Improving Mental Health and Criminal Justice Outcomes

Community Solutions for Effective

Criminal Justice and Behavioral Health Interventions

Leon EvansPresident and Chief Executive Officer, The Center for Health Care Services

Mental Health and Substance Abuse Authority, Bexar County, San Antonio, Texas, levans@chcsbc.org

Raise your hand if you think there

will be more Local, State, andFederal Dollars.

President’s Freedom Commission

On Mental Health Interim Report:

“… the mental health delivery system is fragmented and in disarray…leading to unnecessary and costly disability, unemployment, homelessness, school failure and incarceration.”

2003 President’s Freedom Commission On Mental Health – Final Report

“In addition to the tragedy of lost lives, mental illnesses come with a devastatingly high financial cost. In the US, the annual economic, indirect cost of mental illness is estimated to be $79 billion”.

"abject failure of our society to address critical needs for persons with severemental illness"

FAILED PUBLIC POLICY

The Problem:

Community Wide Jail DiversionThe Problem

• Criminalization of Mentally Ill

• Inappropriate Cost to Society

• 20% + in jail

• Increase use of

emergency rooms

• Homelessness

• Public Safety Net

• Consumers at risk

• Law Enforcement at risk

• Public at risk

The Cost

Costly for taxpayers

Space is taken up which could be used for violent offenders

It's just wrong

In the U.S., the annual economic, indirect cost of mental illness isEstimated to be $79 billion. 2003 President’s New Freedom Commission on Mental Health

The Case of Million Dollar Murray

MILLION-DOLLAR MURRAYby MALCOLM GLADWELLThe New Yorker Magazine, Issue of 2006-02-13 and 20, Posted 2006-02-06

News ReleaseEmergency Departments See Dramatic Increase inPeople with Mental Illness Seeking CareEmergency Physicians Cite State Health Care Budget Cuts at Root of Problem

American Psychiatric AssociationHillarie Turner, 703-907-8536 June 2, 2004hturner@psych.org Release No. 04-30Sharon Reis 202-745-5103

Cost

“in one study, it had been concluded that one homeless person can cost the City and County about $200,000 in one year”. Philip F. Mangano, Executive Director of the United States Interagency Council on Homelessness (USICH), May 1, 2007.

“It cost us one million dollars not to do something about Murray,”

More Challenges

• The United States has roughly 2 million people incarcerated in federal, state and local prisons or jails USA Today July 14, 2011

• 67% of former prisoners are re-arrested, and 52% are re-incarcerated at a cost of $60 billion a year Commission on Safety and Abuse in America’s Prisons

• In Texas, the estimated lifetime cost of maintaining one person in the criminal justice system is more than $2 million Report to 81th Texas Legislature, Integration of Health and Behavioral Health Workgroup, August 2010

• 16 to 20+% of incarcerated persons have a serious mental illness and 64 percent of jail inmates have a mental health problem Mental Health Association, nmha.org et al

• 75% of inmates and prisoners with mental illness also have an addiction disorders Skeem and Louden, 2006

• More than 50% of prisoners have substance abuse problems but only one in ten receive treatment jails USA Today July 14, 2011

Texas Department of Criminal Justices

The Problem gets worse:

Poor and or reduced funding

Scant, limited and rationed services

Reduction of State Hospital treatment beds

Poor communication Poor system design Silos No strategic improvement plan Little use of prevailing best practices Lack of leadership and overview

Why ?

There’s no integrated Plan

The Individual

Vocational ServicesEmployment

Law Enforcement

Treatment Housing

Poor System Design

Poor Communication

Jails

EmergencyRoomsMedical

HomelessServices

Severe Mental Illness:the illness is devastating

because of the illness a person can’t manage their own lives

at onset, most people don’t understand mental illness, families don’t understand it and the person is rejected by the family and friends because of it

many times the person starts self medicating with alcohol or drugs

there is a lack of education and services

because of the pain and suffering personal ties are cut

Homeless persons

People who are homeless frequently report health problems:• 38% report alcohol use problems • 26% report other drug use problems • 66% report either substance use and/or mental health problems

• 39% report some form of mental health problems (20-25% meet criteria for serious mental illness) • 26% report acute health problems other than HIV/AIDS such as tuberculosis, pneumonia, or sexually transmitted diseases • 46% report chronic health conditions such as high blood pressure, diabetes, or cancer

Source: National Resource Center on Homelessness and Mental Illness, 2004

People with Serious Mental Illness die 25 years early:People with serious mental illnesses served in the public system are dying 25 years early, on average, from a full range of preventable health problems such as heart disease and diabetes. (NASMHPD, 2006)

What Can We Do About it

Who’s Gonna Make Us Do It?

