I. Transform the Austin State Hospital Campus

Gap Addressed 

After decades of deferred maintenance, the outmoded Austin State Hospital (ASH) has aged beyond repair. As described previously, the condition of the adult inpatient facility stresses the ability of clinical teams to provide evidence-based care for people whose needs cannot otherwise be met in the community. It does not meet many of today’s recommended design features that optimize care delivery and decrease the risk of violence and other negative outcomes. Additionally, the ASH campus itself is replete with aged and dilapidated support structures similarly suffering from decades of minimal and inconsistent upkeep, many of which are also beyond renovation and simply sit empty serving as little more than potential liabilities to the state. Moreover, these buildings detract from optimal use of the campus as a platform to advance the health of people with mental illness throughout the region.

Solutions

1. Replace the existing outmoded adult hospital with a new state-of-the-art facility.

As identified in the Cannon Report (Appendix 1), prioritized by HHSC’s “A Comprehensive Plan for State-Funded Inpatient Mental Health Services” (Appendix 2), and described in this report, the Austin State Hospital must be replaced. This replacement is the critical first step to transform the ASH Campus into a platform of a modern regional brain health care continuum.

As a starting point toward developing a Master Plan (Appendix 6) for the hospital and the campus, we identified key goals for the new adult inpatient facility to calculate capacity and cost for the biennial budget. We also identified additional factors that must be addressed to optimize this significant investment. As described previously in “Current State: ASH and its Service Area”, the annual operating budget for the inpatient facility is approximately $50M and has been flat for several years. This budget does not include all costs of care as many are embedded in other budget lines across all state hospitals (e.g., electronic health record costs) or the agency more broadly (e.g., employee benefits). This budget staffs and operates 260 to 265 beds. Consequently, if the operating budget remains fixed, it sets an upper limit on the capacity of the new hospital. HHSC set this limit as a relatively fixed guideline on our planning.

One factor that substantially guided considerations for the adult hospital replacement has been the need to transfer people who require mental health care out of jails and other facilities more quickly to ASH; that is, eliminate the waiting lists that exist currently. As noted previously, approximately 95 people daily are waiting for admission into ASH. Based on these considerations, we created a model to calculate the capacity of a new facility in order to clear the waitlists within six months of the new facility opening. To do so, we made two assumptions: 1) the waitlist is largely static (this assumption is largely true), and 2) the behavior of the system will not change with more beds becoming available (this assumption is probably false, and unfortunately what will change is very difficult to predict; we identify several other potential solutions in this section to manage that unpredictability). These assumptions were necessary for capacity calculations.

ASH has operated in FY18 at a capacity of 252 beds with 28 beds allocated to care for children and adolescents. As noted previously, there is minimal pressure to create more inpatient capacity in the youth facility; additionally, unlike the adult facility, the child and adolescent building is FCI rated as ‘fair,’ so can reasonably continue to be used with some improvements provided. At the current level of use, the child and adolescent facility can probably function at 24 beds. Also, as noted, about 70 individuals essentially reside at ASH with lengths of stay more than one year (mean > 900 days), effectively taking these beds off-line. Subtracting these two groups leaves approximately 155 general adult beds that are currently used to move people needing care off the waitlists (these beds include both civil and forensic cases). The average bed turn rate for these beds is 4.7 turns/year. In other words, each of these 155 bed opens up about every 78 days. Table 21, then, illustrates how fast the waitlists can be cleared based upon these assumptions, current bed-turn rates and different numbers of general adult beds. These calculations suggest that a minimum of 185 general adult beds (i.e., an increase in 30 general adult beds) is needed to clear the waitlists in <6 months. If we then add back the 70 long-stay individuals, the new facility requires 255 adult beds, which exceeds the current operating budget limitation noted previously (279 total beds when including a 24-bed child and adolescent unit). With these calculations in mind, we present three alternatives. In all three cases, we recommend leaving the child and adolescent facility where it is, with some minimal updating to be determined (<$5 million), and staff it to a capacity of 24 beds while improving other youth care capabilities throughout the Service Area (see Appendix 9). The alternative solutions, then, are:

Option A: Build a 240 adult bed hospital.

