Bexar County Crisis Care Center Jail Diversion Presentation for 71 st Annual NACO Conference & Expo Chicago Illinois August 4-8, 2006 Paul Elizondo, Commissioner

Bexar County Crisis Care Center Jail Diversion

Presentation for

71st Annual NACO Conference & Expo

Chicago Illinois August 4-8, 2006

Paul Elizondo, Commissioner Leon Evans Gilbert R. GonzalesBexar County, Precinct 2 Executive Director, CHCS Director, CCC/Jail Div., CHCS

• Crisis Care Center • Jail Diversion Initiatives• How the Program works• Summary Review

OVERVIEWOVERVIEW

Public Safety Net

Crisis Care Center

Jail Diversion Initiatives

Crisis Care Center

Crisis Care Center

The Center For Health Care Services (CHCS)

The University Health System (UHS)The University Physicians Group (UPG)The University of Texas Health Science

Center

UTHSCSA, UPG The Center for

Health Care Services

The Vision

A Crisis Care Center (CCC) operating 24/7 providing medical and mental health screenings with six 23 hour holding beds.

The CCC would be located at the UHS downtown facility.

The patient would have a single diagnosis of mentally ill, mentally ill with medical problem, no diagnosis of mental illness but with medical problem. The patient may have a substance abuse diagnosis.

The Plan To Accomplish The VisionThe University Health System

Provide space for the identified CHCS functions to be moved to the downtown facility for an annual lease cost of $1.

Provide additional staff to keep the Laboratory and X-ray functions open 8:00 pm to 8:00 am Monday – Friday and on week ends (funding to be determined).

Provide minor building modifications to accommodate CHCS functions (funded by CHCS).

Agree to co-location of CHCS Crisis Line and Nurse Triage Functions.

The Result

Crisis Care CenterEmergency Psychiatric

Services Unit

• Services – Medical Clearance Psychiatric Services• Staff• Procedure to access services• Who to bring/ Who not to bring• Administrator on Call

Total Visits = 605

Total Visits Medical Clearance = 129

CRISIS CARE CENTER

Aug 29th to Sept. 23rd, 2005

Medical Eval only = 86

Needing XRay = 21

Needing Lab = 23

Needing Minor Procedure - 21

Psych and Med Eval = 27

Psych Only = 476, average 17 per day

Referred by Law Enforcement for Med Clearance = 88 or 68%

Referred by Law Enforcement for Psych only = 89 or 19%

Crisis Care Center Summary

Summary Stats Sep – Dec 05 Average Jan-06 Feb-06 Mar-06

Facility Total 2777 694.25 666 523 770

Psychiatric 2076 519 497 405 609

Express Med (Clearance) 701 175.25 169 118 161

Law Enforcement

Law Enforcement Totals to Date

Totals 865

SAPD 665 Med Eval Only 552

Med and Psych Evaluations 113

BCSO 200 Med Eval Only 186

Med and Psych Evaluations 11

Law Enforcement Man Hours Available for Re-allocation

Jan-06 Feb-06 Mar-06

SAPD 960 639 940

BCSO 49 28 80

Total 1009 667 1020

7 Month Averages: SAPD = 843.85 hours or ($42,192.50)

BCSO= 48.85 hours or ($2,442.50) Cost calculated @ $50.00 per hour

Crisis Care CenterPreliminary DATA (continued)

Then

• Wait times for Medical Clearance/ Screening at UHS ER - 9 hours, 18 minutes. • Wait times for Medical Clearance/ Screening and Psychiatric Evaluation is 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 .

WAIT TIME for LAW ENFORCEMENT

Jail Diversion

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

Targeted Capacity Targeted Capacity Expansion (TCE) Grant Expansion (TCE) Grant

for Jail Diversion for Jail Diversion ProgramsPrograms

“ If you’ve seen ONE jail diversion program, you’ve seen ONE jail diversion program “

Mental Health Screening Processat Local Jails

Based upon a random sample of 100 reports submitted by local jails to TDCJ, the following observations were made:

• Of the 100 inmate records reviewed, 15 or 15% had a mental health diagnosis noted (10 had the same diagnosis as that noted on the Client Assessment Registry, or CARE, system);

• Of the remaining 85, 29 or 34% were found on the CARE system as current or former clients of MHMR, but no mental health notation was indicated by the jail;

• 44% of the 100 were former or current clients of MHMR.

CROSS-REFERENCE OVERVIEWOF CLIENT ASSESSMENT REGISTRY

(CARE) MATCHES

(Total Offender Population: 628,343)

PROBATION: 59,612 (15%)

CID: 33,008 (22%)

PAROLE: 12,332 (16%)

TOTAL: 104,952 (17%)

* CID = Criminal Investigation Division

Approximately 17% of the adult offenders under TDCJ’s supervision were current or former clients of the public mental health system.

