Texas Tribune
Primary care providers take on more mental health duties
by By Stephen Simpson, The Texas Tribune – 2024-06-17 05:00:00
SUMMARY: Barbara Chapman's experience with a cancer patient lacking insurance led her to advocate for integrated mental and medical health care. As a professor at UT Tyler, Chapman promotes a collaborative care model in primary care settings, emphasizing early mental health diagnosis, which can resolve crisis situations more effectively. Mental health and medical treatment remain disparate in structure, finance, and access, particularly in rural Texas, where most counties face severe provider shortages. Programs like Texas's Child Psychiatry Access Network and Healthy Community Collaborative illustrate progress but highlight the need for broader adult mental health services.
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It took one cancer patient 15 years ago to convince Barbara Chapman that the model of mental health treatment needed some serious work.
It was 2009, and she was an advanced practice nurse working in a Dallas primary care practice when she met a female patient diagnosed with breast and lung cancer. The same woman had also been diagnosed with schizophrenia.
The woman didn't have health insurance, but Chapman was determined to help her navigate the medical system for both cancer and mental health treatment. After several weeks, Chapman was able to find a place that would treat her physical and mental illnesses.
“I made a promise to her that I would do everything in my power to make sure nobody had to go through that again,” Chapman said.
That seminal experience is why Chapman, who now serves as an assistant clinical professor for the family nurse practitioner and psychiatric mental health nurse practitioner programs at the University of Texas at Tyler, has been an advocate for a better, collaborative care model for mental and medical health fields.
“There is not a diagnosis that doesn't have a mental health component. I am doing everything in my power to promote that message to my students and others because we can work together to solve this crisis we find ourselves in,” Chapman said. “This means we can be the front line to total treatment.”
Behavioral health has historically been structured, researched, financed, and regulated differently than general health care, and mental health and substance use disorders are typically treated as a specialty.
Even the way people pay for mental health and medical treatment has been vastly different.
“A lot of people don't have psychiatric services in their health insurance, or if they do, it might only cover three visits or something to that effect, and then the rest of it is out of pocket,” Chapman said. “While in medical, the way insurance is set up is pretty straightforward. It's one of the obstacles we haven't gotten past.”
Keeping mental health a separate field has contributed to the workforce shortage Americans are now experiencing. Mental health services are not distributed evenly nationwide, as providers can't keep their doors open in most rural or lower-income areas because reimbursement from health insurance plans is so low.
In Texas, 98% of the 254 counties are designated as mental health professional shortage areas. Texas ranks last in the nation for access to mental health care. In rural Texas, the shortage can be even more problematic because patients earn less than in cities, may not have health insurance, and then there's the added cost of transportation to larger towns and cities that do have therapists or psychiatrists.
Experts say the best way to solve this crisis is by early diagnosing mental illness before it reaches a point where medical treatment, hospitalization, or other intensive services are needed. However, studies have found primary care physicians are often the first point of contact when it comes to mental illness, not behavioral health providers.
“I have had people come into my office for a blood pressure check or routine blood work, and all of a sudden, they break down in tears and start telling me all the other things that are going on with their life,” Chapman, who volunteers her time with mobile health services around the state, said.
This is why people like Chapman believe the answer to the mental health crisis might be in the medical field, starting with the collaborative care model, where every routine primary care check-up can include a screening for behavioral health issues like depression, anxiety, and substance use, similar to what primary care doctors do for blood sugar and cholesterol levels. This gives the primary care provider the responsibility of early detection before a mental health concern turns into a crisis.
Chapman said primary care providers have understandably been slow to adopt this model mainly because some may lack confidence in making a mental health diagnosis and are combating workforce issues of their own.
The federal government estimates that the United States will be short some 68,020 have a primary care physicians by 2036.
“Yes, they're already overwhelmed. And so taking on mental health care issues while dealing with an already very busy primary care practice will be a difficult thing to do,” Chapman said. “But I tell all my students, you have to understand that you are the first line of defense. We are the first to hear about someone being a little depressed or that they are going through a divorce or that a mom died.”