This approach fits within the current ASH annual operating budget while bringing additional beds on line to address the existing waitlists; additionally, by contract, HHSC requested a minimum 240-bed solution and this approach was the assumed recommendation prior to initiating this report. The cost of building this facility includes $246M for a 374,000 square foot, 2- or 3-story hospital and another $37M to prepare the 15-acre site. To prepare this hospital for future additions of up to 48 more beds, an additional $6.6M is estimated to build out the extra support space in the current design. The attached Master Plan provides additional details (Appendix 6).

However, this approach will not successfully empty the waitlist without decreasing and maintaining the number of long-stay (>365 days) individuals to less than 55 people, in order to keep 185 general adult beds available at all times to move people from waitlists. For every long-stay individual located to a better care solution in the community, 4 to 5 additional people can be accommodated annually (and even more with additional redesign components that we recommend). We propose achieving this aim by HHSC funding a team whose only job is to find alternative, more appropriate placements for these individuals; we estimate the cost of this team is $300K annually (two social workers specializing in placement, some legal support and a part-time psychiatrist). Of note, 40% of these individuals are being held for competency restoration far beyond the recommended maximum of 60 days (see Competency Restoration discussion later in this section), so this goal might be accomplished simply by processing these individuals back into or out of the legal system, e.g. by working with local jurisdictions to drop charges and to allow alternative placements. To get this launched, HHSC could charge the team with establishing individual patient reviews to pull together leaders and experts from the various care components to identify and remove barriers to allow better placement of long-stay individuals. These actions taken together could significantly reduce, but likely not eliminate, the total number of long-stay people at ASH until better options are available in the community. With the proposed team created, we expect this reduction to be accomplished while the hospital is being built.

Option B: Build a 216 to 240 adult bed hospital plus a 48 to 72 bed residential care unit.

Continuing to maintain people needing chronic, long-term care within an inpatient, rather than a residential, facility is inefficient, expensive and clinically ineffective. Consequently, an alternative solution is to build a replacement hospital AND move the majority of the people receiving long-term care to a residential care facility on the ASH campus. In this model, the cost of building a 240-bed hospital is the same, but more capacity is immediately created to more rapidly manage waitlists and provide capacity for growth. However, additional costs are incurred, estimated at $15 to 45M to construct a 48 to 72 bed residential facility with an annual estimated operating budget of $4 to 6M in addition to that for the inpatient facility). These costs likely would be managed through an LMHA, which would also own the operations of the facility. This model improves on the first solution for capacity and moves toward a better care continuum on campus, although adds additional construction and operational costs. It eliminates the risk of the first solution that alternative placements for the long-stay individuals cannot be found, by building the alternative. A variation would be to build a smaller inpatient facility (namely 216 beds) with a 48-bed residential facility, which would cost about the same as the previous 240 bed hospital, although could create operational savings.

A potential risk of this smaller facility is that it could be overwhelmed by existing needs prior to other care continuum improvements. Moreover, our HHSC contract required a 240-bed minimum hospital plan, and there are some stakeholders who might misperceive the smaller hospital as not increasing ‘beds’, even though with the residential facility, more capacity would actually be created than the first option. Additional discussion regarding residential care and supported housing are provided later in this document. The Master Plan leaves space for a 2- to 3-story, 48 to 72 bed residential center to accommodate this solution.

Option C: Build a 264-adult bed (or larger) hospital.

This solution requires an increased operating budget to support 264 combined adult and youth beds representing an increased estimated annual operating expense of $4 to 6M, over the current $50M annually. As will be discussed later in this section and as presented in the Master Plan, current best-evidence standards recommending building in 24 bed increments to optimize staffing and therapeutic milieu, which guided this next iteration of capacity. The cost of this larger hospital is $272M with $39M in site clearing costs ($311M total); a 288-bed hospital would cost an additional $19M ($330M total).

