State Advocacy Team Summary - Texas
The Texas (TX) state advocacy team was led by chapter leads Melissa Compton, Executive Director of Lone Star Bleeding Disorders Foundation and Shanna Garcia, Director of Development at Texas Central Bleeding Disorders; and HTC lead, Sabrina Farina, senior social worker at Gulf States Hemophilia Treatment Center. The team was also supported by members Julie Jones, Executive Director of Texas Central Bleeding Disorders; Cheri Huddleston, Legislative Consultant at Hance Scarborough, and Mark Hobraczk, Director of Policy and Advocacy at the Hemophilia Federation of America.
Summary of Achievements
In their first year, the BD SUMHAC TX team successfully:
Engaged with state officials from the Texas Health and Human Services (HHS)
Identified two state champions (one for SUD and one for MH)
Mapped the regulatory landscape of MH and SUD facilities, with particular attention to policies related to:
Self-administration of infusion and injection medications
Staff assisted administration of infusion and injection medications
External provider assisted administration of infusion and injection medications
Patients’ ability to bring in their prescribed medications from home/outside of the facility (i.e., white and brown bagging)
Patient cherry-picking
Presented and shared more about BD SUMAC’s local advocacy work at the 2024 Texas Bleeding Disorders Conference
The team’s accomplishments were also highlighted in a BD SUMHAC article that can be found here.
Regulatory Landscape Mapping
Sorted by landscape area. All regulatory Information is as of July 2024
SUD Facility Information
Use of infusion/injection medication
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“(h) Individuals shall not be denied admission or discharged from treatment because they are taking prescribed medication.”
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TX Administrative Code prohibits residential SUD facilities from denying access or discharging clients based on use of prescribed medications. This means that SUD facilities cannot deny people because they use infusion/ injection medications.
Self-administered infusions/injections
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Title 26 Part 1 Chapter 564 Subchapter J RULE §564.1004 Administration of Medication:
(c) Clients may self-administer medication under the supervision of staff who are trained as described in §148.603 of this title.
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TX Administrative Code permits people to self-administer medication at SUD facilities provided that the individuals are supervised by trained facility staff.
While the code does not explicitly include self-administration of infusion or injection medications, HHS staff agreed that it should be included under this general provision.
The code does not include any specific training related to the supervision of infusions or injections.
Staff administered infusions/injections
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Title 26 Part 1 Chapter 564 Subchapter J RULE §564.1004 Administration of Medication:
(b) Prescription medication shall be administered only by nurses and other staff who are legally authorized to administer medication.
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TX Administrative Code permits SUD facility staff who are legally authorized to administer medication. While it is not explicit in the code, HHS staff agreed that facility staff are able to give infusions and injections if it within the scope of the staff member’s license under the general provision.
External provider assisted infusions/injections
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Title 26 Part 1 Chapter 564 SubchapterI RULE §564.901 Requirements Applicable to All Treatment Services:
(g) The program shall facilitate access to physical health… if those services are not available through the program and are necessary to meet treatment goals and shall document these efforts.
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If the facility doesn’t have legally authorized staff and the person can’t self-administer their medication, TX Administrative Code requires SUD facilities to facilitate access to infusions or injections.
HHS staff agreed that potential options could include:
• Permitting an external provider who is legally authorized to administer infusions or injections to do so in the facility
• Bringing the person to a local emergency department for the infusion or injection
Policies to prevent cherry-picking
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Title 25 Part 1 Chapter 448 Subchapter 1 RULE §448.912: Miscellaneous Policies and Protocols: “A licensed chemical dependency treatment facility shall not discriminate based on a client's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S (relating to Allocation of Kidneys and Other Organs Available for Transplant).
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TX administrative code specifically prohibits SUD facilities from discrimination on the basis of disability. Additionally, facilities that accept federal assistance do have to comply with federal requirements such as Section 504 and provide reasonable accommodations.
