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“Implementing a Public Health Approach to Drug

Abuse and Mental Illness”

Designing a National County Based strategy to significantly lower recidivism for juvenile/adult offenders and people in psychiatric crisis who find themselves homeless, in crowed emergency rooms, and inappropriately placed in jails.

National Association of Counties (NACo) January 28-31, 2009

Lee County (Estero), Florida

Leon EvansPresident, National Association of County Behavioral Health Directors;

President and Chief Executive OfficerThe Center for Health Care Services

Bexar County Mental Health AuthoritySan Antonio, Texaslevans@chcsbc.org

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

FAILED PUBLIC POLICY

The Problem:The Problem:

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President’s Freedom CommissionPresident’s Freedom Commission

On Mental Health Interim Report:On Mental Health Interim Report:

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

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

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

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Community Wide Jail DiversionCommunity Wide Jail DiversionThe ProblemThe Problem

Criminalization of Mentally IllCriminalization of Mentally Ill Inappropriate Cost to SocietyInappropriate Cost to Society

20% + in jail20% + in jail Increase use of Increase use of emergency roomsemergency rooms HomelessnessHomelessness

Public Safety NetPublic Safety Net Consumers at riskConsumers at risk Law Enforcement at Law Enforcement at riskrisk Public at riskPublic at risk

The Problem

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

Why ?

The Problem

6There’s no integrated Plan

The Individual

Vocational ServicesEmployment

Law Enforcement

Treatment Housing

Poor System DesignPoor System Design

Poor Communication

The Problem

Jails

EmergencyRoomsMedical

HomelessServices

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Police and Sheriff's Deputies are upset because they have to deal with the mentally ill

Frustration due to lack of known options and alternatives

People in the MH system are scared to deal with folks in the Law Enforcement/Criminal Justice system

People in hospital emergency rooms are overwhelmed

Communication across systems:

People who concentrate in vocational jobs aren’t focused on Housing

Folks in housing don’t understand mental illness and need for vocational services

Everybody's goal is different

The Problem

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One in 100: Behind Bars in America

Between 1987 and 2007, the national prison population has nearly tripled.

Total Behind Bars - 2,319,258 SOURCE: Bureau of Justice Statistics; Pew Public Safety Performance Project, 2008

The Problem

PRISON COUNT PUSHES UP

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An Ounce of PreventionAn Ounce of PreventionTaxpayer Costs Avoided through Preventing Taxpayer Costs Avoided through Preventing

CrimeCrime

Criminal Behavior and Its Cost to SocietyCriminal Behavior and Its Cost to Society 1.7 Trillion including victimless 1.7 Trillion including victimless crime – crime – Perazzo 2002Perazzo 2002

674 Billion Federal, State and Local – 674 Billion Federal, State and Local – Shapiro 1999Shapiro 1999

1.0 Trillion (2 million people incarcerated) – 1.0 Trillion (2 million people incarcerated) – AdrienneAdrienne

20052005

Cost Avoided if One Criminal Career is PreventedCost Avoided if One Criminal Career is Prevented$ 976,217.81$ 976,217.81 Average annual adult cost (2004) - $40,865Average annual adult cost (2004) - $40,865 Average annual juvenile cost (2004) - $32,888Average annual juvenile cost (2004) - $32,888

Source: Dr. Victoria Reinhardt, An Ounce of Prevention presentationTo NACo, July 2008

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Texas Department of Criminal JusticeTexas Department of Criminal JusticeMHMR Match StatisticsMHMR Match Statistics

October, 2007October, 2007

C.I.D.C.I.D. ParoleParole ProbatioProbationn

TotalTotal

Total TDCJ Total TDCJ PopulationPopulation 152,661152,661 77,75577,755 432,359432,359 662,775662,775

# of Care Matches*# of Care Matches* 40,88340,883 19,76319,763 54,72754,727 115,373115,373

% of Total Population% of Total Population 26.78%26.78% 25.41%25.41% 12.65%12.65% 17.40%17.40%

*Represents all Clients served since 1985, including those whose diagnosis is no longer eligible for MHMR *Represents all Clients served since 1985, including those whose diagnosis is no longer eligible for MHMR

Source: Texas Correctional Office on Offenders with Mental and Medical Impairments Source: Texas Correctional Office on Offenders with Mental and Medical Impairments

The Problem

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Revocation Rates 2007Revocation Rates 2007Federal 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 = 15.8% Top 5 Largest Community and Corrections Departments = 16.1 %

Local Revocation Rate: Bexar County Mentally Impaired Caseload Department Probation Department = 8% Manos Diversion Program, CHCS = 6.2%

Rearrest Rate

0

10

20

30

40

50

60

70

Federal State Probation CHCS

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The Problem gets worse:

Poor and or reduced funding

Scant, limited and rationed services

Reduction of State Hospital treatment beds

The Problem

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Shortage of State Psychiatric BedsShortage of State Psychiatric Beds The Problem

Severe Shortage of Psychiatric Beds Sounds National Alarm BellReport finds US deficit of nearly 100,000 inpatient beds; result is increased homelessness, emergency room overcrowding, and use of jails and prisons as de-facto psychiatric hospitals.

