Appendix XV Bed Capacity Study.pdf

Behavioral Health Gap Analysis

Table of Contents Legislative Charge

Executive Summary

Behavioral Health Prevalence

Behavioral Health Workforce

Florida’s Behavioral Health Care Landscape

Bed Capacity Analysis

Stakeholder–Identified Gaps in the System of Services and Supports

Conclusions

Appendix A – Methodology

Appendix B – Detailed Results – Bed Capacity Analysis

Legislative Charge

On March 21, 2024, Governor Ron DeSantis signed Senate Bill 330, also known as the Behavioral Health Teaching Hospitals Act. 2024 Legislature, Senate Bill 330, Section 7, upon which the study and report are guided by and based on, indicates that:

Effective upon this act becoming a law, the Department of Children and Families must contract for a detailed study of capacity for inpatient treatment services for adults with serious mental illness and children with serious emotional disturbance or psychosis in this state’s forensic inpatient, safety-net voluntary and involuntary civil inpatient placement, and Medicaid statewide inpatient psychiatric programs. The study must include analyses of current capacity, current and projected future demand, and the state’s current and projected future ability to meet that demand and must include recommendations for enhancing the availability of inpatient treatment services and for providing alternatives to such services. The study must be completed by January 31, 2025, and must include, at a minimum, the following:

1) By facility and by program type, the current number and allocation of beds for inpatient treatment, the number of individuals admitted and discharged annually, and the lengths of stay.

2) By department region, the current number and allocation of beds in receiving, treatment, and state treatment facilities and residential treatment centers for children and adolescents for inpatient treatment between forensic and civil placements, the number of individuals admitted and discharged annually, the types and frequency of diagnoses, and the lengths of stay.

3) By department region, the current and projected future demand for civil and forensic inpatient placements at receiving, treatment, and state treatment facilities and residential treatment centers for children and adolescents, any gaps in current and projected future availability of these services compared to current and projected future service demand, and the number of inpatient beds needed by facility type and placement type to meet current and projected future demand.

4) By agency region, the number of individuals admitted and discharged annually, the types and frequency of diagnoses, and the lengths of stay for Medicaid statewide inpatient psychiatric program services, the current and projected future demand for these services, any gaps in current and projected future availability of these services compared to current and projected future service demand, and the number of inpatient beds needed by facility type to meet current and projected future demand.

5) Policy recommendations for ensuring sufficient bed capacity for inpatient treatment at treatment facilities, state treatment facilities, or receiving facilities, or at residential treatment centers for children and adolescents, and for enhancing services that could prevent the need for involuntary inpatient placements.

6) A gap analysis as recommended by the Commission on Mental Health and Substance Use Disorder in the Annual Interim Report dated January 1, 2024.

Executive Summary

The Florida Department of Children and Families is committed to supporting local communities to protect vulnerable populations, promote strong and economically self–sufficient families, and support personal and family recovery and resiliency. The agency accomplishes this through public and private partnerships with other governmental agencies, Managing Entities and providers of mental health and substance use services and supports. These partnerships support service delivery for adults, children, and adolescents across the statewide system of prevention, treatment and recovery services and supports.

Behavioral health includes both mental health and substance use conditions and has become more broadly used to describe a whole person approach to supporting the needs of children, adolescents, and adults. The growing need for mental health and substance use services experienced throughout our nation requires state governments to focus on the extent of mental health and substance use experienced, assess individuals’ needs for services and support, and thoroughly understand the capabilities and capacity of the system of care.

In Florida, approximately 5% of the state’s civilian population have serious mental illness and over 400,000 children and youth experience emotional, behavioral, and developmental issues, but only about half are able to access services.

2,3 Additionally, an estimated 13% of Florida's citizens, or roughly 2.9 million people, used illicit drugs within the past month, and an estimated 15% of individuals have struggled with substance use disorder within the past year.

To address the state’s behavioral health challenges, the Florida Legislature allocates funds to the Department of Children and Families (DCF) for behavioral health services, including through multiple specific appropriations to designated state funded providers of these services. Additional funding for core behavioral health services includes time–limited federal grants, such as grants to combat the opioid epidemic and support case management for homeless individuals with behavioral health condition (e.g., Projects for Assistance in Transition from Homelessness –PATH, State Opioid Response Grant– SOR, Mental Health Block Grant– MHBG). During the past two years there have been investments of nearly $1.47 billion. Additionally, the state of Florida is receiving $3 billion in Opioid Abatement Settlement Funds over an 18-year period to support opioid addiction and recovery services, harm reduction services, school, and community prevention campaigns.

To further the state’s efforts at mitigating the factors contributing to the mental health and substance use disorder crisis, on March 21, 2024, Senate Bill 330, known as the Behavioral Health Teaching Hospitals Act was signed, requiring the DCF to conduct a detailed study on the capacity of behavioral health facilities. The study includes information on several indicators such as (but not limited to) current bed allocation, admissions, discharges, and average lengths of stay by facility, program type, and region for children, adolescents, and adults; current and projected demand for civil and forensic inpatient placements, bed needs by facility and placement type; and lengths of stay for Medicaid statewide inpatient psychiatric services. Additionally, a gap analysis, including demographic profile, service availability and costs will be conducted to evaluate the behavioral health system of care. Policy recommendations will be developed to address opportunities to enhance services, supports, and bed capacity.

