Leavenworth County Mental Health Task Force

1. Leavenworth County Mental Health Task Force Overview of Report to the Leavenworth Board of County Commissioners September 11, 2019

2. About the Report This study examined the mental health crisis in Leavenworth County, Kansas to identify the needs of citizens with mental illness and recommend solutions to meet these needs. • A group of elected officials and subject matter experts from the county and cities was formed to mine data, ascertain facts, propose and analyze options, and recommend solutions to the Board of County Commissioners (BOCC). • Known as the Mental Health Task Force (TF) this group met on six separate occasions, for 90 minutes each time, in the late winter/early spring of 2019. • TF worked through the process described above, documenting its findings and producing a written report with recommended solutions addressing the mental health crisis. • Report was delivered to the BOCC on July 24, 2019.

3. Problem Statement Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • Part I of the report provides evidence of this situation, including delineating the insufficiency of the County’s current mental health care and services to meet the needs of citizens with mental health problems. • The following functions, institutions, and programs (FIP) are addressed: • Opportunity costs are commented upon near end of Part I (page 26).

4. Recommended Solutions (Slide 1 of 3) In Part II of the report each solution is described briefly, costed out, and scheduled for implementation over multiple years. The first three of six recommended solutions are: • Recommendation 1. Youth Mental Health Initiative. • Recommendation 2. Enhance The Guidance Center (TGC) Services. • Recommendation 3. Establish a Residential Crisis Facility Within Leavenworth County. This recommendation is contingent on conducting a feasibility study to determine the financial viability of this facility.

5. Recommended Solutions (Slide 2 of 3) Each solution in the report is described briefly, costed out, and scheduled for implementation over multiple years. The last three recommended solutions are: • Recommendation 4. BOCC Continue to Fund Sheriff Department’s Mental Health Therapy (MHT) Program. • Recommendation 5. BOCC go on record as supporting expansion of the number of state hospital beds as recommended by Kansas Mental Health TF in January 2019. • Recommendation 6. BOCC consider going on record as supporting the expansion of Medicaid eligibility (as recommended by Kansas Mental Health TF in January 2019), and raising the rates of reimbursement.

6. Recommended Solutions (Slide 3 of 3) These recommendations are crafted to meet the mental health needs of the County’s youth, adults, juveniles in the Leavenworth County Community Corrections Program, prisoners in the County jail, and homeless people with mental illness. These needs are documented in the report and fall across the broad spectrum of mental illness: • Ranging from less serious but persistent problems affecting one’s everyday life, • To the most serious problems which result, not only in danger to the mentally ill themselves, but people they come in contact or interact with.

7. Underserved Populations While a good number of the mentally ill receive services, too many in this group are underserved, such as: • Juveniles in the County’s Community Corrections Program, some of whom could benefit from dual diagnosis treatment services to target both mental health and substance abuse issues. • And of course, an undetermined but significant number of the mentally ill are undiagnosed and/or not receiving mental health services. • This is the case with youth, ages 6-18, in Leavenworth County, where the TF estimates almost 1300 children not being served, the great majority of whom are in middle and high school. • For homeless citizens with less serious mental health problems, out-patient care and services, if available, can be and often is helpful. • But, for homeless citizens with more serious mental health problems requiring hospitalization, the lack of an in-patient treatment facility in Leavenworth County is an impediment to helping them get better.

8. Recommendations and Action Steps (Slide 1 of 2)

9. Recommendations and Action Steps (Slide 2 of 2)

10. Action Steps and Projected Costs (Slide 1 of 2) * In Part II of the TF’s Report projected costs for Leavenworth County are calculated for each action step. The action steps are a result of developing a concept to implement each recommendation. Concept and costing are subparagraphs under each of the report’s recommendations.

11. Action Steps and Projected Costs (Slide 2 of 2) * In Part II of the TF’s Report projected costs for Leavenworth County are calculated for each action step. The action steps are a result of developing a concept to implement each recommendation. Concept and costing are subparagraphs under each of the report’s recommendations.

12. Funding Strategy A phased strategy to fund the six recommendations and their action steps over a five-year period is included in the report and outlined in the next slide. • The annual mental health funding requirement for Leavenworth County is: • Approximately $1.4M in 2021 and 2022. • And $1.8M per year from 2023-2025.

13. Mental Health Funding Strategy Green Text – One Time Cost *Costs for 2023, 2024, and 2025 do not include any fiscal resources for a Residential Crisis Facility in Leavenworth County. A decision to establish such a facility will depend on the Feasibility Study conducted during Phase I in 2021

14. Strategic Communication The TF recognizes the importance of raising awareness of the mental health crisis among the citizenry of the county. • Formulating a plan to strategically communicate this study’s major findings would go a long way in accomplishing this task. • Best for the County government staff, working with the Cities, to prepare the plan, and then have the BOCC approve it for implementation.