Dr. Zachary Sartor, a family medicine faculty physician at Waco Family Medicine who treats the underserved residents of McLennan and Bell counties, said the collaborative care model has become an essential part of the medical field. He said his clinic has taken a unique approach to collaborative care by having mental health providers work alongside primary care to ease the burden on both fields.
“The collaborative model can take a lot of time and can limit our ability to do this, so having those providers working beside us in the clinic makes that time limit feasible. If I see someone for hypertension, they can also see someone for depression, allowing us to see more people without putting an additional burden on the clinician,” he said.
Sartor believes primary care is well-positioned to impact the mental health crisis in Texas. He said patients usually prefer to meet with their primary care doctor about mental health, which allows them to be treated for everything under one roof, which is key for rural areas of the state.
“I believe most mental illness can be treated in primary care with the right training,” Sartor said. “There will always be a need for specialists in mental health, but primary care has a broad scope of practice, and this will allow us to treat most of these effectively.”
Chapman, at UT-Tyler, believes that if primary care providers are only tasked with handling low-level mental illnesses like ADHD, anxiety, and low-scale depression, then the medical field can help mental health providers without overwhelming themselves in the process.
“There are things primary care providers can't handle like schizophrenia or bipolar disorder and higher level diagnosis like that. But we are in an all-boots-on-the-ground situation. None of us are doing well,” she said.
A new approach
In Austin, Dr. Roshni Koli, is one voice primary care physicians turn to when they need help with a mental health diagnosis for a child.
As a psychiatrist and assistant professor of psychiatry at Dell Medical School, Koli has been answering primary care doctors' questions as part of the state's Child Psychiatry Access Network, which provides telehealth mental health consultations.
The questions she takes range from “What kind of diagnosis goes with these symptoms?” to “What kind of medication is needed for anxiety?” to “Where should I refer someone with suicidal thoughts?”
“I just got off a call where a primary care physician was asking about a plan for anxiety for one of his patients. They had already figured out the diagnosis but just needed some help with medication. Most people call me with some idea already,” Koli said.
The Texas Legislature created CPAN in 2019 as part of a larger group of programs designed to improve psychiatric care for young people. These include the Perinatal Psychiatry Access Network, which allows reproductive care providers to call a mental health provider for assistance with their patients.
“Mental health and physical health are inextricably intertwined. Both are essential for good health, but oftentimes, those notes collected by primary care doctors and psychologists are not shared with each other,” Koli said. “We are starting to see that change.”
Koli said that ever since the COVID-19 pandemic, she has seen a strong willingness from primary care providers to start getting involved with the program.
Since 2019, CPAN has enrolled more than 12,700 providers and nearly 2,500 clinics and completed over 34,000 calls either for consultation with a psychiatrist or for specialized resources and referrals.
“It kind of just makes sense for primary care to take this on. Physicians are already monitoring if you have high blood pressure, or high cholesterol and do follow-ups based on those reports. We can apply those same principles to mental health,” Koli said.
The Meadows Mental Health Institute released a study in 2020 that suggested if every Texan with major depression had access to the Collaborative Care Model, between 725 and 1,100 lives could be saved every year.
Texas Health and Human Services also has its own model called the Healthy Community Collaborative, which promotes partnerships between public and private sectors to integrate services for people experiencing homelessness and mental illness and/or substance use disorders.
“We have seen once you treat someone's mental illness, their physical health improves as well,” Koli said.
Chapman said these state-sponsored collaborative care programs show Texas is moving in the right direction. However, she said these programs currently only cater to very specific populations, and the state has a dire need for overall adult mental health services.
“We need to set up something with the same model for adult care. I think it's a good model that needs to be implemented in all other areas,” she said. “We need this for everyone.”
Dell has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.
Just in: Former U.S. Rep. Liz Cheney, R-Wyoming; U.S. Sen. Jon Fetterman, D-Pennsylvania; and Oklahoma Gov. Kevin Stitt will take the stage at The Texas Tribune Festival, Sept. 5–7 in downtown Austin. Buy tickets today!
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The Texas Tribune is a nonprofit, nonpartisan media organization that informs Texans — and engages with them — about public policy, politics, government and statewide issues.