Data presented in this assessment describes gaps in capacity across the following behavioral health facilities and services included in the scope of the study: public and private hospitals, state mental health treatment facilities (SMHTF) – civil, forensic, and juvenile incompetent to proceed programs (JITP), facilities providing inpatient psychiatric treatment services, crisis stabilization units (i.e. emergency receiving), and residential treatment centers and facilities. This assessment examined the availability of behavioral health community-based services and gaps in the system of care and offered options for service enhancement.

SAMHSA, 2022 State-by-state estimates of serious mental illness

Florida Department of Health, Behavioral Health and Related Topics | Florida Department of Health

Ibid

SAMHSA, 2022 NSDUH State Estimates https://www.floridahealth.gov/programs-and-services/childrens-health/cms-specialty-programs/title-5-program/Behavioral-Health-Services/index.html

Further this assessment identified factors impacting the behavioral health system of care including Florida’s behavioral health workforce shortages and outdated behavioral health service reimbursement rates. The assessment is organized by service type as detailed above, and by services that support children and adolescents and adults.

The analysis examined bed availability and projected demand based on 75%, 85%, and baseline utilization rates across psychiatric inpatient facilities, including emergency receiving/Baker Act facilities, state treatment facilities, and residential treatment centers for inpatient treatment between forensic (inpatient hospital that provides a secured level of care for individuals committed as incompetent to proceed or not guilty by reason of insanity) and civil (inpatient hospital that serves individuals who do not require a secured level of care) placements. Projected gaps in bed capacity are presented in the tables below, for children, adolescents, and adults. The projected number of additional beds that will be need throughout the 2025 to 2029 timeframe are indicated in the table. Instances where there are surpluses in bed capacity, a positive symbol (+) is noted in the table. Instances where a specific facility type is not present in a region and consequently, projections could not be calculated are denoted with a N/A. Details on the surpluses as well as on gaps in bed capacity across regions can be found in Appendix B:

Table 1: Summary of projected gaps in bed capacity for children and adolescents (2025-2029)

Facility/Service Type Region

Projected Gaps in Bed Capacity (i.e., the projected number of additional beds that will be needed)

2025 2026 2027 2028 2029

Hospital with psychiatric beds/inpatient units

Northeast 1 1 1 2 2

Northwest 0 1 1 1 1

Central 4 5 6 8 9

Southeast 9 10 10 11 11

Suncoast 2 3 3 4 5

Southern 0 0 0 0 0

Specialty psychiatric hospital (Class 3)

Northeast 2 2 3 4 4

Northwest 0 1 1 1 3

Central 4 5 6 8 11

Southeast 1 1 2 2 3

Suncoast 2 3 3 4 10

Southern N/A N/A N/A N/A N/A

Crisis Stabilization Units (i.e., Emergency receiving)

Northeast 1 1 2 2 2

Northwest N/A N/A N/A N/A N/A

Central 3 4 5 6 7

Southeast + + + + 1

Suncoast + + + + 5

Southern + + + + 0

Residential Treatment Center

Northeast 2 3 4 5 5

Northwest + + + + +

Central 72 74 76 78 80

Southeast + + + + +

Suncoast + + + + +

Southern + + + + +

Specialized Therapeutic Group Home

Northeast + + 0 0 0

Northwest N/A N/A N/A N/A N/A

Central 1 1 2 2 2

Southeast 2 2 2 3 3

Suncoast 1 1 1 1 1

Southern 0 0 0 0 0

Short-term Residential Treatment Unit

Northeast N/A N/A N/A N/A N/A

Northwest N/A N/A N/A N/A N/A

Central N/A N/A N/A N/A N/A

Southeast N/A N/A N/A N/A N/A

Suncoast N/A N/A N/A N/A N/A

Southern 0 0 0 0 0

Notes: + indicates a projected surplus in bed capacity for the given region; surplus details can be found in the Appendix B. N/A indicates that there were none of the given type of facility in the specified region and thus demand projections could not be calculated.

Table 2: Summary of projected bed capacity gaps for adults (2025-2029)

Facility /Service Type

Region

Projected Gaps in Bed Capacity (i.e., the projected number of additional beds that will be needed)

2025 2026 2027 2028 2029

Hospital with psychiatric beds/inpatient units

Northeast 12 16 21 26 31

Northwest 6 9 11 14 16

Central 12 17 22 27 32

Southeast 13 19 24 30 36

Suncoast 15 22 28 35 41

Southern 12 17 22 28 33

Specialty psychiatric hospital (Class 3)

Northeast 6 9 11 14 17

Northwest 3 5 6 8 9

Central 23 32 42 52 62

Southeast 9 13 17 21 25

Suncoast 19 27 35 44 52

Southern 1 2 3 3 4

Crisis Stabilization Units (i.e., Emergency receiving)

Northeast 2 3 4 5 7

Northwest 1 2 3 3 4

Central 10 14 18 22 27

Southeast 2 3 4 5 6

Suncoast 5 8 10 12 14

Southern 2 2 3 4 4

Residential Treatment Facility

Northeast 22 27 32 36 41

Northwest + + + + +

Central 2 8 13 19 25

Southeast 27 37 47 58 68

Suncoast 20 26 32 39 45

Southern 14 17 20 23 26

Short-term Residential Treatment Unit

Northeast N/A N/A N/A N/A N/A

Northwest 9 9 9 10 10

Central + + + + +

Southeast 0 1 1 2 2

Suncoast 10 10 10 11 11

Southern N/A N/A N/A N/A N/A

Notes: + indicates a projected surplus in bed capacity for the given region; surplus details can be found in the Appendix B. N/A indicates that there were none of the given type of facility in the specified region and thus demand projections could not be calculated.