15. Questions/Comments

16. Backup Slides

17. Functions, Institutions, and Programs Affected by the Crisis

18. Local Hospitals Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • Emergency Room (ER) visits to local hospitals for depression, suicidal ideation, and homicidal ideation are: * These numbers are projections through the end of 2019 based on the number of ER visits through the month of March 2019 • The upward trend in these ER visits is unmistakable. • Lacking health insurance many of these patients do not pay for their treatment at the ER. • Getting these patients the placement they need, most of whom do not volunteer for inpatient treatment, is an ongoing challenge.

19. Suicide(Slide 1 of 4) Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • Leavenworth County exhibits the highest rate of hospital discharges for mental health visits for ages 15-24, in the KC Metro Area. • Suicide in Kansas and Leavenworth County is another indicator of the mental health crisis affecting our fellow citizens. • Suicide rate in Kansas has risen 45% since 1999. • Number of suicides in Leavenworth County from 2013-2017 is 70; for Kansas during the same period the figure is 2,413. • This equates to an age-adjusted suicide death rate (95% CI) per 100K population of 17.2, which is higher, but not significantly different than the overall suicide death rate for Kansas of 16.7. • Since 2010 the number of suicides of people 24 years or younger in Leavenworth County is 14, with 8 of those occurring in the last 3 years. • 90% of people who die by suicide have a diagnosable and treatable psychiatric disorder at the time of their death.

20. Suicide (Slide 2 of 4) Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • As shown in the table below, during the last two years the number of suicide attempts and completions in the county total 78 and 20, respectively, a 26% completion rate.

21. Suicide (Slide 3 of 4) Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • Over a seven-year period (2012-2018) the Leavenworth Police Department averaged 195 suicide calls per year. • Over the last three years calls have risen from 180 in 2016, to 218 in 2018, an increase of 21%. • According to Chief Pat Kitchens, “We continue to struggle with mental illness as a primary public safety concern. In 2018 the Leavenworth Police Department responded to 218 calls for service, and with a lack of proper infrastructure and support it will continue to be difficult to make progress.” • Also, from 2012-2018 the department averaged 647 domestic disturbance calls per year, a significant percentage of which involved individuals with mental health problems.

22. Suicide (Slide 4 of 4) Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • Providing increased services as outlined in the recommendations of this report come with the expectation that suicide, another pernicious aspect of the mental health crisis in Leavenworth County, would decrease. • Or said another way, lowering the number of suicide attempts and successful completions in the county, and the number of suicide and domestic violence calls in the First City of Kansas is not likely if “business continues as usual,” with no ratcheting up of mental health services. • The goal is getting more people with diagnosable and treatable psychiatric disorders into treatment before they have thoughts of committing suicide. • Benefits would accrue not only to the mentally ill individuals receiving treatment, but the public at large as less mentally ill individuals in the community should lead to a decline in violent incidents relating to suicide and domestic abuse.

23. Community Corrections Program Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • Another dimension of the crisis within the county is reflected in the significant number of adults and juveniles in the Leavenworth County Community Corrections Program diagnosed with mental illness. • As shown in the table below, the number of juveniles in the program receiving mental health services over the last two fiscal years (FYs) is not insignificant. • Top four diagnoses are ADHD, • depression, conduct disorder, and • bipolar disorder. • Juveniles in the program were referred • to a variety of mental health services • [They] could have benefited from more • intensive, effective, and accessible mental • health treatment.

24. Leavenworth County Youth (Slide 1 of 5) Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • The mental health crisis affects the youth in our community. Not surprising given that 1 out of 5 children, ages 13-18, has a diagnosable mental health disorder; and 50% of all lifetime cases of mental illness begin by age 14. • Elementary, middle, and high schools in Leavenworth County have students with mental illness, which not only impacts their quality of life and ability to learn, but also results in the following: • Higher rates of delinquency, such as school suspensions • More cases of depression and suicidal ideation, and • Significant behavioral problems such as school suspensions, physical attacks, and bullying • Security concerns • On a macro level these byproducts of mental illness can and often do negatively affect the learning environment and educational outcomes in schools. • This issue was highlighted to the BOCC in July 2018 when Ms. Kimberly Knight, Assistant Principal, Leavenworth High School, presented a proposal addressing the need to provide services for students with diagnosable mental illness.

25. Leavenworth County Youth (Slide 2 of 5) Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • The existence of a mental health crisis among the youth in Leavenworth County is supported by the results from the 2019 Kansas Communities That Care (KCTC) Student Survey. • This survey measures youth risk factors related to depression/suicide, substance use/abuse, and problem behaviors, including, among others, delinquency, violence, and bullying. • Protective factors such as opportunities for positive involvement are also measured. • Results from this survey provide reliable and valid measures of student attitudes, perceptions, and behavior, and are used in planning risk mitigation programs in schools and communities. • The survey is funded by the Kansas Department for Aging and Disability Services Behavioral Health Services Commission, and provided at no cost to all public and private schools in Kansas for students (i.e., youth) in the 6th, 8th, 10th, and 12th grades. • Participation in the KCTC Student Survey is voluntary for every district and every student eligible for participation. Approximately 250 districts and 90,000 students participate in the survey each year.