Therapeutic Justice Model: The Integration of Treatment and Justice

“The Therapeutic Justice model is defined as a systemic approach which insures a collaborative partnership between the Courts, the Criminal Justice

System and the Health/Behavioral Health system while providing that the public safety net is able to

provide for the most efficient and effective support for persons who are in crisis and or are experiencing

psychiatric and substance abuse disorders.”

Leon Evans, President and CEO, CHCS Bexar County Mental Health Authority

Starting PointsTwo Views

Sequential Intercepts for Developing CJ-MH

PartnershipsGains Center

The Bexar County Jail Diversioin ModelSystem County Wide

Entry Points

Sequential Intercepts for Developing CJ-MH Partnerships*

* The Center for Mental Health Services, National GAINS Center

Law EnforcementDetention/Jail

CIT

Judicial/CourtsMagistrate

County District

Mental HealthPublic and Private

Providers

Crisis Care CenterJail DiversionPsychiatric and Medical

ClearanceSubstance Abuse ServicesSpecialty Offender Services

Community

DynamicCrisis Jail Diversion

Information Exchange

Po

lice

, Sh

eri

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rob

ati

on

, Pa

role

CIVIL AND CRIMINAL DIVERSION INITIATIVES T

rea

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uity

of C

are

County City-wide

Emergency Services• Community Collaborative• Crisis Care Center• Crisis Transitional Unit• Crisis Hotline (Nurselink)• CIT/DMOT•Jail and Juvenile Detention• Statewide CARE Match

System County City-wideEntry Points System Level

The Bexar County Jail Diversioin Model

System County Wide Entry Points

Collaboration: It’s an unnatural act between…

…two or more unconsenting adults.

“ If you want a partner, you have to be a partner”.

First StepsIdentify one single accountable person – full time

Engage Continuous Quality Improvement

Show the data

Show me the Data!!!

How the Process Worked

• Designated Full Time (Coordinator)• Empowered Staff assigned to attend meetings• Monthly Stakeholder meetings• Recorded Minutes with Action/No Action updates• Set Community Priorities• Reported all successes/failures• Followed Data Based Outcomes with Continuous Quality Improvement (CQI)• Focused on creating a culture of collaboration

Community PartnershipCommunity Partnership

City GovernmentCounty GovernmentState GovernmentUniversity – LocalPrivate HospitalsLaw EnforcementCriminal/Civil CourtsAdvocacy – NAMIConsumersSan Antonio State HospitalsMental Health Partners

The Jail Diversion Over-sightThe Jail Diversion Over-sightCommitteeCommittee

The Jail Diversion Planning The Jail Diversion Planning & Advisory Committee& Advisory Committee

Community Medical Directors Community Medical Directors RoundtableRoundtable

Private SponsorshipPrivate Sponsorship

• Jail Diversion Oversight Committee (34+ Community Agencies/Stakeholders)

• Community Medical Directors Roundtable

• Children’s Medical Directors Roundtable

• Bexar County Children’s Diversion School District Sub Committee

• Bexar County Children’s Diversion Child Protective Services Sub Committee

• Bexar County Children’s Diversion Juvenile Justice Probation Sub Committee

• Community Co-Location Coalition (29 Community Agencies including law enforcement entities meeting to address the homeless & public inebriate)

Stakeholder Collaboration via:

Evolution - Milestones

2002 – Bexar County Jail Diversion Collaborative meets for 1st time

2003 – First Crisis Intervention Team Training begins

2004 – Specialty Jail Diversion Facility opens

2005 – 24/7 One Stop Crisis Care Center Opened

2006 – Bexar County Jail Diversion receives APA’s Gold Award

2008 – Detox, Sobering, Drug Abuse Restoration Center Opened

2010 – Haven for Hope 1,600 Bed Homeless Facility Opened

2010 – International Crisis Intervention Team Conference hosts 1,600 Officers

2000 – CEO begins diversion efforts, full time coordinator is hired

2003 – Deputy Mobile Outreach Team begun

Across the Nation with Diversion Efforts

http://gainscenter.samhsa.gov/html/jail_diversion/jd_map.asp

With more mental health utilization there is less incarceration.