Additionally, an assessment of the behavioral health system of care and support was conducted based on publicly available information, data provided by the Florida Department of Children and Families and the Agency for Health Care Administration, and insights gathered from interviews with Managing Entities and providers. Ranges of proposed increases in bed counts reflect low and high bed demand estimates based on differences in projected bed utilization rates, including 75% and 85% utilization, as well as the utilization rate at baseline. Key opportunities to improve services and supports are as follows:

Opportunities for Enhancement

Conduct broad scale, multi–channel, community public information campaigns to spread information about behavioral health services and access (e.g., messaging via social media, public transportation, roadways, movie theaters). These campaigns should be designed to reach diverse audiences, including youth, adults, and individuals from various cultural backgrounds.

Enhance the availability of targeted care coordination to ensure that individuals with complex behavioral health needs receive personalized, coordinated care and appropriate navigation of services that address their unique circumstances and supports their long–term treatment and recovery goals.

Increase availability of integrated behavioral and physical health services. Models include physicians and nurses physically located within a behavioral health clinic, and/or the co–location of behavioral health specialists (e.g., psychiatrists, psychologists, and clinical social workers) within a primary care setting.

Increase co–located services for the uninsured and underinsured population of individuals across the state to promote a comprehensive health care system that meets the primary and behavioral health needs of individuals, decreasing reliance on emergency department visits and subsequent inpatient admissions.

Clubhouses are community–based settings staffed by behavioral health professionals and paraprofessionals that provide structured support and socialization for adults and youth living with behavioral health needs.

Clubhouses are intended to improve quality of life, create purpose and connection with the community.

Increase the availability of recovery clubhouses by at least one in the Northwest region to provide recovery– oriented supports for individuals with behavioral health conditions.

Increase the number of adult residential beds by 149-205, and child and adolescent residential beds by 72- 106, across short-term residential treatment, and therapeutic group home facilities throughout the state. These transitional beds provide a structured and supportive living environment for individuals with behavioral health needs, and crucial stabilization and treatment for individuals transitioning out of psychiatric inpatient care, helping to reduce inpatient lengths of stay and support successful community reintegration.

Addition of at least 29 Florida Assertive Community Treatment community–based services to support diversion from inpatient admission and readmission across the state. Additional FACT teams by region: Southern – 4, Suncoast – 4, Southeast – 8, Central – 8, Northeast – 4, and Northwest – 1. Addition of at least one Intermediate Level FACT team each in the Southern, Suncoast, and Central regions.

State of Florida needs:

• At least 34 additional psychiatrists to provide sufficient coverage and availability such that each county has at least one psychiatrist and that no county has fewer than 1 psychiatrist per 30,000 residents.

• 25,133 additional mental health professionals are needed statewide. Mental health provider, in this context, refers to marriage and family therapists, clinical social workers, and mental health counselors. Of note is the newly created USFs Florida Center for Behavioral Health Workforce implemented in SB330, Section 6.

Expand the availability of short-term residential treatment services for adults and children and adolescents such that there is at least one facility present in each region for each of the two populations.

Expand the availability of crisis stabilization unit beds (additional 62–369 for adults and 26–48 for children and adolescents) to provide community–based alternatives to inpatient and ensure that each county has sufficient capacity to meet the needs of individuals experiencing a behavioral health crisis, help prevent unnecessary hospitalizations, and provide timely, appropriate care in a less restrictive setting.

The state mental health facilities gap for civil beds in 2025 is estimated to be 248 beds. If no new civil beds are added, the gap is forecast to grow to 770 beds in 2029. The state mental health facilities gap for forensic beds in 2025 is estimated to be 612 beds. If no new forensic beds are added, the gap is forecast to grow to 1,074 beds by 2029.

The following table provides the number of proposed additional units and the corresponding unit(s) costs (estimated) per year for services, and beds across facility type. The estimated time to implement service enhancements (e.g., includes operationalization and implementation but not construction) will vary based on the types of new services implemented, priority of service needs (i.e., short, medium, or long-term), staffing needs, and facility construction, if applicable. It is anticipated to take at least twelve to twenty-four months accounting for procurement, staff training, and resource acquisition factors and constraints. Construction may increase the timeline to thirty-six months.

