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Health and Human Services

### Executive Summary

#### Key Objectives
- Identify the types of mental health and substance abuse services provided by State agencies, including who provides the services, division of responsibilities for delivering services, and how outcomes are measured.
- Determine if any duplication of services exists among state agencies and private providers and examine opportunities to better alignment of expertise with delivery of services.
- Identify challenges facing mental health and substance abuse providers in delivering services.
- Evaluate best practices among States for the delivery of mental health and substance abuse services and identify opportunities for improved outcomes.

Nationally, mental health and substance abuse are recognized as conditions affecting the overall health of individuals. The high degree of co-occurrence between mental health and substance abuse have resulted in grouping services for both these conditions together under the category of “behavioral health.” Oklahoma ranks 33rd among states for prevalence of mental illness.  However, it is difficult to determine the true scope of the mental health needs of Oklahomans, as statewide figures are primarily from surveys and self-reported data.

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Oklahomans’ mental health needs are met through a combination of private providers, non-profit organizations, and state entities. Those with private health insurance often receive services from private providers. The State Department of Mental Health and Substance Abuse Services (ODMHSAS) serves as the State’s “safety net,” providing emergency services to all populations, and prevention and treatment services to children, Medicaid recipients, and indigent populations who are either underinsured or uninsured. Other populations, such as students within public school districts or those incarcerated at State correctional facilities, receive services through other State agencies.
ODMHSAS is responsible, through contract and direct operations, for mental health and substance abuse prevention and treatment services statewide. This includes acute care and inpatient services, residential treatment, community-based treatment, outpatient services, crisis stabilization, programs for assertive community treatment, services for children and families, a statewide community prevention network, and education and awareness activities. The Department also oversees and manages the behavioral health component of Oklahoma’s Medicaid program.
ODMHSAS providers must treat all individuals for emergency services without regard to ability to pay. The Department is deemed as the “payer of last resort,” meaning providers must seek other third-party reimbursement through eligibility determination, billing, and collection prior to the use of Department funds. In FY22, the Department of Mental Health and Substance Abuse Services received more than $529 million in total funding, 62 percent of which was from State appropriations and dedicated funds.

With this evaluation, LOFT sought to evaluate Oklahoma’s organizational structure for the delivery of mental health services, examine how outcomes are measured, and identify opportunities for improved delivery and outcomes. Additionally, LOFT examined the challenges facing the delivery of services and identified best practices from other states that could be adapted by Oklahoma for improved outcomes.
LOFT identified two key domains for the delivery of public services: those delivered directly by or through the State Department of Mental Health and Substance Abuse Services, and those delivered separate from the agency.

#### Services Delivered by or in Coordination with ODMHSAS
In FY21, approximately 182,000 Oklahomans received mental health and substance abuse services through ODMHSAS. Of the nearly 843,000 Oklahomans in need of behavioral health services, the Department estimates there are approximately 100,000 who are eligible for State provided services but are not receiving them.
ODMHSAS is responsible for the operation of 11 facilities within the state, some of which have multiple locations. These facilities offer specialized services, and some cater to a particular demographic. The State facilities serve as mental health providers of last resort, supporting the criminal justice system and serving some of the most challenging mental health populations.

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The range of facilities can be compared to those within a traditional health care delivery model. Crisis centers are the equivalent of an emergency room, stabilizing individuals who are experiencing a mental health crisis and pose a threat either to themselves or others. Inpatient hospitals operate similar to other hospitals, providing a bed and treatment services until the patient is deemed improved enough to leave. Community Mental Health Centers provide the most accessible treatment services, offering outpatient services akin to a general practitioner’s office. In addition to State operated facilities, ODMHSAS uses a network of non-profit providers to help meet the mental health needs of Oklahomans. These clinics provide a broad range of behavioral health services, from outpatient therapy and vocational services to inpatient treatment and psychotherapy.

#### Services Provided by Non-ODMHSAS Agencies
While the Department of Mental Health and Substance Abuse Services delivers services to children through State operated facilities and contracted private providers, the majority receiving mental health services do so through their schools. Oklahoma public schools are required to provide suicide awareness training to staff. School counselors provide short-term counseling to students and make referrals for long-term support or crisis intervention. Some school districts have partnered with private providers (using Medicaid funds) to provide students with on-site services from licensed mental health counselors. 
Other specific populations receiving State supported services include veterans, first responders, incarcerated individuals, and justice-involved youths. While LOFT did not observe any direct duplication of services across ODMHSAS and other agencies, the limited coordination among entities serving the same population (such as children under the age of 18) and the lack of unduplicated data presents the likelihood of inefficient delivery of services. Additionally, some agencies, like the Department of Corrections, may be providing services that could be provided by mental health entities. 