The Bottom LineOutcomes:

•Treatment Works – Revocation Rates

•Involuntary Outpatient Commitment Data

•Impact on Wait Time for Law Enforcement

•Documented and Immediate Cost Avoidance

•Jail Census

Revocation Rates 2010Federal Revocation Rate: 66%

Two-thirds of returning prisoners are re-arrested for new crimes within 3 years or their release. Second Chance Act, 110TH CONGRESS REPORT to US HOUSE OF REPRESENTATIVES

State Revocation Rate: Texas Felony Revocation Rate = 11.8% * For Offenders enrolled in TDCJ Casemanagement

Local Revocation Rate: Bexar County Mentally Impaired Caseload Department Probation Department = 10.8%

* Report to the Governor and LBB, December 2010

Rearrest Rate

0

10

20

30

40

50

60

70

Federal State Bexar

Involuntary Outpatient CommitmentProgram

0

50

100

150

# Bed Days Used

1 Yr Prior 132

1 Yr Post 27

State Hospital Bed Day Utilization Rate

PreIOPCProgram

Post

79% Reduction in BedDay Use, Post Program

First Year Evaluation

Then (prior to Sept 2005)• Wait times for Medical Clearance/ Screening at UHS ER - 9 hours, 18 min.

• Wait times for Medical Clearance/ Screening and

Psychiatric Evaluation was between 12 and 14 hours.

Now• The wait time for Medical

Clearance/ Screening at the Crisis Care Center is 45 minutes.

• Wait time for Medical Clearance/Screening and Psychiatric Evaluation is 60-65 minutes.

Impact on WAIT TIME for LAW ENFORCEMENT

Combined CCC and Restoration Documented and Immediate Cost AvoidanceCost Category City of San Antonio Bexar County Direct Cost Avoidance

Public Inebriates Diverted from Detention Facility

$435,435$925,015

A.

$1,983,574$2,818,755*

B.

$2,419,009$3,743,770

Injured Prisoner Diverted from UHS ER $528,000$435,000

C.

$1,267,200$1,044,000

D.

$1,795,200$1,479,000

Mentally Ill Diverted from UHS ER Cost $322,500$283,500

E.

$774,000$676,000

F.

$1,096,500$959,500

Mentally Ill Diverted from Magistration Facility

$208,159$179,833

G.

$371,350$322,300

H.

$579,509$502,133

Reduction in Competency Restoration Wait Time in Jail for Hosp Admission

0 $255,055$1,020,000

I.

$255,055$1,020,000

Reduction in Wait Time in Jail for Outpatient Competence/Wait Time for Restoration compared to Inpatient

0 $137,898$900,000

J.

$137,898$900,000

Reduction in Jail Time for Competency Restoration on Bond and on Return

0 $385,522$221,000

K.

$385,522$221,000

Total Year 1Total Year 2

TWO YEAR TOTALS

$1,494,094$1,823,348$3,317,442

$5,174,599$7,002,055

$12,176,654

$6,668,693$8,825,403

$15,494,096

Documented and Immediate Cost Avoidance, Two Year Analysis April 16, 2008 – March 31, 2010

BEXAR COUNTY DETENTION CENTERSYSTEM POPULATIONMONTHLY AVERAGES

(Main, Annex)

4222

3743

4133

40153987

3941 39464015

40814095

4171 4156

4094

38453807

3897

3981

4109

42634253

4040

3993

40624033

4066

3960

4079

4096

4084

4094

4095

41394173

4208 4261

4289

4225

4124

4158

4337

4272

4292

4197

421042544179 4193

4280

4357

43004300 4302

4053

4130

4001

4260

40284077

4231

4190

4017

379137903854

3982

3700

3800

3900

4000

4100

4200

4300

4400

JAN

FE

B

MA

R

AP

R

MA

Y

JUN

JUL

AU

G

SE

P

OC

T

NO

V

DE

C

SY

ST

EM

PO

PU

LA

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2006 2007 2008 2009 2010 2011

As of May 2011, there were 883 empty beds in the jail

Leon Evans, President and Chief Executive Officer, The Center for Health Care Services San Antonio, Texas

For additional information contact: Leon Evans, Ph. 210 731-1300 Email: levans@chcsbc.org

Thank you !