Of note, in preparing the Master Plan we considered the possibility of adding additional 24-bed units in later years, so we suggest leaving space on campus adjacent to the new hospital for that purpose. Regardless of which option is chosen, the hospital must be built. To this end, we developed a campus master plan that includes an initial estimate for building the new 240-bed facility (Option a.) as well as describing potential longer-term use of the campus. The inpatient facility has a number of best-evidence design features to provide state-of-the-art psychiatric care upon its completion and for the decades that the building will provide services. These features are described in detail in the Master Plan, but we highlight a few examples here.

a.    Single occupancy rooms.

As referenced in the Master Plan, single occupancy rooms, contrasted with double or multiple occupancy rooms, provide the optimal therapeutic environment thereby decreasing time to clinical improvement and the risk of aggression and violence, keeping safer the people receiving and providing care. Most health care facilities are moving toward single-occupancy solutions and there is little chance that this trend will reverse in the future. Anticipating the use of this facility for many years, this design feature is critical to keep it consistent with evolving standards. 

b.    A treatment mall.

Centralized treatment capacity is strongly recommended in modern facilities. This treatment mall is located on the first floor and creates a more efficient and effective comprehensive care delivery structure. This approach prepares individuals receiving care for transition to outpatient settings while consolidating multidisciplinary care providers to create a more collaborative work environment.

c.    Violence reduction.

The design of this hospital incorporates key features demonstrated to reduce the risk of aggression and violence toward people working and receiving care in the facility. These include:

i. Efficient 24 bed units create smaller, more residential autonomous subunits housing 6 to8 patients.

ii. Private bedrooms with ensuite bathrooms as noted.

iii. Day rooms and lounges providing a range of seating and setting choices.

iv. Views of nature and access to outdoors (especially porches and courtyards).

v. Patient privacy (and control).

d.    Functional efficiency.

The design of the hospital reduces staffing costs while facilitating work performance for support services through use of proximity and connectivity. This design feature allows for reallocation of scarce resources to direct care of people.

Additionally, as detailed in the Master Plan, there are several ‘optional’ expenses to consider as the facility is being financed and constructed. These include: 

a. Additional capacity built into the building with shared infrastructure to support the addition of 24 bed unit in the future to expand hospital capacity ($6.6M as noted).

b. Abatement and demolition of existing hospital buildings ($8M) to clear sites for future continuum of care partnerships; some of these expenses could be borne by partners.

c. Develop a Campus Square ($3.6M) that provides a signature space to function as the heart of the campus, linking the new hospital with historic Building 501 “Old Main”.

d. Extension of North/South drive ($3M) creates a central spine through the campus to improve ease of access to the new hospital and to provide a connective circulation amenity for linking future continuum of care partners.

e. Replacement of electrical gear and building enclosure ($11M) upgrades aged equipment and a deteriorating facility that currently acts as the electrical feed for the entire campus; a replacement will include a purposefully built facility for long-term use of the campus and likely operational savings with more modern energy equipment.

Specifically, then, we recommend legislative approval in this biennium of at least $285M to replace the Austin State Hospital. Although we prepared a Master Plan based on the first option (240 bed hospital only), largely related to original HHSC requests and assumptions, we prefer option b (216 to 240 bed primary hospital with 48 to 72 separate residential care beds, $288 to $330M) as we believe it better reflects the ultimate needs of the Service Area. It also creates more and variable capacity. To accomplish this second choice, changes in campus operations would need to occur. Moreover, funding of a residential center, and its operations, would likely flow through a Local Mental Health Authority. Consequently, funding for this resource might proceed through a different mechanism. We are not in favor of the third option (264+ bed hospital), unless there is no plan to proceed with other recommended system changes so that over-reliance on inpatient capacity will still be necessary. The Master Plan and next phases of construction planning can be easily adapted to any of these options.

2. Improve ASH operations.

With a new facility comes an opportunity to alter the structure and culture of hospital operations; in fact, in the absence of these operational changes, many of the advantages of a new facility will be lost. As identified in the “Current State: ASH and its Service Area” section of this report, the hospital struggles with a number of operational issues including frequent staff and management turnovers, difficulty recruiting and retaining experienced clinicians, high rates of restraint relative to other state facilities, and poor rates of survey engagement based on patient satisfaction. Although some of these challenges will improve simply with a new facility, others would benefit from alternative approaches to hospital management.