“ Today’s Misdemeanants, Tomorrow's Felon “

If No Programs Are In Place

Continued Increase/Overcrowding in Jail Population

Continued Increase/Overcrowding in Prison Population

Increased and Inappropriate Use of Emergency Rooms

Strategies for Success Don’t Let Them Go to Jail in the First Place Diversion in all appropriate settings Set up:

Primary Diversion/Intervention Pre Booking services Cross match of jail population In jail screening/services

Secondary Diversion/Intervention Post Booking services Intensive Outpatient Treatment for

Probation/Parole (Genesis) Residential MH Services (MIOF)

Continuity of Care Intensive Ongoing Case management Timely updates to Judges MH/Judicial Joint Staffing

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

The Partnership

The beginning

City of San AntonioMayor

Ed Garza

Bexar CountyCounty Judge

Nelson Wolf

Community PartnershipCommunity Partnership

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

The Jail Diversion Over-sightThe Jail Diversion Over-sightCommitteeCommittee

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

How We StartedHow We Started

Community Medical Directors Community Medical Directors RoundtableRoundtable

Private SponsorshipPrivate SponsorshipAztrazenecaAztrazeneca

GOALSGOALS

• Establish a community-based partnership among stakeholders within the Judicial/Mental Health systems.

• To implement a City/County wide model for the mentally ill and mentally retarded who may or has come in contact with the criminal justice system.

• Establish a comprehensive Jail Diversion Program to reduce the number of individuals jailed because no alternative action or treatment was available.

Point of Contact with Law Enforcement

Magistrate Court

Bexar County Jail

Post-Booking Diversion

Community-based Wraparound Care

CIT/Deputy Mobile Outreach

Team

Genesis Probation, Incarceration,

Parole

Emergency Transport to

Hospital

Pre-Trial Diversion

Referrals to Community Providers

*Pre-Arrest Diversion

Residential Respite

Arrested

The Diversion ProcessThe Diversion Process

Treatment in lieu of Incarceration

24/7 CrisisServices

* Federal Grant Award

DMOTCIT PreTrial Svcs Magistration Genesis

1732

1148884

1768

0

500

1000

1500

2000

FY04 FY06

Diversions

Diversions

OutcomeIn Bexar County Texas 3,764 persons suffering

from mental illness were diverted from inappropriate incarceration(Sep 2004-March 2006).

# Diverted

FY 2004 1732 ActualFY 2005 1148 ActualYTD 2006 884 Actual(six months)

*** mid year projection for FY06FY05

The ModelThe Model

The Bexar County Jail Diversion Model is a comprehensive, coordinated delivery network which is tasked with the identification, diversion from incarceration and treatment of the mentally ill for those persons who are placed or who are about to be placed within the criminal justice system. The model is symptom based and is designed to cover 46 specific intervention points within the mental health/criminal justice system.

Features of the ModelFeatures of the Model

• Active partnership with all stakeholders• Early Intervention• Early Screening and Assessment• Service Coordination at MH and Judicial points of access• 24/7 Crisis Center and Medical Clearance access – One Stop• Targeted program data tracking

• Deputy Mobile Outreach Team is established

The PathThe Path 2002 - 20052002 - 2005

• Jail Diversion Planning Advisory Committee met for one year• Mental Health Docket is expanded• Jail Diversion Over-sight Committee established• Bexar County JD Model approved by JDPAC • 78th Legislature in session/reorganization in process – Jail Diversion Law• Crisis Intervention Training for Police/Sheriff continues

The Path The Path (cont.):(cont.):

• Adult Crisis Services and Law Enforcement Medical Clearance 24/7 - central location established

• County/City Wide consolidation of crisis services and minor medical triage in process

• Data on ER utilization and jail admissions for misdemeanors tracked and showing decrease

• Jail diversions show an eightfold increase

• Expansion of Pre and Post Diversion programs continue

CHCS Service Units within CHCS Service Units within the Modelthe Model

1. The Deputy Mobile Outreach Team – Mental health professionals accompany an MH

trained Deputy Sheriff to calls from the community for assistance involving the mentally ill and the mentally retarded.


2. The Mental Health Docket – This docket is the combined efforts of the criminal courts, probation and mental health personnel to advise the court on consumer assessment, treatment and continuity of care. Court ordered referral is direct to intensive case management.


3. The Pre-Trial Services Program –The program obtains release from jail through a mental health bond (which can be obtained without cost to the consumer) and provides referral with transportation from the jail to designated treatment facilities. Reviews and assesses CARE

Match daily arrest activity with follow-up.


4. Involuntary Outpatient Commitment Program - On site court assigned case manager liaison monitors IOPC and works directly with Judges

5. Magistration Screening Program – Addresses the assessment and referral needs of the magistrate before booking and incarceration.