Texas Tribune
Texas to double state fund aimed at expanding power grid
by By Kayla Guo, The Texas Tribune – 2024-07-01 17:05:54
SUMMARY: The state of Texas plans to double the Texas Energy Fund from $5 billion to $10 billion to expand the power grid as electricity demand is expected to nearly double by 2030. This follows a forecast by the Electric Reliability Council of Texas, which estimated the state's main grid would need to supply nearly twice its current power. The fund, approved by voters in November 2023, offers low-interest loans for new gas-fueled power plants. The state's grid has faced scrutiny since a 2021 winter storm caused extensive outages. Companies must apply for loans by July 27.
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The state of Texas plans to double a state fund aimed at expanding the power grid as demand for electricity is expected to nearly double over the next six years.
The state will look to boost the Texas Energy Fund from $5 billion to $10 billion, Gov. Greg Abbott and Lt. Gov. Dan Patrick announced on Monday. The fund was approved by voters in November 2023 to offer low-interest loans to incentivize development of new gas-fueled power plants.
The announcement comes soon after a new prediction by the state's main grid operator that said electricity needs will surge in the coming years. The Electric Reliability Council of Texas estimated that the state's main power grid would have to provide nearly double the amount of power it currently supplies by 2030.
The numbers in the new forecast, Abbott and Patrick said in a press release, “call for an immediate review of all policies concerning the grid.”
The state's grid came under intense public and legislative scrutiny after a winter storm in 2021 knocked out its operations, causing dayslong power outages across the state in freezing temperatures that left millions of Texans without lights or heat. Hundreds died.
The Texas Energy Fund set aside $5 billion to fund 3% interest loans to help construct new gas-fueled power plants that are not dependent on the weather and that could power 20,000 homes or more.
The fund was also designed to pay out bonuses to companies that connect new gas-fueled plants to the main grid by June 2029, and to offer grants for modernizing, weatherizing and managing vegetation growth around electricity infrastructure in Texas outside the main electricity market, which meets around 90% of the state's power needs.
The state received notices of intent to apply for $39 billion in loans — almost eight times more than what was initially set aside, Abbott and Patrick said. They added that the average plant will take three to four years to complete, and new transmission lines will take three to six years to complete.
Companies have until July 27 to apply for a loan.
Just in: Former U.S. Rep. Liz Cheney, R-Wyoming; U.S. Sen. John Fetterman, D-Pennsylvania; and Oklahoma Gov. Kevin Stitt will take the stage at The Texas Tribune Festival, Sept. 5–7 in downtown Austin. Buy tickets today!
The post Texas to double state fund aimed at expanding power grid appeared first on TexasTribune.org.
The Texas Tribune is a nonprofit, nonpartisan media organization that informs Texans — and engages with them — about public policy, politics, government and statewide issues.
Texas Tribune
Commanding officer confirms Troy Nehls has two Bronze Stars
by By Isaac Yu, The Texas Tribune – 2024-07-01 13:02:57
SUMMARY: The Texas Tribune reports that the military record of Rep. Troy Nehls has come under scrutiny. A CBS investigation revealed discrepancies in Nehls' service decorations, including claims of a second Bronze Star and a Combat Infantryman Badge (CIB), which the Pentagon has not corroborated. Nehls' former commanding officer, Jason Burke, affirmed awarding him a second Bronze Star in 2008. Despite the Pentagon's records indicating only one Bronze Star and no CIB, Nehls insists on social media that he earned both awards. Nehls, facing criticism, has stopped wearing the CIB, which was revoked in 2023 due to service in a non-combat role.
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WASHINGTON — The commanding officer of a 2008 tour in Afghanistan that included then-U.S. Army Major Troy Nehls told The Texas Tribune that he recalls awarding the now-congressman his second Bronze Star award.
That award — which recognizes service members who show heroism in the field — has been called into question after a CBS investigation reported Nehls had been touting military decorations that did not match his service record provided by the Pentagon. In campaign ads and in his House biography, Nehls, R-Richmond, has posted pictures wearing an Army uniform and two Bronze Star medals. He has also worn the Combat Infantryman Badge lapel pin, awarded to soldiers for service in combat.
The investigation found that the Pentagon reported Nehls received only one Bronze star and that the Combat Infantryman Badge was awarded in error and rescinded in 2023. Nehls, who has been publicly criticized by members of his own party amid the claims of stolen valor, said on social media that he did have two Bronze Stars. But he has since stopped wearing the CIB.