Table 3. Estimated Number of Additional Service and Supports Needed and Associated Costs Per Year

Services Cost per unit per

Year Total Units

Average Estimated Total Costs per Year

Recovery clubhouse* $125,000 1 $125,000

Florida Assertive Community Treatment* $1,401,639 29 $40,647,531

Intermediate Level Florida Assertive Community Treatment* $1,000,000 3 $3,000,000

Mobile response team* $647,058 7 $4,529,406

Adults – Additional Beds

State Mental Health Treatment Facility – Civil** $268,640 770 – 934 $228,881,280

State Mental Health Treatment Facility – Forensic** $271,560 1,074 – 1,429 $339,857,340

Hospital with psychiatric beds/inpatient units** $318,645 53 – 190 $38,715,368

Specialty psychiatric hospital (Class 3)** $318,645 137 – 177 $50,027,265

Crisis stabilization unit** $166,440 62 – 369 $35,867,820

Residential treatment** $71,631 149 – 205 $12,678,687

Short–term residential treatment** $127,385 46 – 67 $7,197,253

Children and Adolescents – Additional beds

Juvenile Incompetent to Proceed (JITP)** $161,695 22 – 37 $4,770,003

Hospital with psychiatric beds/inpatient units** $187,245 29 – 102 $12,264,548

Specialty psychiatric hospital (Class 3)** $187,245 57 $10,672,965

Crisis stabilization unit** $169,360 26 – 48 $6,266,320

Residential treatment** $96,238 72 – 106 $8,565,182

Short–term residential treatment** $162,060 80 $12,964,800

Specialized therapeutic group home** $49,175 17 $835,975

Total NA NA $817,866,741

Notes: Total costs per service are calculated as the product of total units and annual cost per unit. Ranges of additional units, high and low estimates for projected bed need, are calculated based on projected service demand sensitivity analysis as described in Tables 9 and 16-18 in addition to estimated beds per new facility where relevant.

*Additional unit estimates identified based on current utilization and demand.

**Additional unit estimates identified based on projected gap in bed availability by 2029.

Behavioral Health Prevalence

Behavioral health includes an individual's emotional, psychological, social state of wellbeing , and the consumption of selected substances . Mental illnesses and substance use disorders involve a range of conditions including:

• Mood disorders (e.g., anxiety, bipolar, major depression)

• Thought disorders (e.g., schizophrenias, psychosis, delusional disorders)

• Stress and trauma related disorders (e.g., post–traumatic stress disorder (PTSD))

• Eating disorders (e.g., anorexia, bulimia)

• Impulse control disorders (e.g., conduct disorder, oppositional defiant disorder)

• Self–injury, suicidal thoughts, suicidal attempts

• Substance use disorders (e.g., alcohol, nicotine, cocaine, opioid, cannabis)

Behavioral health can be negatively impacted by lack of access to safe and stable housing, and inadequate healthcare. Exposure to violence and trauma also negatively impacts individuals' behavioral health. Behavioral health disorders can be influenced by genetic, biological, and environmental factors. Depending on the severity of symptoms and impact on functioning, individuals' behavioral health needs may be met by various community–based, outpatient, crisis, residential or inpatient services.

Nationally:

o Suicide death rate was 17.2 per 100,000 o 8.8% of adults experienced a major depressive event (MDE), and of those 6.2% experienced a MDE with severe impairment o 12.3% of adolescents (12–17 years) had serious thoughts of suicide, 5.6% of adolescents made a suicide plan, and 3.3% attempted suicide o All–drug overdose rate was 32.69 per 100,000 o The opioid-related overdose death rate was 32.6 per 100,000

In Florida:

o Suicide death rate was 17.2 per 100,000 o 17.8% of adults have ever been told that they had a depressive disorder o 34.8% of students have thought about committing suicide one or more times in the past 12 months, and

9.1% attempted suicide o All–drug overdose rate was 35.9 per 100,000 o The opioid-related overdose death rate was 29 per 100,000 and 19,782 opioid–involved non–fatal overdoses emergency department visits

SAMHSA, What is Mental Health, https://www.samhsa.gov/mental-health

CDC, National Center for Health Statistics, Substance use, https://www.cdc.gov/nchs/hus/sources-definitions/substance-use.htm

CDC, Suicide Data and Statistics | Suicide Prevention, 2022 suicide rate, https://www.cdc.gov/suicide/facts/data.html#cdc_data_surveillance_section_4-suicide-rates

SAMHSA, 2022 National Survey on Drug Use and Health

Ibid

Spencer MR, Garnett MF, Miniño AM. Drug overdose deaths in the United States, 2002–2022.NCHS Data Brief, no 491. Hyattsville, MD: National Center for Health Statistics. 2024.