26. Leavenworth County Youth (Slide 3 of 5) Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • As shown in the figure below, the participation rate for Leavenworth County in the 2019 KCTC Student Survey was 44.97, an increase of 11.23% from 2018, and 16.18% from 2017. • Of note, the county’s 44.97% lags participation rates for the neighboring counties of Atchison, Jefferson, and Johnson, 58.29, 53.12 and 48.23, respectfully, but • Exceeds Wyandotte’s and Douglas’ participation rates of 35.54 and 18.91, respectively.

27. Leavenworth County Youth (Slide 4 of 5) Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • The 2019 KCTC Student Survey identifies significant percentages of depression and suicide ideation among Leavenworth County survey respondents, as well as problem behaviors, namely school suspensions, physical attacks, and bullying. • In particular, the 33% of respondents answering “Yes” to a signature question on depression is significantly higher than the corresponding NAMI statistic in which “approximately 1 in 5 youth aged 13–18 (21.4%) experiences a severe mental disorder at some point during their life. • The response rates for the three questions on suicide ideation are not comforting either, especially when almost 19% of respondents have seriously thought about killing themselves in the past year. • This rate is higher than the age-adjusted suicide death rate (95% CI) per 100K population of 17.2 for Leavenworth County cited earlier in the report.

28. Leavenworth County Youth (Slide 5 of 5) Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • The results from the 2019 KCTC Student Survey also point out that substance use/abuse among Leavenworth County youth is not insignificant. • 4% using prescription drugs not prescribed by a doctor “in the last 30 days” and over • 4% and 13% using marijuana and alcohol, respectively, during this same period. • Furthermore, although this study focuses on mental health, it recognizes that many individuals suffering from mental illness also have issues with substance use/abuse. • Thus, services to treat patients with a dual, mental illness and substance use/abuse, diagnosis are not only desirable, but necessary to achieve successful treatment outcomes.

29. The Guidance Center (Slide 1 of 3) Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • At the first meeting of the Mental Health Task Force (TF) on February 14, 2019, Mr. Rickard, stated unequivocally his concern about the gap in services that currently exists with TGC. • “We do not have enough of what we currently have; we also do not have the resources that are needed going forward (i.e., to provide care and services for people with mental illness who are currently not being treated).” • To explain his statement Mr. Rickard had the facilitator bring up a chart, see Figure on next slide, comparing the relationship between clients served and funding available to provide the requisite mental health services.

30. The Guidance Center (Slide 2 of 3) Not a picture of sustainability for The Guidance Center Going Forward.

31. The Guidance Center (Slide 3of 3) Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • Mr. Rickard made the following points about the chart: • “This chart reflects that since the year 2000 our funding streams from all sources have been constant or shrinking except for Medicaid.  The client numbers have also increased since 2000, to over 5,000 clients per year.”  • “Around 2014 you begin to see Medicaid revenues shrinking because of Medicaid Managed Care overseeing our work and making decisions that reduce the level of care that clients receive.” • “The main point of the slide is to demonstrate that we have operated on level or shrinking funding over these many years, so it is not surprising that the community is experiencing a mental health crisis.”  • “We can’t operate in this way for many more years without beginning to further reduce the type and amount of service provided to our citizens.”

32. Funding (Slide 1 of 3) Impacting the ability to provide mental health services is, of course, the issue of funding. • Here the record is clear, namely, that out of 105 counties in Kansas, Leavenworth ranks 101st in funding for mental health. • And besides ranking fourth from the bottom of Kansas counties in per capita funding for mental health, Leavenworth’s $2.50/person funding in 2019 is below its neighboring counties of Atchison, Douglas, Jefferson, Johnson, and Wyandotte. • Leavenworth County fairs better when viewing mental health expenditures as a percentage of county budget. • Specifically, the county is ranked 62nd out of 105 counties, spending .348% of its budget on mental health. • Although, of Leavenworth’s neighboring counties, only Jefferson is ranked lower in this category.

33. Mental Health Per Capita Funding Comparison (Slide 2 of 3)

34. Mental Health Funding 2007-19 Comparison (Slide 3 of 3) While an almost 82% increase for Leavenworth is significant, it equates to a total increase of only $88,906 over 11 years, with $39,581 of this amount added in 2019.

