Continuity of Care Task Continuity of Care Task ForceForcePreliminary Recommendations

BACKGROUNDBACKGROUNDThe Texas State Psychiatric

Hospital system is nearing capacityWhile total admissions and civil

commitments have decreased, the number of forensic commitments has increased

Forensic commitments generally involve longer lengths of stay

The increased number of forensic commitments and longer term patients has overcome the impact of decreased admissions

TASK FORCE GOALSTASK FORCE GOALSExamine the overall continuum of

care for individuals with severe mental illness who move through multiple systems

Examine barriers to discharge for individuals in State Hospitals with extended lengths of stay

Make and prioritize recommendations to improve continuum of care and resolve barriers to discharge

TIMELINETIMELINEFour Task Force Meetings

◦February 5, 2010◦February 19, 2010◦March 26, 2010◦June 18, 2010

Final Report—August 31, 2010

Public ForumsPublic ForumsMarch 3rd, Czech Heritage Center, La

Grange, TXMay 7th, Rio Grande State Center

Auditorium, Harlingen, TX 12:30-2:00 PM

May 11th, Dallas County Health and Human Services Building, Room 627,Dallas, TX 12:30-2PM

May 21st, Big Spring State Hospital Auditorium, Big Spring, TX 12:30-2PM

May 27th, DSHS West Auditorium, Austin, TX 1PM-3PM

Global IssuesGlobal IssuesIs the increase in the number of

forensic commitments a positive or negative development? Both◦Lack of intermediate care options◦Better awareness

Recommendations will be challenging because of significant differences between urban and rural communities

Better mental health care and treatment for children and adolescents would be successful prevention approach

Environmental Perspective: Environmental Perspective: Public Health EpidemicPublic Health EpidemicIncidence and prevalence of specific

diagnosesTrajectory of growing populationIncreasing numbers of uninsured and

underinsuredDecreasing capacity in the private

service systemAppreciation of behavioral health

disorders as chronic conditions, much like diabetes and hypertension

Potential for decreasing hospital bed capacity in the near future

Environmental Environmental PerspectivePerspectivePrimary care needs—need for

expansion of integrated careLack of residential alternatives to

hospitalization, including permanent supportive housing, is major barrier

Current service system doesn’t address significant overlap between Axis I, Axis II, Substance Use Disorders, Intellectual Disabilities, Head Injuries

Data DevelopmentData Development

Jail treatment prior to finding of incompetency

Individuals admitted > 3 times in 180 days

Individuals with > 5 forensic admissions in FY 2009

Outpatient Restoration of Competency Pilot Participants

Individuals with length of stay > 365 daysForensic commitment/re-commitment of

misdemeanants

Policy/Practice IssuesPolicy/Practice IssuesHousingCommunity supervision and medical

necessity—judicial expectations“Step-down” levels of careFunding for non-crisis servicesNeed for cognitive rehabilitative

servicesImproved communication between

courts and hospitals

Crisis

Person is seen by law enforcement

Is this a psychiatric

emergency?

Disposition per Law Enforcement

Contact Local Mental Health

Authority No Yes

Is the person a known consumer?

Yes

No

Medical status is known

Is there a known medical emergency?*

Disposition per Mental Health

Authority

No

Medical status is not known

Is there reason to suspect a medical

emergency?*

Medical treatment would be prudent to insure patient safety and safety in transport. **

Yes

Person is medically stable and safe for Law Enforcement transport?

Yes

No

Kept at hospital until stabilized

No

*The Peace Officer may use the following indicators to determine if a medical emergency exist:

1. Overdose2. Acute intoxication with alcohol or drugs.3. Chest pain4. Fluctuating consciousness.5. Stab wound, bleeding or serious injury.6. Seizure activity.7. Complications from diabetes 8. Injured in assault or fight9. Victim of a sexual assault10. Person is a resident of a nursing home or assisted living facility. Note: With the elderly, sometimes medical problems can cause symptoms that look like mental illness but are not. It's important to rule-out medical problems as the cause.

Psychiatric Emergency Flow Chart

Draft 4-23-10

Yes

**An inpatient mental health facility or amental health facility is not statutorilyauthorized to require a peace officer totransport a person in custody under chapter 573, Health and Safety Code, to a medical facility for a medical evaluation prior to taking that person to the mental health facility.

The opinion of Law Enforcement as to whether a medical emergency exist is final in the screening conducted with the Local Mental Health Authority.

Medical Clearance

Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermStatutory—46B

◦Clarify that maximum time commitment includes “time served” in jail from the date of booking

◦Include commitment expiration dates in court orders to facilitate communication between hospitals and courts

Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermStatutory—46B

◦Limit the maximum commitment period for misdemeanants to 90 days (civil commitment is alternative if criteria met)

◦Restore provisions in forensic expert reports about individuals not likely to be restored to competency in the for-seeable future to allow for better analysis and disposition of individuals with repeat forensic commitments

Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermStatutory—46B

◦Allow for voluntary jail treatment for 14-21 days prior to evaluation for competency to stand trial—with option for contest by defense counsel (involuntary treatment currently authorized under H&S Code 574.106 for certain individuals in jail settings

◦Clarify judicial authority under 46B.079(b)(2) (forced medications)

Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermStatutory—17.032

◦Link 17.032 provisions to Permanent Supportive Housing legislative appropriations request—create incentives throughout 17.032 to utilize PSH for misdemeanor defendants

Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermStatutory

◦Extended outpatient commitment for subset of outpatient commitment candidates

Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermMedical Clearance

RecommendationsPermanent Supportive Housing

for Misdemeanants with Conditional Release provisions

Alternative levels of residential care, including Assisted Living, for individuals with long term hospital stays

Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermTraining

◦Judges◦Prosecutors◦Defense Attorneys◦Mental Health Professionals◦Law Enforcement◦On-Line peer consultation for judges,

defense attorneys, prosecutors◦Law Schools

Preliminary Preliminary Recommendations:Recommendations:Intermediate TermIntermediate TermClinical

◦Clinical competencies◦Professional development◦Salary analysis◦Peer support approach◦Trauma informed care◦Cognitive Rehab and appreciation of

co-morbidities in RDM◦Expanded time for testing,

assessment, record analysis

Preliminary Recommendations: Interim Studies?

◦ Mental Health Code

◦ Consideration of Medicaid Waiver

◦ Study of clinical issues for long term hospitalizations

◦ Improve data systems to better clarify issues around repeat forensic commitments and charges