DOI:https://dx.doi.org/10.15620/cdc:135849

Ibid

FLHealthCHARTS, Suicide and Behavioral Health, Suicide and Behavioral Health Profile, 2022 suicide deaths

Florida Department of Health, 2022 Behavioral Risk Factor Surveillance System (BRFSS)

Florida Department of Children and Families, 2022 FYSAS State Report, https://www.myflfamilies.com/sites/default/files/2022-12/2022%20Statewide%20FYSAS%20Report%20Per%20Section%20C2- 2.3.pdf

Florida Department of Health, FLHealthCHARTS, 2022 Substance Use Dashboard, Substance Use Dashboard: Overview | CHARTS

Ibid https://www.flhealthcharts.gov/Charts https://www.myflfamilies.com/sites/default/files/2022-12/2022%20Statewide%20FYSAS%20Report%20Per%20Section%20C2-2.3.pdf https://www.myflfamilies.com/sites/default/files/2022-12/2022%20Statewide%20FYSAS%20Report%20Per%20Section%20C2-2.3.pdf https://www.flhealthcharts.gov/ChartsDashboards/rdPage.aspx?rdReport=SubstanceUse.Overview&islCounty=69 o Naloxone was administered 51,752 times

Behavioral Health Workforce

Nationally, there is a shortage of behavioral health professionals, including addiction counselors, marriage and family therapists, mental health counselors, psychologists, psychiatric physician assistants/associates, psychiatrists, and school counselors

. Florida’s patient-–to-–mental health provider ratio, 550:1, is higher than the national average patient-–to-–mental health provider ratio of 340:1, indicating that Floridians, on average, have less access to mental health providers than the national population.

As illustrated in Figure 1, 98.5% of the counties in Florida have either partial or complete shortage of mental health professionals. Only one county – Clay County – does not have a shortage of mental health professionals.

Specific to psychiatrists, according to the Health Resources and Services Administration, the prevalence of fewer than one psychiatrist per 30,000 individuals in an area indicates a shortage of mental health professionals. In Florida, the following 20 counties (with populations below 30,000) do not have a resident psychiatrist.

Florida’s Behavioral Health Care Landscape

Florida’s behavioral health system of care provides mental health and substance abuse services to residents.

These services are supported through a combination of state legislative allocations, federal grants, and county funding. Over the past two-years, investments in Florida’s behavioral health system of care include enhancement to the healthcare workforce by passing the “Live Healthy” legislation ($1.1 billion, Chapter 2024- 015, Laws of Florida), $313 million appropriation for a behavioral health teaching hospital (Chapter 2024-012, Laws of Florida), $11.5 million appropriation for mobile response teams and enhancement of access to emergency mental health services (Chapter 2024-015, Laws of Florida), and $50 million for mental health and substance use crisis services (Chapter 2024-245, Laws of Florida). Further, the State of Florida is receiving $3 billion in Opioid Abatement Settlement Funds, which can be used to support opioid addiction and recovery services, harm reduction services, and school and community prevention campaigns.

Several government agencies contribute significantly to addressing the diverse behavioral health needs of individuals and communities. These agencies collaborate to ensure that mental health initiatives are integrated into educational settings, correctional facilities, services for individuals with disabilities, and juvenile justice programs.

Ibid

HRSA, State of the Behavioral Health Workforce, 2024, November 2024

2024 State of Mental Health in America Report, Mental Health America

Rural Health Information Hub, https://www.ruralhealthinfo.org/charts/7?state=FL

Counties with no resident psychiatrist:

Calhoun, Dixie, Franklin, Gilchrist, Glades, Gulf, Hamilton, Hardee, Holmes, Jackson, Jefferson, Lafayette, Liberty, Madison, Suwannee, Taylor, Union, Wakulla, Walton, Washington

Figure 1: Health Professional Shortage Areas: Mental Health, by County, October 2024 - Florida

The Florida Department of Children and Families (DCF) is responsible for overseeing a statewide system of care focused on the prevention, treatment, and recovery of children and adults with serious mental illnesses or substance use disorders. These include community–based programs, crisis services, and state mental health treatment facilities.

This array of programs, services, and support for children and adults is funded via the

Florida legislature and federal block grant funds. Public funds are contracted through regional Managing Entities to local community behavioral health providers. DCF funds behavioral health (mental health and substance use) services to both adults and children, encompassing a variety of community–based programs such as outpatient and inpatient psychiatric care, crisis intervention, residential treatment, in–home care, and therapeutic foster homes.

The Department of Children and Families directly operates six state mental health facilities: three that are state–owned and operated, and three that are state–owned but privately operated under contract. Additionally, there are 20 local Substance Abuse and Mental Health (SAMH) offices distributed across Florida's Judicial Circuits, which manage and oversee the public behavioral health system within each Circuit.

Managing Entities

The mission of the seven Managing Entities across the state is to educate, promote, facilitate, collaborate, and advance the behavioral health recovery of individuals and their families in Florida – Broward Behavioral Health Coalition (BBHC), Central Florida Cares Health System (CFCHS), Central Florida Behavioral Health Network (CFBHN), Lutheran Services Florida Health Systems (LSFHS), Northwest Florida Health Network (NWFHN)/Big Bend Community Based Care (BBCBC), Thriving Mind South Florida (TMSF) (South Florida Behavioral Health Network (SFBHN)), and Southeast Florida Behavioral Health Network (SEFBHN). Managing Entities are local nonprofit organizations with community boards that oversee the state and federal substance abuse and mental health system of care throughout Florida, ensure the accountability of state and federal funds allocated for substance use and mental health services, and collaborate with various systems of care, including child welfare, local governments, law enforcement, private care providers, state hospitals, courts, the Department of

Corrections, the Department of Juvenile Justice, local school districts, and other community partners.