MH Facility Information
Use of infusion/injection medication
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(a) Inpatient mental health treatment. A hospital shall provide inpatient mental health treatment and medical care to a patient under the direction of a physician, in accordance with the highest standards accepted in medical practice, and in accordance with the patient's treatment plan and this subchapter.
Title 26 Part 1 Chapter 568 Subchapter D RULE §568.62 Medical Services:
(h) Provision of medical services. A hospital shall provide:
(2) other medical services, as needed by the patient, or transfer the patient to a health care entity that can provide the medical services in accordance with the following, as applicable:
(A) §510.43 of this title (relating to Patient Transfer Policy), or a transfer agreement made in accordance with §510.61 of this title (relating to Patient Transfer Agreements); or
(B) 25 TAC §133.44 (relating to Hospital Patient Transfer Policy), or a transfer agreement made in accordance with 25 TAC §133.61 (relating to Hospital Patient Transfer Agreements).
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The general requirement in the administrative code is that MH facilities provide medical care, “in accordance with the highest standards accepted in medical practice.” Since prophylactic treatment through use of infusion or injection medication is the standard of care for individuals with bleeding disorders, the administrative code suggests that an individual with a bleeding disorder should be able to receive this care in an inpatient mental health facility.
However, the code is ambiguous but language in a later section appears to suggest that a facility can meet the requirement in the code to provide medical services (which includes infusion or injection services) by either providing the medical service or by transferring them to another health care entity who can provide the service.
It appears that a facility could meet this requirement by simply transferring an individual to a general hospital that does not offer psychiatric services, which would leave the individual without access to needed services.
Self-administration of infusion/injection medications
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The administrative code is silent on self-administration of medication in mental health facilities.
(2) The treatment plan shall contain
(A) a list of all diagnoses for the patient with notation as to which diagnoses will be treated at the hospital, including:
(iv) any other non-psychiatric conditions;
(c) Treatment plan content within 72 hours.
(1) Within 72 hours of the patient's admission the hospital shall:
E) add to the treatment plan:
(ii) the specific treatment modalities for each treatment intervention by type and frequency
(iii) the interdisciplinary treatment team (IDT) member responsible for providing or ensuring the provision of each treatment intervention;
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It is unclear whether self-administration of medication is permitted in MH facilities.
The code requires the facility to develop a treatment plan that identifies the specific treatment modalities for each treatment intervention by type (which would include the identification of an infusion or injection medication) necessary to meet the individual’s medical needs.
Further the plan must identify a member of the staff who is responsible for providing or ensuring the provision of each treatment intervention.
This could be interpreted as including the oversight of self-administration of medication. However, the code is silent as to whether this is permitted.
Staff-administration of infusion/injection medications
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(2) The treatment plan shall contain
(A) a list of all diagnoses for the patient with notation as to which diagnoses will be treated at the hospital, including:
(iv) any other non-psychiatric conditions;
(c) Treatment plan content within 72 hours.
(1) Within 72 hours of the patient's admission the hospital shall:
E) add to the treatment plan:
(ii) the specific treatment modalities for each treatment intervention by type and frequency
(iii) the interdisciplinary treatment team (IDT) member responsible for providing or ensuring the provision of each treatment intervention;
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The code requires the facility to develop a treatment plan that identifies the specific treatment modalities for each treatment intervention by type (which would include the identification of an infusion or injection medication) necessary to meet the individual’s medical needs. Further the plan must identify a member of the staff who is responsible for providing or ensuring the provision of each treatment intervention.
This suggests that staff members could be responsible for administering infusion and injection medications.
Next Steps for Advocacy
The TX team has determined the following goals for Phase 2:
Provide education for SUD/MH facilities on BDs, infusion and injection medcations, and related topics to support staff development across the state.
Deepen our understanding of the MH regulations and potentially seek to clarify as necessary through HHS statements, updated regulations and/ or statute.
Provide education and resources for HTCs on steps to take in the event of a patient denial to an inpatient or residential MH/SUD facility.