A new facility is an opportune time to make a clean break from existing operations and redesign them. Several approaches to such a redesign could be considered including: 1) allowing HHSC to simply continue in its current iterative approach toward hospital operational improvement, 2) bringing in a temporary consulting team from outside HHSC to develop short- and long-term improvement plans that HHSC then implements, 3) partnering with private hospital operational teams to bring their experience into running ASH, and/or 4) employing a local medical school to manage the hospital and its operations. Supporting this latter approach in general, Senator Jane Nelson recently introduced Senate Bill 63 (SB63) in which she proposes an academic consortium of Psychiatry Departments in Texas to improve the clinical care delivery, workforce development and research processes across the public mental health system. Academic leadership within the hospital and its operations brings the potential of continuously updating evidence-based care approaches, integrating with other components of the medical school’s health system collaborations, developing research and educational programs that improve care and create employee development programs, thereby attracting and training a highly qualified workforce. Having Health Related Institutions (HRIs) assist with direct operations of new state hospitals might be an extension of the intent of Sen. Nelson’s bill. This type of HRI involvement was an important component of the intent of the original bills that authorized funding and involvement of HRIs in the current planning.

A second relatively straightforward improvement would be to change the manner in which salaries for ASH staff are established so that they are competitive with the local market. In Austin, the current salary levels are below the city’s averages; coupled with an aging facility, ASH therefore becomes a less desirable option for people seeking employment opportunities.

At this time, we recommend developing a plan to move the management of ASH and ultimately the ASH campus to an academic partner, providing the right incentives and risk protection to make doing so feasible. This model has been successful at the Harris County Psychiatric Center (HCPC) where, for example, competency restoration averages about 52 days with a restoration rate of 87%. The HCPC units receive between the 50th and 95th percentile on Press Ganey performance measures, and all physician positions are typically filled with a waitlist of graduating residents who want jobs there. It also generates a small margin (e.g., 1% to 2%) most years. As second recommendation, we recommend increasing ASH’s operating budget to permit paying competitive salaries for ASH employees. This recommendation will likely require changes in HHSC operations to move away from statewide mandated salaries that ignore local market economics.

3. Change the ASH reporting structure.

The current mental health care system is not designed for smooth transitions among the various components of the mental health care continuum. An effective brain health care continuum requires strong collaboration and coordination among the stakeholders and providers of the various levels of service. This care coordination will not only provide better, evidence-based care “at the right place at the right time”, but will also better use limited resources. Health systems that provide this type of population health care (e.g., Kaiser Permanente) are integrated to incentivize placing people needing care at the most appropriate place within the system. Ideally, each of the levels of care benefit from efficient use of resources and provision of best practices across all of the components comprising the system. In contrast, ASH sits within a complex, siloed organizational structure that provides few incentives for any of the stakeholders to facilitate better inpatient utilization or collaboration across entities. State funding streams to ASH, Local Mental Health Authorities and the legal system are largely managed separately so that each entities’ incentives are independent of the success of other components of these intersecting systems. Consequently, ASH clinicians report constant barriers to hospital discharge, ranging from an inability to override a court’s order leaving the patient in the hospital for prolonged competency restoration to refusals to accept referrals into outpatient services. Leaders among the sheriffs, police, courts and LMHAs report essentially the same experiences in reverse when referring individuals into ASH.

Compounding this problem, ASH reports into a massive bureaucratic entity (HHSC) responsible for a myriad of loosely or unrelated functions including managing very large insurance products (Medicaid, CHIP), providing health related regulatory responsibilities, and overseeing statewide health care and other procurement; i.e. HHSC is a giant, mostly 8 am to 5 pm, mostly contract procurement and oversight agency. Inside of this giant bureaucracy, HHSC attempts to efficiently and effectively run a 24-hour, emergency-and-acute-care health services network, that functions completely differently than what is needed for regulatory or procurement processes. Ideally, the state hospitals would function more like one of HHSC’s provider-agents than like HHSC (as is done in Houston at HCPC). The executive skills and administrative operational support needed for procurement and regulatory oversight are vastly different than those needed for hospital operations. Hiring processes, IT systems, legal oversight and clinical services are all different for a procurement agency than they are for a service-providing agency. For example, the latter must be able to adjust salaries to assure full staffing, bill for its services, and negotiate provider rates that are competitive with the local, not statewide, market. Local markets vary widely based on the size of the community, its desirability as a place to live, its job market and many other factors that preclude a statewide solution.

