates a natural support system.
Helen Eisert, LCSW, MFP-BH Project Coordinator, Department of Psychiatry, UT Health Science Center
Helen The team approach is critical to this program and to the effectiveness of the services that we do. When you’re out in the field meeting with clients, there are so many different things that could be happening with them. It could be that they didn’t take their medication or they took too much of their medication, or they have low blood sugar, or they’re severely depressed and there’s something that’s related to mental health going on. So it’s wonderful as a social worker to be able to go and meet with clients and while I’m there, to be able to pick up the phone and talk to a nurse or talk to a substance abuse counselor, or talk to a physician and make all of those decisions in the field in the moment and get all of those perspectives at the same time.
As a social worker, I’ve worked with a lot of different collaborative groups in various positions, various jobs, and this one is pretty amazing to see actually work. The clients that we’re working with have such a high medical vulnerability and so many different issues happening at the same time, and to see a team approach empower the client to move forward and each member of the team being on the same page and that actually having that positive impact on the client is exciting to be a part of. It’s exciting to see.
Susan One of the most difficult parts of the program is when the CAT therapists and the substance abuse therapist are no longer going to be there and we have to start discharge planning. Reintroducing someone in that role, the role of a CAT therapist or a substance abuse therapist, people are very hesitant because they’ve grown so attached to the therapist that they have, and for a lot of people, they’ve never talked about these things with anyone else. It would be really nice if we could get two years with them. Two years post-community just because one year seems to go so quickly for people. I mean these are people that may have been homeless before they went to the nursing facility. They’ve never ridden a bus, they’ve never ridded you know, CARTS, Medicaid transportation, or gone to a primary care physician on a regular basis. These are all new behaviors that we’re trying to teach and trying to reinforce and trying to set as a pattern for them to continue in the future to maintain their health.
If this program was not offered in this community, the nursing homes would have an overflow of people. We would not have the ability, under my companies, to bring them out of the nursing home and into the community with supportive services. We just wouldn’t have the capability of doing that all by ourselves because most of these folks are complicated and they have complicated needs. This is a wonderful way to help people that really don’t need to be in a skilled nursing facility to transition back into the community, and we’ve had major successes with this program.
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