The Florida Agency for Health Care Administration (AHCA) administers the state’s Medicaid program, providing health coverage to low–income individuals and families, and is primarily responsible for the state's estimated $35 billion Medicaid program, which serves 4.3 million Floridians in SFY 2024–25. Additionally, the Agency for Health Care Administration licenses and regulates over 50,500 health care facilities, including hospitals, nursing homes, Source: Florida DCF 2022 Florida Cultural Health Disparity and Behavioral Health Needs Assessment: An Analysis of the Managing Entities Behavioral Health System of Care

Figure 2: Map of DCF Regions and Circuits and assisted living facilities, ensuring they meet established standards of care and safety. The agency also disseminates health care data through the Florida Center for Health Information and Policy Analysis, engages in health policy development, collects health care data, and implements health care reforms to improve the efficiency and effectiveness of the state's health care delivery system.

Health Insurers

Health insurers across Florida provide coverage for mental health services enabling residents to have access to care. Plans are offered by various health insurance providers and include coverage for services such as therapy, counseling, psychiatric evaluations, medication management, and inpatient and outpatient treatment for mental health and substance use disorders. The state has implemented regulations to ensure that mental health coverage is on par with physical health coverage. Additionally, Florida's Medicaid program, administered by the Agency for Health Care Administration, provides mental health services to eligible low–income individuals, guaranteeing that even the most vulnerable populations have access to necessary care. The Agency for Health Care Administration’s role in managing Medicaid is crucial, as it ensures that mental health services are available to low–income populations, thereby promoting health equity and improving the overall well–being of Florida's residents.

Behavioral Health Service Providers

Behavioral health service providers are spread across all regions of Florida and address the diverse behavioral health needs of the state's population. These providers include a wide range of professionals and organizations, such as psychiatrists, psychologists, licensed counselors, social workers, and include community–based agencies. They offer an array of services, including individual and group therapy, psychiatric evaluations, medication management, crisis intervention, and support for substance use disorders. Florida's behavioral health service providers are dedicated to improving access to care, particularly for underserved and vulnerable populations. Through these efforts, service providers have created a supportive and responsive system that promotes mental wellbeing and resilience across the state.

The Florida Department of Education (FLDOE) oversees public education in Florida. The Florida Department of Education plays a crucial role in implementing mental health education programs, providing school–based mental health services, and collaborating with other state agencies to coordinate support for students. Additionally, FLDOE offers training for educators to identify and assist students with behavioral health needs, advocates for policies that integrate behavioral health services within schools and establishes crisis intervention protocols. Through these efforts, the FLDOE ensures that students receive comprehensive support to thrive both academically and personally.

The Florida Department of Juvenile Justice (DJJ) is dedicated to preventing, intervening, and treating juvenile delinquency and enhancing public safety by reducing juvenile crime through effective services that strengthen families and rehabilitate youth. DJJ plays a crucial role in the behavioral health system of care by addressing the mental and emotional well– being of at–risk and delinquent youth. The DJJ integrates comprehensive behavioral health services into its programs, including mental health assessments, counseling, substance abuse treatment, trauma–informed care, and family involvement. By collaborating with mental health professionals and community organizations, the DJJ Justice creates a holistic support system that addresses the root causes of delinquent behavior, reduces recidivism, and promotes the overall well–being and resilience of the youth it serves.

Florida Department of Education. (n.d.). About us. Retrieved from https://www.fldoe.org/about-us/ https://www.fldoe.org/about-us/

The Florida Department of Health (DOH) is committed to protecting and promoting the health of all Floridians through comprehensive public health services, disease prevention, and health education. The DOH provides mental health assessments, counseling, substance abuse treatment, crisis intervention services, implements public health initiatives, and develops integrated care models. By offering resources and training to communities and healthcare providers, the DOH aims to improve health outcomes, reduce behavioral health issues, and foster healthier communities.

The Agency for Persons with Disabilities (APD) serves the needs of over 60,000 Floridians with developmental disabilities who may receive social, medical, behavioral, residential, and/or therapeutic services. The APD assists individuals with unique abilities and their families in living, learning, and working within their communities by creating multiple pathways to possibilities.

The Florida Department of Corrections (FDC), the state's largest agency and the third–largest state prison system in the U.S., is responsible for the custody and rehabilitation of inmates and the supervision of offenders in the community

. The FDC provides mental health assessments, counseling, and treatment, as well as substance abuse programs aimed at long–term recovery. The FDC also offers crisis intervention services and implements evidence–based rehabilitation programs to address behavioral health issues and equip inmates with skills for successful reintegration. Collaborating with mental health professionals and community organizations, the FDC creates a comprehensive support system for inmates and offenders, aiming to improve their well–being, reduce recidivism, and enhance public safety through a holistic approach to correctional management.

The Florida System of Services and Supports

A comprehensive behavioral health system is characterized by its ability to provide children, adolescents, and adults with services and supports that meet the varied behavioral health needs and leads to fulfilling lives. The Florida Department of Children and Families behavioral health system includes treatment, rehabilitation, and supports

Treatment Florida Assertive Community

Treatment (FACT)

Intermediate Level

FACT

Teams provide a 24–hour–a–day, seven–days–a week, multidisciplinary approach to deliver comprehensive care to people where they live, work, or go to school, and spend their leisure time.