6. The Crisis Intervention Teams (CIT) – Officers trained by Law Enforcement

and Mental Health Personnel via a 40 hour curriculum including role play demonstrations. Attends weekly operational

meetings with MH and Community Stakeholders

Annual National CIT ConferenceColumbus, Ohio

National Award for Service ExcellenceBanquet, April 10th 2006 Orlando Florida

7. Not Guilty By Reason of Insanity Program (NGRI) -

Targets consumers who have been found to be not guilty by reason of insanity and no longer a danger to self or others. Intensive case management services are offered.

Regular contact with the committing court is also maintained to substantiate compliance with services. Staff act as a liaison between the client, the court, the hospital system and the outpatient treatment team.


8. Cognitive Adaptive Training -

CAT is a psychosocial intervention that concentrates on re-structuring a patient’s physical environment in ways that promote desired behaviors (e.g. taking medications, dressing appropriately, keeping clinic appointments).

CAT involves establishing environmental supports in the patient’s home or work environment and organizing the environment to cue and sequence adaptive behavior.

CHCS Service within the ModelCHCS Service within the Model


9. The Genesis Special Needs Offenders Program – This unit provides intensive case management, psychiatric services and rehabilitation training for offenders on probation and parole in collaboration with local and state probation and parole departments.

Provides treatment for 60 (MI) and 100 bed (Substance Abuse) residential units operated by Bexar County Probation Department

Genesis203 Clients

16 Staff

Omega (AppleWhite)65 Clients13 Staff *

Manos100 Clients

8 Staff

ProbationProbationers within Mentally Impaired Facility

Client Court Ordered

PrisonParole

Genesis - TCOOMMI

Omega – TCOOMMI, CJAD, CHCS

Manos - AstraZenica

POST DIVERSION CLINICAL EXPANSIONPalo Alto

Combined Substance Abuse and MH Services

FundingSource

Pasos75 Clients

6 Staff

Pasos – Department of Justice

Substance Abuse Treatment Facility

100 Clients10 Staff

Probationers within SA Treatment Unit

FundingSource

Bexar County Treatment FacilityTreatment Alternative to Incarceration Program

10. Research - Measuring the Potential Economic and Societal Benefits

Interim results of the program show over 1,700 diversions from jail incarcerations during state Fiscal Year 2004, potentially resulting in an estimated range of $3.8 million to $5.0 million dollars in avoided costs within the Bexar County Criminal Justice System.

Jail diversion programs have been shown to have positive impacts on

decreasing incarceration time for the severely mentally ill, while increasing access to, and utilization of, comprehensive psychiatric services.

Due to the organized structure of the Bexar County Jail Diversion Program and the thoroughness of the concurrent data collection process, a unique opportunity exists to measure the actual societal cost-benefit derived (in city, county and state dollars) from the jail diversion program in the near future, with continuance of the program.

CHCS Service within the ModelCHCS Service within the Model

Bexar County Jail Diversion Economic Analysis

2006 Conducted by RTI International

Dr. Alex Cowell is principal investigator Also working with Dr. Nahama Broner and Mr.

Arnie Aldridge Considerable help from

Leon Evans, CEO CHCS Dr. Edwardo Sanchez, Commissioner Texas

Department Of State Health and Human Services Multiple city and county organizations

Funded by the National Center for Behavioral Health Solutions

Study Motivation

Legislators, providers, and stakeholders need to know What resources does BCJD need? Which agencies provide these resources? To what degree can criminal justice costs be

reduced? Does BCJD make fiscal sense?

Requires external and independent research Credibility with legislators Credibility with stakeholders Credibility with academic peers conducting similar

evaluations

Using comprehensive data with a quasi-experimental design, the study will Analyze the costs of pre- versus post-

booking diversion Measure cost shifting between the health

care and criminal justice systems Calculate the cost effectiveness of BCJD

for improving mental health and criminal justice outcomes

Calculate the net benefit of BCJD

Study Objectives

Measure Program impact on outcomes – City, County, State and Federal

Increase Stakeholder input to evidence based services

Expand service capacity through collaborative partnerships

Continue educational efforts with target groups within community and the judicial/mental health systems

Engage Legislators, propose legislative change where needed

Engage in program evaluation and dissemination

The Path Leads to:The Path Leads to:

Leon Evans, Executive Director, The Center for Health Care Services San Antonio, Texas

For additional information contact: Gilbert R. Gonzales, Ph. 210 358-9804 Email [email protected]

Thank you !

Documents

Bexar County Crisis Care Center Jail Diversion Presentation for 71 st Annual NACO Conference & Expo Chicago Illinois August 4-8, 2006 Paul Elizondo, Commissioner