#### Service Delivery Strengths, Challenges, and Opportunities
Oklahoma’s system of mental health services is delivered across local governments, court systems, law enforcement, private providers, and non-profit organizations. Throughout the evaluation, LOFT identified both strengths and overarching challenges within the State’s mental health system, as well as opportunities for stakeholders to improve collaboration, identify and close gaps in services, enhance data collection, and build a more robust framework for the delivery of mental health services.

_Strengths_
Oklahoma is the first and only state with full statewide coverage of Certified Community Behavioral Health Clinics (CCBHCs). These clinics are part of a national pilot program for an expanded behavioral health model, providing 24-hour crisis care, care coordination with local primary care and hospital partners, and integration with physical health care. The additional services offered by CCBHCs use a new Medicaid model for payment that offers providers more flexibility regarding treatment and greater financial stability than the traditional fee for service model.
Additionally, the Department of Mental Health and Substance Abuse Services created a performance pay program to reward providers who meet or exceed established benchmarks for health care treatment. Since the program’s inception in 2009, providers have consistently increased performance scores. The success of this program has resulted in national recognition, with many states looking to Oklahoma as the example for developing their own provider incentive system.
LOFT also found participation in Oklahoma drug courts to be strongly associated with socioeconomic gains including employment, education, and incomes levels, in addition to yielding significant cost savings over incarceration. Oklahoma is also one of just 15 states with a Cohen clinic, a public/private partnership between the State and the Cohen Veterans Network to serve military veterans and their families. 

_Challenges_
Challenges facing state-operated inpatient facilities include a rising demand for services, limited bed capacity, insufficient data to accurately project outstanding and future needs, workforce shortages and high employee turnover. Specific facilities have unique challenges, such as the Oklahoma Forensic Center (OFC), which is the only state facility that houses and treats people adjudicated as Not Guilty by Reason of Mental Illness (NGRMI). COVID-19 and a rising NGRMI population have resulted in a significant increase in OFC’s wait list.
There are also program-specific challenges. For example, while participation in drug courts has positive outcomes, participation is declining due to reclassification of simple drug possession as a misdemeanor instead of a felony. The prior incentive of avoiding incarceration led to individuals receiving treatment. Another delivery challenge is limited targeted services to Oklahoma veterans, who have a suicide rate exceeding that of Oklahoma’s broader population. 
Systemwide challenges that exist across the State’s delivery of mental health services include:
- A lack of comprehensive and quality data from which to assess program outcomes or examine specific populations (such as students and first responders)
- Compartmentalized data and information within State agencies that limits an overall assessment of Oklahoma’s mental health and behavioral needs
- No statewide coordination or unified strategy for funding or meeting the multifaceted behavioral health needs of Oklahomans, which results in service gaps, the potential for duplication of State services, inconsistent data collection and usage, and limits the ability to assess outcomes
- Rising demand for services amid a forecasted workforce shortage of mental health professionals
- Limited rural access to behavioral health treatment and services
- Continuum of care to assist in transitions and reduce relapses in health

_Opportunities for Improved Outcomes_
LOFT identified several best practices from other states’ mental health delivery systems that could be adapted by Oklahoma, including requiring interagency data sharing and coordinated usage and reporting of information, offering relocation tax credits for mental health providers and practitioners, conducting an inventory of current services available across school districts to identify service gaps, having the State Department of Veteran Affairs take on a more direct role in providing resources and treatment to veterans, and using community partnerships to better coordinate services to those engaged with the criminal justice system.
Creation of a coordinating council, similar to what the Texas Legislature established in 2017, could provide a roadmap for Oklahoma to develop a strategic statewide approach to efficiently and effectively deliver behavioral health services. Already, the Texas Council has identified 15 targeted population service gaps within its system. Additionally, the Council works to ensure agencies’ legislative appropriation requests avoid duplication and are consistent with the goals of the strategic plan. Key steps in implementing a similar model are using a central governance structure to deliver behavioral health services across the state, paired with a long-term strategy for better alignment of resources. Strategy goals are aimed at using data to develop evidence-based solutions for improving behavioral health services and outcomes.



Executive Summary

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August 2022

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