The programmatic goals are to prevent recurrent hospitalization and incarceration and improve community involvement and overall quality of life for program participants.

Teams provide a 24–hour–a–day, seven–days–a week, multidisciplinary approach to assist continued recovery and ease of service access until a full transition to community–based care is optimal. The programmatic goals are to prevent recurrent hospitalization with the promotion and maintenance of independent living in the community.

Crisis Support /Emergency

Non–residential care is generally available twenty–four hours per day, seven days per week, or some other specific time period, to intervene in a crisis or provide emergency care. Examples include mobile response teams, crisis support, crisis/emergency screening, crisis telephone, and emergency walk–in.

Crisis Stabilization Acute care service offered twenty–four hours per day, seven days per week, provides brief, intensive mental health inpatient treatment services. This service meets the needs of individuals who are experiencing an acute crisis and who, in the absence of a suitable alternative, would require hospitalization.

Community Action Treatment Teams

(CAT)

Strive to help children and young adults with behavioral health concerns to recover at home safely.

These teams also assist families in building and maintaining a support system within their community. CAT is a safe and effective alternative to out-of-home treatment or residential care for children with serious behavioral health conditions.

Florida Department of Corrections. (n.d.). About the Florida Department of Corrections. Retrieved from https://www.fdc.myflorida.com/about

Florida Department of Children and Family Services The System of Services and Support,https://www.myflfamilies.com/services/samh/treatment-services/AMH/system-of-services-and-support, Children’s Mental Health Program, https://www.myflfamilies.com/services/samh/childrens-mental-health-program

Florida Department of Children and Families, Community Action Treatment Teams (CAT), https://www.myflfamilies.com/catt https://www.fdc.myflorida.com/about

In–Home and On– Site Services

Therapeutic services and supports rendered in non–mental health provider settings, such as nursing homes, assisted living facilities (ALFs), residences, schools, detention centers, commitment settings, foster homes, and other community settings.

Inpatient Services These services are provided in psychiatric units within hospitals licensed under Chapter 395, F.S., as general hospitals and psychiatric specialty hospitals. They are designed to provide intensive treatment to persons exhibiting violent behaviors, suicidal behaviors, and other severe disturbances due to substance abuse or mental illness.

Medical Services Primary medical care, therapy, and medication administration. Designed to improve the functioning or prevent further deterioration of persons with mental health or substance abuse problems, including psychiatric mental status assessment. For adults with mental illness, medical services are usually provided on a regular schedule with arrangements for non–scheduled visits during times of increased stress or crisis.

Intervention Intervention services focus on reducing risk factors generally associated with the progression of substance abuse and mental health problems. Intervention is accomplished through early identification of persons at risk, performing basic individual assessments, and providing supportive services that emphasize short–term counseling and referral. These services are targeted toward individuals and families.

Outpatient Services Provide a therapeutic environment that is designed to improve the functioning or prevent further deterioration of persons with mental health and/or substance abuse problems. Outpatient services are usually provided on a regularly scheduled basis by appointment, with arrangements made for non–scheduled visits during times of increased stress or crisis. This may include evidence-based treatments (EBTs) such as trauma informed care (TIC), dialectal behavioral therapy (DBT), and multisystemic family therapy (MFT), motivational interviewing (MI), integrated dual disorder treatment (IDDT), and cognitive behavioral therapy (CBT)., Residential Level I Licensed services that provide structured, live–in, non–hospital settings with 24–hour supervision, seven days per week. There is a nurse on duty in these facilities at all times. For adult mental health, these services include two different kinds of programs: group homes and short–term residential treatment services. Group homes are for residents who may require longer lengths of stay.

Residential Level II Licensed, structured rehabilitation–oriented group facilities that have 24–hour a day, seven days per week supervision. Level II facilities house individuals who have significant deficits in independent living skills and need extensive support and supervision.

Short–term Residential

Treatment (SRT)

Individualized, acute, and immediately sub–acute care services provide short and intensive mental health residential and rehabilitative services 24 hours a day, seven days per week. These services meet the needs of individuals who are experiencing an acute or immediately sub–acute crisis and who, in the absence of a suitable alternative, would require hospitalization.

Residential Treatment

In some cases, residential treatment may be necessary for children who have been diagnosed with severe emotional disturbance and are recommended for residential level of mental health treatment by a Florida licensed psychologist or psychiatrist, and who are not eligible for public or private insurance.

Juvenile Incompetent to Proceed (JITP)

Program

Juvenile Incompetent to Proceed (JITP) Program provides competency restoration services to juveniles who have been charged with a felony prior to their 18th birthday and do not have the ability to participate in legal proceedings due to their mental illness, intellectual disability, or autism.

Rehabilitation Aftercare services

These services include but are not limited to relapse prevention and are a vital part of recovery in every service level. Aftercare activities include customer participation in daily activity functions that were adversely affected by mental illness and/or substance abuse impairments.

Comprehensive Community Service Team – Individual or Group

Comprehensive Community Service Team (CCST) services render assistance in identifying goals and making choices to promote resiliency and facilitate recovery for adults and children with mental illnesses. Services take place in either an outpatient or community setting.

