Paul Elizondo, Commissioner Leon Evans Gilbert R. Gonzales

1. Bexar County Crisis Care Center Jail DiversionPresentation for 71st Annual NACO Conference & ExpoChicago Illinois August 4-8, 2006 Paul Elizondo, Commissioner Leon Evans Gilbert R. Gonzales Bexar County, Precinct 2 Executive Director, CHCS Director, CCC/Jail Div., CHCS

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

3. Public Safety Net Crisis Care Center Jail Diversion Initiatives

4. Crisis Care Center

5. Crisis Care Center The Center for Health Care Services UTHSCSA, UPG The Center For Health Care Services (CHCS) The University Health System (UHS) The University Physicians Group (UPG) The University of Texas Health Science Center

6. 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.

7. 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.

8. The Result

14. Crisis Care Center Emergency Psychiatric Services Unit • Services – Medical Clearance • Psychiatric Services • Staff • Procedure to access services • Who to bring/ Who not to bring • Administrator on Call

15. CRISIS CARE CENTER Aug 29th to Sept. 23rd, 2005 Total Visits = 605 Total Visits Medical Clearance = 129 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%

16. Crisis Care Center Summary

17. Law Enforcement Cost calculated @ $50.00 per hour

18. Crisis Care Center Preliminary 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. WAIT TIME for LAW ENFORCEMENT • 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 .

19. Jail Diversion

20. 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

21. Targeted Capacity Expansion (TCE) Grant for Jail Diversion Programs

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

23. 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.

24. 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%) Approximately 17% of the adult offenders under TDCJ’s supervision were current or former clients of the public mental health system. * CID = Criminal Investigation Division

25. “ Today’s Misdemeanants, Tomorrow's Felon “

27. 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

28. 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

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

30. The Partnership The beginning City of San Antonio Mayor Ed Garza Bexar County County Judge Nelson Wolf

31. How We Started Community Partnership City Government County Government State Government University – Local Private Hospitals Law Enforcement Criminal/Civil Courts Advocacy – NAMI Consumers San Antonio State Hospital Mental Health Partners The Jail Diversion Over-sight Committee The Jail Diversion Planning & Advisory Committee Community Medical Directors Roundtable Private Sponsorship Aztrazeneca

32. GOALS • 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.

35. The Diversion Process Point of Contact with Law Enforcement CIT/Deputy Mobile Outreach Team 24/7 Crisis Services Emergency Transport to Hospital *Pre-Arrest Diversion Referrals to Community Providers Arrested Magistrate Court Post-Booking Diversion Pre-Trial Diversion Bexar County Jail Community-based Wraparound Care Genesis Probation, Incarceration, Parole Treatment in lieu of Incarceration Residential Respite * Federal Grant Award

36. DMOT CIT PreTrial Svcs Magistration Genesis

37. Outcome In Bexar County Texas 3,764 persons suffering from mental illness were diverted from inappropriate incarceration (Sep 2004-March 2006). # Diverted FY 2004 1732 Actual FY 2005 1148 Actual YTD 2006 884 Actual (six months) FY05 *** mid year projection for FY06

38. 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. The Model

39. Features 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

40. The Path 2002 - 2005 • Deputy Mobile Outreach Team is established • 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

41. The Path (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

42. CHCS Service Units within the Model • 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.

43. CHCS Service Units within the Model • 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.

44. CHCS Service Units within the Model 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.

45. CHCS Service Units within the Model • 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.

46. CHCS Service Units within the Model • 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

47. Annual National CIT ConferenceColumbus, Ohio

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

49. CHCS Service Units within the Model 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.

50. CHCS Service within the Model 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.