But Jason Burke, the Navy captain who led the 130-person joint task force Nehls served on during his tour, recalled awarding the medal to Nehls. Nehls received the medal at a ceremony with several other officers in the fall of 2008, shortly before Nehls finished his tour and returned to Texas, Burke told the Tribune.
“You're getting that award if you've done a good job and met the criteria,” said the now-retired Burke, who is listed on the award certificate as Nehls' commanding officer. “He earned it, and received it.”
Nehls, who represents a swath of Houston suburbs, served as Burke's second-in-command under a joint effort called Task Force Currahee. Their unit, which included both Army and Navy officers, worked on provincial reconstruction, building roads, clinics and schools in eastern Afghanistan's Ghazni Province. Burke said the team's convoys regularly came under Taliban ambushes and guerrilla attacks.
The Bronze Star award must be recommended by a commander, and any service member in any branch of the military working an operation involving a conflict with an opposing force is eligible. The CIB, by contrast, is only given to those in combat roles.
It was relatively standard during the U.S.'s war on terrorism, after the Sept. 11, 2001, attacks, for officers of certain ranks to receive a some kind of award upon completing a tour, often a Bronze Star. Nehls' first star was awarded for Operation Iraqi Freedom in 2004, where he trained 13 staff members of an Iraqi government office to perform financial assessments, according to the certificate.
A spokesperson for Nehls declined to comment on this story, pointing to a post on X Nehls made last month defending his record and posting photos of the certificates of his two Bronze Stars, and his copy of the underlying nomination forms. Burke's sign-off can be seen on the 2008 documentation, known as a Form 638, along with signatures from two higher-level officials.
CBS reported the Pentagon would conduct another review of Nehls' record. The most recent summary of his service and awards, provided to the Tribune by a Pentagon spokesperson on Friday, lists only one Bronze Star and no CIB.
The systems for keeping records for military awards can be difficult to navigate. A soldier often becomes responsible for making sure awards paperwork is turned over to a personnel officer.
That means documentation for awards sometimes slips through the cracks, according to retired Army sergeant Anthony Anderson, who has investigated numerous instances of stolen valor.
“I wouldn't say it's common, but it does happen,” Anderson said.
Anderson said he had previously spoken with Nehls' chief of staff, encouraging them to submit documentation of the second Bronze Star to the Pentagon to be added to Nehls record.
He said he would be surprised if an officer in Nehls' position hadn't received a Bronze Star.
Nehls' military record has become a thorn for him in recent months. He announced that he would stop wearing the Combat Infantryman Badge last week in response to reports that the badge had been revoked in 2023.
Nehls was found to be ineligible for that badge because he had served in Afghanistan in a civil role, not as a combatant infantryman. Nehls did serve as an infantryman during his time with the Wisconsin National Guard in the 1990s, completing a tour in Bosnia.
Just in: Former U.S. Rep. Liz Cheney, R-Wyoming; U.S. Sen. John Fetterman, D-Pennsylvania; and Oklahoma Gov. Kevin Stitt will take the stage at The Texas Tribune Festival, Sept. 5–7 in downtown Austin. Buy tickets today!
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The Texas Tribune is a nonprofit, nonpartisan media organization that informs Texans — and engages with them — about public policy, politics, government and statewide issues.
Texas Tribune
Robert Robertson execution day set in Texas shaken baby case
by By Kayla Guo, The Texas Tribune – 2024-07-01 11:33:10
SUMMARY: A Texas court has scheduled Robert Roberson's execution for October 17. Roberson, sentenced to death in 2003 for his 2-year-old daughter's death, has consistently challenged the conviction, claiming it was based on questionable science. Despite halting his execution in 2016 due to doubts about shaken baby syndrome, the Texas Court of Criminal Appeals upheld his death sentence in 2023. Roberson's attorneys argue new evidence shows his daughter died of natural causes, not head trauma, and question the shaken baby syndrome diagnosis. The execution date triggers deadlines for last-minute legal and clemency filings.
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A Texas court on Monday set an execution date for Robert Roberson, who was sentenced to death in 2003 for killing his 2-year-old daughter but has consistently challenged the conviction on the claim that it was based on questionable science.
