Innovating Mental Healthcare in Texas and Beyond: Q&A with Dr. Octavio Martinez

by Beth Blevins

Dr. Octavio Martinez is the fifth executive director and the first Hispanic to lead the Hogg Foundation for Mental Health at The University of Texas at Austin (UT Austin). Dr. Martinez is also a clinical professor in the university's School of Social Work and holds an adjunct professor appointment at the San Antonio School of Medicine's Department of Psychiatry. He is the chair of the board of the National Hispanic Council on Aging, serves on the National Academy of Medicine's Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities, and the National Advisory Committee on Rural Health and Human Services, as well as serving on other statewide and national committees. Dr. Martinez has an MD from Baylor College of Medicine, an MPH from Harvard University's School of Public Health, and master's and bachelor's degrees in business administration from UT Austin. Before entering medical school, he worked in commercial real estate, banking, and finance.

Recently, we discussed how the Foundation is helping to improve and innovate mental healthcare delivery in Texas, and the challenges that remain in Texas and nationwide.

The Hogg Foundation publishes an extensive Mental Health Guide. Why did you create the guide? What is its purpose and intended audience?

We are on our third edition. The main audience we developed it for was policy folks and legislators. Our legislature meets every other year, so we prepare it in the interim between the legislative sessions to have it ready in January. My policy team distributes it to all staffers at the capitol and to mental health advocates and stakeholders. Our plan is to continue it every other year until we don't need it anymore, which, unfortunately, I don't see happening anytime soon. As far as I know, our guide is unique.

The guide came out of recognizing how complex the mental health system was — of course, the word "system" was being used very loosely not only nationally but definitely in the state of Texas. It was a very fractured system and it was not coordinated at all, which is to say that we needed to involve the justice system, the educational system. They were doing pieces of legislation or funding for those different settings and nobody was looking at the bigger picture. We felt that there needed to be a tool for our policymakers to start looking at things in an inter-systemic way and understand that if you use funds to do something in the criminal justice system, you also need to think about the public mental health system, the hospitals, and forensics beds, because they are all inter-related. The guide helps facilitate that discussion and change that philosophy. And we see that it's already had an impact.

What are some of the major challenges in providing mental health care in Texas that are summarized in the guide? Are there some challenges that have remained the same from year to year?

Where we have definitely helped out is working with our legislators and helping our advocacy organizations to be much more focused, in a granular way. The guide has helped folks look at where the gaps are and where we should focus to make change. After the first guide was put out with the 83^rd legislature, we had an increase in public mental health funding. It was the same with the 84^th. And now, before the 85^th legislature kicked off, the governor announced there would be a decrease in budgets across the board except for mental health funding.

Let's be creative and think of what a state hospital of the future would look like and also address the huge increase in forensic use of hospital beds…

The increase in funding is infrastructural — to decrease the wait list at mental health centers. This legislative session, they'll look at upgrading our state hospitals, which are in dire need of upgrading or completely replacing. We are working with them on that, saying don't just replace them with another hospital from the past. Let's be creative and think of what a state hospital of the future would look like and also address the huge increase in forensic use of hospital beds, which is impacting the use of civilian beds — they just don't exist. We've criminalized mental health so much. Another place funds have gone to is creating more Crisis Intervention Teams (CITs) and working to create funding that addresses issues like the diversion programs that now exist in different metro areas, so it doesn't continue to all flow into the criminal justice system.

So funding is going across a whole spectrum of things. Now we're trying to help folks see how it truly interrelates. If we do diversion programs, we also need CITs to help our local police forces, and we need to allow drug courts to put folks into treatment and not just into the criminal justice system because that's an expensive place to deliver care. Some of the funding is going to the counties to work with local mental health authorities to deliver care. We're dealing with the realities of today while still trying to move into a different kind of delivery system for the future. Another area we've been working with and getting some traction is moving the entire Medicare/Medicaid system to an integrated care model.

It's not just one thing, but a lot of different pieces. With the guide and the resources that we're putting out there to help our policymakers, they are seeing the big picture and the pieces that go into that puzzle. There are still some missing puzzle pieces, but at least we are addressing quite a few of these, much more now than historically. This has all happened within the last five to six years. We haven't done a study to see if there's a direct correlation, but the changes we've seen have been really encouraging.

What other Hogg Foundation programs are making an impact in your state?

One of the other things we've created is the Policy Academy. I see it as being synergistic with the Mental Health Guide. Basically, we funded an organization to create a curriculum and now we fund advocacy organizations to have either one- or two-year fellows. The fellows just have to have recently received their master's or law degree.

When an organization submits a grant asking for a policy fellow, we pay for them to have the fellow and offer additional funds for a seasoned policy mentor. We send the fellows to the Policy Academy and train them in how to be advocates and create policy briefs. It also includes a one-week immersion program at the federal level, where we send them to SAMHSA (the Substance Abuse and Mental Health Services Administration) and other relevant organizations. We're now into our sixth cohort.

As we developed the Mental Health Guide, we were also developing this cadre of young advocates who are completely focused on mental health. What we discovered is that many organizations had the heart but didn't have the capacity or the skills to follow through. With the fellows, they not only have the passion and the heart, they also have the skill set. Now, when we go to the capitol and they're having hearings on mental health legislation, I usually see at least 10 to 12 of our Policy Academy fellows there.