Day–night Services

These services provide a structured schedule of non–residential services for three (when Medicaid funded) or four or more consecutive hours per day. This may include delivery of services during evening hours. Activities for children and adult mental health programs are designed to assist individuals to attain the skills and behaviors needed to function successfully in the living, learning, work, and social environments of their community.

Educational Services

Include providing educational assessments; day treatment; case management; drop–in, self–help centers; and the Florida Assertive Community Treatment Team (FACT) program's specific educational service entitled Education, Support and Consultation to Family, and Other Major Supports. With the exception of the Florida Assertive Community Treatment Team –specific service for education, most educational services may be provided on–site of providers, with instructors funded through local school boards.

Florida Self– Directed Care

Florida Self–Directed Care is available in two parts of the state – the Jacksonville area and Southwest Florida. People eligible for public mental health services are given a budget and can choose the services and supports they want to purchase, and from whom they will purchase them.

Supportive Housing

Supported housing/living services are designed to help people with substance abuse or psychiatric disabilities find and keep living arrangements of their choice. Supported housing/living services also provide services and supports to ensure continued successful living in the community. The goal of Supportive Housing is to ensure that everyone has the opportunity to live as independently as possible.

Supported Employment

An evidence-based practice that helps individuals with mental health conditions attain or regain productive employment. Supported Employment services are community–based and take place in an integrated work setting, which provides regular contact with non–disabled co–workers or the public. A job coach provides long–term ongoing support as needed to give an individual every opportunity to maintain employment.

Mental Health Clubhouse

Structured, community–based interventions where members can strengthen and/or regain interpersonal skills, get psycho–social therapy toward rehabilitation, develop the environmental supports necessary to thrive in the community, meet employment and other life goals, and recover from the effects of a mental illness.

Residential Level 3

Licensed facilities, provide 24–hour a day, seven days per week supervised residential alternatives and structured care to persons who have developed a moderate functional capacity for independent living. For adults with serious mental illnesses, these are supervised apartments.

Supports Case Management

Case managers help people identify their needs, plan services, link them to the service system, coordinate the various system components, monitor service delivery, and evaluate the effect of the services received.

Day Care Services

Day Care Services provide a structured schedule of activities for four hours or more consecutive hours per day for children of individuals who are participating in a substance abuse or mental health day–night service or residential service.

Drop–In/Self–Help Centers

These centers are intended to provide a range of opportunities for persons with serious and persistent mental illnesses to independently develop, operate, and participate in social, recreational, and networking activities. Many are operated by consumers of mental health services.

Incidental Expenses

These may include the costs of medications that can't be paid for any other way, as well as things like clothing, medical care, educational needs, housing subsidies, transportation, or one–time expenses like the cost of turning on utilities for a new place to live.

Information and Referral

Provides information about resources in the community, and agencies/organizations that offer assistance; links individuals needing assistance with service providers.

Prevention

Prevention services involve strategies that avoid or deter the development of substance abuse and mental health problems. Prevention services include increasing public awareness through information, education, and alternative–focused activities.

Residential Level 4

The facility may have less than 24 hours per day, seven days per week on–premises supervision.

This is the least intensive level of residential care and is primarily a support service. For adults with serious mental illnesses, this includes satellite apartments, satellite group homes, and therapeutic foster homes.

Respite Services Respite service is an organized program designed to sustain the family or other primary caregiver by providing time–limited, temporary relief from the ongoing responsibility of care giving.

Room and Board with Supervision

Levels 1–3

Payment for room and board costs for people living in Medicaid–funded residential programs.

Medicaid pays for the clinical services, and the SAMH program pays for non-clinical services.

Service Planning and Coordination

Multi–disciplinary planning teams, often called Family Service Planning Teams are family–focused and community–based and serve as a focus for identifying supports and service planning for the family.

Peer Support

A system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful. Peer support is not based on psychiatric models and diagnostic criteria. It is about understanding another’s situation empathically through the shared experience of emotional and psychological pain and is delivered by individuals with lived experience with mental health and or substance use conditions and recovery

Bed Capacity Analysis

The study evaluates the capacity of facilities to meet the demand for inpatient mental health care, for children, adolescents, and adults and identifies critical bed capacity gaps by examining bed availability and usage. This analysis spans various facility types, including civil and forensic state mental health treatment facilities

(SMHTF) for adults, Juvenile Incompetent to Proceed (JITP), hospitals with psychiatric beds, specialty psychiatric hospitals (Class 3), crisis stabilization units for children and adults, and residential treatment centers for both children and adults, including short-term units and specialized therapeutic group homes.

An assessment of the current system of care capacity was conducted to identify potential gaps in meeting the mental health needs of children, adolescents, and adults across the six DCF regions. The analysis examined bed availability and usage across psychiatric inpatient facilities, including emergency receiving, treatment facilities, state treatment facilities and residential treatment centers for inpatient treatment between forensic and civil placements. Two key metrics that measure the utilization of beds are described below.

• Total bed days: Total bed days are estimated as the number of discharges per year times the average length of stay. It represents the total number of days that all beds in a facility are occupied each year.

• Occupancy rate: The occupancy rate is calculated…