It is hard to imagine, then, how an effective health system can be managed within the sheer size and scope of HHSC’s structure. To create the best mental health care system, ultimately alternative approaches are necessary. We recommend creating an independent hospital board that is given governance and fiduciary responsibility for ASH that includes appointed stakeholders tasked to improve incentives for system-wide collaboration. Stakeholders might include leaders of Service Area LMHAs, sheriffs, justices, leaders from peer organizations (e.g., NAMI) and people experienced with private health system management. HHSC, then, would do what it is designed to do; i.e. contract for services with this regional state hospital board for services in a defined service area, similar to how it does with the LMHAs. The hospital board would be responsible for hospital performance and developing better regional cross-service care integration to truly move individuals needing care to the right place at the right level of care at the right time. While the new ASH facility is being built, there is an opportunity to address these changes, implementing them with the new facility opening.

4.  Initiate a brain health platform on the ASH campus and beyond.

Our vision for the ASH campus transformation extends beyond simply replacing a hospital to creating a platform that establishes best practices for mental health across the entire continuum of care and the ASH Service Area. Specifically, after completing the first phase of transformation (building the new adult hospital and possibly some residential care), we propose a series of phases that remove existing outmoded and empty buildings and replace them with functional examples of additional components of a brain health care continuum. In most instances, we propose that components built on the campus are then leveraged through telehealth or new programs and facilities in other counties throughout the Service Area to build out a true regional care model. This model will depend on strong links with academic, public and private partners. As these components of the brain health care continuum are built on campus and across the Service Area, these improvements will lead to decreasing emphasis on expensive crisis and inpatient care to more efficient and effective outpatient and preventive mental health support, optimizing both the state’s investment in mental health and the improved brain health of its citizens. For example, an additional 24 bed unit with the current bed-turn rate would treat approximately 110 individuals and cost $6.5 million additional dollars to operate (and $23 million to build); if instead these operating funds were spent on 3-month intensive outpatient programs, 8 times as many people (976 individuals) could be treated in the same period, diverted from inpatient care and likely experience better outcomes. The Phases of the transformation are detailed in the Master Plan, and are summarized here.

Phase 1. Clear site and then build new hospital with a minimum of 240 adult beds.

Phase 2. Remove old hospital buildings.

Phase 3. Use old hospital sites for new brain health care components (with duplicates in other counties in the Service Area as appropriate). These could include, but are not limited to:

1. Community- or privately-owned short-term acute stabilization hospital

2. Residential care/supported housing

3. LMHA intensive outpatient clinic or day hospitalization

4. Substance use disorder treatment center

5. Medical facility, e.g., FQHC

6. Other components (please see Master Plan (Appendix 6) for additional examples)

Phase 4. Remove HHSC administrative offices to alternative locations to create campus space for additional components and brain health-related functions.

Other than Phase 1, which has an established timeframe based on funding appropriations we hope to obtain in the 86th Texas Legislature, the other Phases will occur over several years and legislative sessions. Many of these additional brain health components would be created in partnership with other public and private organizations that would provide substantial funding to build and operate the facilities and programs. To facilitate the use of the ASH Campus, we recommend that the state develop a program of business incentives, e.g. tax or land credits. Additionally, we recommend as a next step toward this longer-term campus transformation, that HHSC will soon release a Request for Information (RFI) to begin to identify these potential partners. Following that, we recommend appointment of and funding for a campus oversight team to develop specific partnerships, resources and recommendations to fulfill this strategic vision. With the right planning and incentives, the ASH campus can become a national model for the care of people struggling with mental health conditions.