In the last iteration of the Policy Academy, we expanded it to include certified peer specialists. Peers are individuals with lived experience — folks who have had depression, schizophrenia, anxiety, PTSD, whatever the case may be, and who are wanting to make a difference. We see this as helping to address the workforce issue. Along with the Department of State Health Services, we helped to create Via Hope six years ago, which trains and certifies peer specialists. We see peers as being integral to the 21^st century delivery model for mental health and behavioral health, creating and understanding the concept of recovery, as well as having true patient engagement with our communities.

What do you see as the biggest challenges for rural populations when it comes to mental health?

The biggest challenge we have in rural America, including rural Texas, is that we are a crisis-oriented society.

The biggest challenge we have in rural America, including rural Texas, is that we are a crisis-oriented society. Take the opioid crisis.  It takes away attention from looking at the underlying infrastructure. I know we try to address it, but the crisis takes everything — it pulls you back from a prevention focus and public health approach. We can continue to fund just to deal with the crisis itself, but it doesn't change the infrastructure or the mental health system that's delivering the care. I believe if we had an integrated delivery system as an underlying infrastructure in place, our ability to deal with something like the opioid crisis would be so much more effective and humanistic. And if it could be done, no disparities would exist.

When I look at rural Texas or rural America, that infrastructure was already woefully inadequate; when a crisis comes along, it highlights how bad it really is. We need to get ahead of the workforce issue. It is so dire and so deficient. You can't really deliver good quality care if you don't have the workforce. It's not just numbers — it's also the quality of the workforce and the skill sets and whether you have an innovative model to do that. It's unfortunate that we had to get to a crisis to get us to change. I'm hoping we can move in that direction without waiting for the crisis to pull us into it. But we are a reactive society.

Specifically, what do you mean when you say there's an issue with the workforce and with infrastructure?

First, we don't have enough people working in the mental health field and, of the folks we do have, not enough of them are culturally and linguistically competent. Take, for example, the training I received as a medical student. I received inadequate behavioral health training, inadequate training on the interface between physical medicine and mental health, inadequate training for working with geriatric populations — most doctors are trained to work with adults, not children or the elderly. Then there's residency, which perpetuates the same things that happened in medical school. We don't have enough folks in the fields of geriatrics or geriatric psychology or social work or psychopharmacology. Then you take a look at a population like in Texas, which is a minority/majority state – the number of physicians who are culturally and linguistically proficient is almost non-existent. You can find pockets where a community is doing a good job, but across the board, it's not true.

Our largest mental health provider in Texas is the Harris County Jail. In California, it's the Los Angeles County Jail, et cetera. That's the wrong place to deliver care.

Second, we don't have enough state hospitals or beds to take care of folks who need hospitalization. There's a tug of war between forensics versus civil needs. We have so underfunded our outpatient public mental health clinics that too many folks aren't accessing the care that they need, and too many folks end up interfacing with our judicial and criminal justice systems. Jails and prisons have the largest number of people requiring mental health services. Our largest mental health provider in Texas is the Harris County Jail. In California, it's the Los Angeles County Jail, et cetera. That's the wrong place to deliver care. We're putting folks in the wrong setting — all because we have inadequate infrastructure. We don't have enough outpatient clinics. I also think we need to move away from brick and mortar infrastructures toward mobile crisis teams that can go to where people are.

To me, mental health is a crisis situation in Texas and for the whole nation, and it gets even more exacerbated in our rural areas.

To me, mental health is a crisis situation in Texas and for the whole nation, and it gets even more exacerbated in our rural areas. We've had rural hospitals closing down and we're not creating new clinics. We allow too many barriers to interfere with creating innovative virtual networks — why haven't we expanded and completely utilized telehealth and telepsychiatry and mobile units to visit folks? It's because we're a capitalistic society, and where you spend the money shows what you care about.

Before earning your MD and MPH degrees, you worked as a commercial real estate banker in Austin. How did you decide to make the leap to public health and medicine?

I wanted to be able to say I was part of something meaningful that helped people and communities.

What really was the catalyst to make me look for a different career than banking and commercial real estate was that I was part of the savings and loan crisis, which was the biggest bank failure the country had seen up until that time. First Republic, where I worked, was among the biggest bank failures. It had me reflect on what I wanted to do. Banking wasn't meeting my needs. I had seen some shady stuff happen. I wanted to be able to say I was part of something meaningful that helped people and communities.

After weighing the pros and cons of getting a degree in law, medicine, or business, I decided to pursue a career in medicine because it seemed a more ethical industry and it helped people. I never knew I was going to head a foundation! I thought I was going to be a family doctor somewhere.

The Hogg Foundation is really my third career. The first was commercial real estate banking; the second was being an academic physician; the third, since 2008, is philanthropy. All the things I've done historically have come into play in running the Hogg Foundation. When I was faculty at the health sciences center at San Antonio, I helped to build two clinics. I was doing integrated care but didn't know it at the time. That's why the term resonates with me so much. To me, it seemed a logical way to deliver care where you're being respectful and engaging with the individual, their family, and their community to address all the issues that affect us. Now we call it the social determinants of health — they are all so important and impact how individuals see health and access it, and whether they utilize intervention and follow through. If we're not working with families to recognize that dynamic, then we're falling short. And I think we've fallen short for way too long.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.