Critical bed storage (less than 12 beds per 100,000 population)Nevada‡ 5.1 Ohio 10.6Arizona 5.9 South Carolina 10.6 Arkansas 6.7 Oklahoma 11.0Iowa 8.1 Idaho 11.3Vermont 8.9 Alaska 11.3Michigan 9.9

Severe bed shortage (12–19 beds per 100,000 population)Florida 12.1 Colorado 16.9Texas 12.1 North Carolina 17.1Rhode Island 12.5 New Hampshire 17.2Maine 12.6 California 17.5Wisconsin 13.0 Tennessee 18.1Hawaii 13.5 Georgia 18.5Utah 13.8 Pennsylvania 18.9West Virginia 14.2 Washington 18.9Illinois 14.3 Oregon 19.2Kentucky 15.6 Indiana 19.3Massachusetts 15.8

Marginal bed shortage (35–49 beds per 100,000 population)South Dakota 40.3

Meets minimal standard (50 or more beds per 100,000 population)Mississippi 49.7

Source: TreatmentAdvocacyCenter.org

Serious bed shortage (20-34 beds per 100,000 population)Louisiana 20.2 New Mexico 22.3Nebraska 20.7 Wyoming 24.1Montana 20.9 Connecticut 25.4Missouri 21.5 North Dakota 25.9Maryland 21.6 Minnesota 26.8Kansas 21.7 New York 27.4Alabama 22.1 New Jersey 32.4Virginia 22.2 Delaware 33.8

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The CostThe 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

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San DiegoSan Diego

529 high utilizers ran up a cost of 529 high utilizers ran up a cost of $18 million dollars (2000-2003) $18 million dollars (2000-2003) including:including:

$4 million for Emergency, Police, and $4 million for Emergency, Police, and CourtCourt

$14 million for medical, ICU and surgery$14 million for medical, ICU and surgeryImpact San Diego SIP, Annals of Emergency Medicine, Vol 47, No.4:April 2006

15 chronic homeless inebriates (ineighteen months) cost $1.5 million

The New Yorker Magazine, Million Dollar Murray, Issue 2006-02-13 and 20, 2006

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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,”

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Mental illnesses are costly. The failure to treat them affects not only an individual’s overall health but the cost of health care, including costs that must be borne by public systems.1

• Mental illness is the leading cause of disability in the United States for people between the ages of 15 and 44.2

• The Global Burden of Disease study indicates that the burden of disease from mental disorders for countries like the U.S. exceeds that of any other health condition.3

• Mental illnesses and substance use disorders resulted in $193 billion in lost productivity in 2002. By 2013 this loss is estimated to rise to more than $300 billion.4 (1,2,3,and 4 -Integrating Mental Health in Healthcare, The Bazelon Center)

• 75 to 90 % of people with psychiatric disabilities are outside the labor force in the US. Anthony and Bianch, 1987

The Nature of Mental Illness

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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

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Homeless persons

The Nature of Mental Illness

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 SMI 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)

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HousingHousing

Source: Community Conversations Guide

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Is funding all we need?

Even if everyone had insurance, availability to pay for treatment, the people with mental illness would still not avail themselves with treatment

Many providers deliver services, give bus tokens, incentives, call and remind about appointments, call family and still havea high no show rate; appointments and even medication is forgotten

Without special supports, wraparound services, care coordinators, patient navigators this population wouldn’t get the kind of services or rehabilitation they need

The Nature of Mental Illness

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How about our Children?

For troubled kids there is no early Intervention; treatment is fragmented

Schools are challenged and ill equipped to handle kids with mental illness

Columbine and others are places where no early identification and limited to no resources produced tragic results

67% to 70% of youth in the juvenile justice system have a diagnosable mental health disorder (Skowyra & Cocozza, 2006)

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Essential NeedsEssential Needs Leadership to help make sense so we can Leadership to help make sense so we can

get fragile outcomes for these fragile folksget fragile outcomes for these fragile folks

Community based solutions

Early intervention and preventionEarly intervention and prevention

Treatment, Housing, EmploymentTreatment, Housing, Employment

Collaboration

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Collaboration: It’s an unnatural act between…

…two or more unconsenting adults.

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What we know is

what works in one community may not work in another community

but you can take bits and pieces of what works in one into another, to rural or metropolitan areas

we need to find a way to share that information and identify best practices

What Works

Meeting the ChallengeMeeting the Challenge

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Meeting the ChallengeMeeting the Challenge

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The Individual

Vocational ServicesEmployment

Law Enforcement

Treatment

Housing

Focused Communication

What Works

Medical

Jails

HomelessServices

•Early Identification•Access

•Treatment•Consumer Navigators

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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

What Works

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Emergency Room utilization has dropped 40% since the inception of the Crisis Care Center.

40% of (7619 total seen at CCC) 3048 Persons diverted from the ER (in 2006 first year)

X $1545Cost Savings relative to ER Utilization $4,709,160

Source: Jean R. Setzer, Ph.D., University Health System

Emergency Room Utilization (Medical Clearance)

What Works

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There are many more effective solutions in our States,

in our Counties, and all acrossthe Country !

What Works

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Conclusion

As elected officials and policy makers we must help drive the right solutions so taxpayers

reap the benefit of efficient governance and persons with mental illness aren't criminalized and

inappropriately placed in jails and prisons, emergency rooms and or our streets

Create a National Commission which would involve elected officials who would oversee a unified and

outcome driven solution

Recommendation

Call for Action

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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 !

www.chcsbc.org