Roberson has maintained his innocence while being held on death row for more than 20 years. The Texas Court of Criminal Appeals previously halted his execution in 2016. But in 2023, the state's highest criminal court decided that doubt over the cause of his daughter's death was not enough to overturn his death sentence.
His new execution date is set for Oct. 17.
Roberson's attorneys objected to the scheduling of an execution after Anderson County prosecutors requested on June 17 that a date be set. His attorneys said they have new evidence to bolster their case and that they planned to file a new request to overturn his conviction.
As a result, his attorneys argued, setting an execution date would be “premature and unjust.”
Roberson was convicted of killing his sickly 2-year-old daughter, Nikki Curtis, after he rushed her blue, limp body to the hospital. He said that Nikki fell from the bed while they were sleeping in their home in the East Texas town of Palestine and that he awoke to find her unresponsive. But doctors and nurses, who were unable to revive her, did not believe such a low fall could have caused the fatal injuries and suspected child abuse.
At trial, doctors testified that Nikki's death was consistent with shaken baby syndrome — in which an infant is severely injured from being shaken violently back and forth — and a jury convicted Roberson.
The Court of Criminal Appeals in 2016 stopped his execution and sent the case back to the trial court after the scientific consensus around shaken baby syndrome diagnoses came into question. Many doctors believe the condition is used as an explanation for an infant's death too often in criminal cases, without considering other possibilities and the baby's medical history.
The Court of Criminal Appeals' decision was largely a product of a 2013 state law, dubbed the “junk science law,” which allows Texas courts to overturn a conviction when the scientific evidence used to reach a verdict has since changed or been discredited. Lawmakers, in passing the law, highlighted cases of infant trauma that used faulty science to convict defendants as examples of the cases the legislation was meant to target.
Roberson's attorneys, in their opposition to setting an execution date, cited “overwhelming new evidence” that Nikki died of “natural and accidental causes” — not due to head trauma.
They wrote that Nikki had “severe, undiagnosed” pneumonia that caused her to stop breathing, collapse and turn blue before she was discovered. Then, instead of identifying her pneumonia, doctors prescribed her Phenergan and codeine, drugs that are no longer given to children her age, further suppressing her breathing, they argued.
“It is irrefutable that Nikki's medical records show that she was severely ill during the last week of her life,” Roberson's attorneys wrote, noting that in the week before her death, Roberson had taken Nikki to the emergency room because she had been coughing, wheezing and struggling with diarrhea for several days, and to her pediatrician's office, where her temperature came in at 104.5 degrees.
“There was a tragic, untimely death of a sick child whose impaired, impoverished father did not know how to explain what has confounded the medical community for decades,” Roberson's attorneys wrote.
They have also argued that new scientific evidence suggests that it is impossible to shake a toddler to death without causing serious neck injuries, which Nikki did not have.
And they cited developments in a similar case in Dallas County, in which a man was convicted of injuring a child. His conviction was based in part on now partially recanted testimony from a child abuse expert who provided similar testimony on shaken baby syndrome in Roberson's case. Prosecutors in Dallas County have said the defendant should get a new trial.
In 2023, when the Court of Criminal Appeals denied Roberson a new trial, prosecutors argued that the evidence supporting Roberson's conviction was still “clear and convincing” and that the science around shaken baby syndrome had not changed as much as his defense attorneys claimed. Witnesses also testified at trial that Roberson had a bad temper and would shake and spank Nikki when she would not stop crying.
The scheduling of Roberson's execution triggers a series of deadlines for any last filings in state and federal court to seek relief and begin a request for clemency.
Just in: Former U.S. Rep. Liz Cheney, R-Wyoming; U.S. Sen. John Fetterman, D-Pennsylvania; and Oklahoma Gov. Kevin Stitt will take the stage at The Texas Tribune Festival, Sept. 5–7 in downtown Austin. Buy tickets today!
The post Robert Robertson execution day set in Texas shaken baby case appeared first on TexasTribune.org.
The Texas Tribune is a nonprofit, nonpartisan media organization that informs Texans — and engages with them — about public policy, politics, government and statewide issues.
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