35. The Shelter of Hope (Slide 1 of 2) • An increase in almost 100 guests and 3500 cots/night from 2017 shows a definite upward trend. • Cots/night from 2017 to 2018 increased 54%, while the number of unduplicated • guests showed only a 34% increase, a statistic highlighting the problem of chronic homelessness. • 323 guests stayed at the night shelter in 2018 resulting in 8253 cots/night. • Based on assumption regarding number of adults and HUD statistic, 63 of these guests likely suffer from • a serious mental illness, with a greater number also struggling with a substance use disorder.

36. Welcome Central (Slide 2 of 2) • 589 intakes generated the 878 referrals shown on this chart. Issues are: • Affordable housing • Transportation to food sources • Access to health care, including mental health services • Access to long-term alcohol and drug treatment programs • For homeless citizens with more serious mental health problems requiring • hospitalization, the lack of an in-patient treatment facility in Leavenworth County is • an impediment to helping them get better.

37. Leavenworth County Jail (Slide 1 of 4) • 2017 Inmate Mental Health Sessions Total – 559 • 2018 Inmate Mental Health Sessions Total – 802 • 43% Increase in Mental Health Services Sought/Provided

38. Leavenworth County Jail Mental Health Observations (Slide 2 of 4) • 25-30% of inmate population seek mental health services monthly. 30% of inmates in segregation seek mental health services. • 2/3 of inmates who participate are age 30 and older, with the majority being in their thirties. • 1/3 of all sessions are more than an hour in duration, while the average session is 35-45 minutes.

39. Leavenworth County Jail Mental Health Observations (Slide 3 of 4) • Inmates spending more than one hour in session are twice as likely to utilize mental health services on a weekly basis. • Inmates who use mental health services weekly are 80% more likely to show an improvement in mood, behavior, coping and life skills. • Regular participation in services reduces the request or need for medication for emotional/behavioral issues.

40. Leavenworth County Jail Mental Health Observations (Slide 4 of 4) • The majority of inmates are incarcerated as a direct or indirect result of illegal drug usage. Meth continues to be the reported number one drug of choice. • There was an increase in the reported usage of heroin from 2017 to 2018. • Majority of inmates have reported drug usage started at an early age to cope with serious familial issues to include addiction and violence. • Majority of inmates have experienced trauma as a result of physical, sexual, emotional and/or mental abuse or neglect.

41. Lack of Inpatient Treatment Options Similar to the mental health trends occurring nationwide and within our state, Leavenworth County is in the throes of a mental health crisis. This crisis affects a broad swath of important functions, institutions, and programs throughout the county. • Leavenworth County does not have an inpatient facility for mental health patients in crisis there is a volunteer inpatient facility (Valley Hope) for patients with substance abuse issues in Atchison County with 16 beds; Saint Luke’s in Smithville has an inpatient facility, Saint Luke’s North Hospital’s Behavioral Health Program, with 30 beds. • Osawatomie State Hospital is the state’s psychiatric hospital for acute care patients and now with its CMS certification reinstated, currently has 166 beds, which is a decrease of 40 beds from the number at the hospital before losing its certification in December 2015. There is a waiting list for Osawatomie, at any given time ranging from 4-20 mentally ill people on the list.

42. Point(s) made by Mr. Keith Rickard in Email to Linda Johnson and Kelly Butler dated 25 February 2019, Subject: My Assignments • “I would just say that the number one priority for TGC, Leavenworth, and Kansas is to expand Medicaid.  Thirty-four percent of the clients at TGC are slide fee clients, meaning they have no insurance to pay for their care.  TGC wrote off over $1 million dollars in care to this group of citizens in 2018.   WE must find new revenues to meet the ever increasing demand for services.”

43. About the Report

44. Task Force (TF) Focus Going Forward • TF Mission: Study the mental health crisis in Leavenworth County to identify the needs of citizens with mental illness and recommend solutions to meet these needs. Simultaneously, raise awareness of the crisis among the citizenry of the county. • TF Method: Form a group of elected officials and subject matter experts from the county and cities to mine data, ascertain facts, propose and analyze options, and recommend solutions to the Board of County Commissioners (BOCC). Also, formulate a plan to strategically communicate the study’s major findings. • TF Endstate: A written report with recommended solutions completed and delivered to the BOCC in time for its consideration as part of the 2020 or 2021 budget process.

45. TF Composition (Slide 1 of 2) * Executive Committee Member; < TF Chairperson; > TF Vice Chairperson

46. TF Composition (Slide 2 of 2) * Executive Committee Member; < TF Chairperson; > TF Vice Chairperson

47. Outline for Mental Health TF Meeting: 14 Feb 19 • Introduction – 5 minutes • Problem Statement Discussion – 20 minutes • TF Focus Going Forward Discussion – 30 minutes • Tasks and/or Action Steps for TF – 20 minutes • Initial Synch-Up of Tasks/Action Steps with the Calendar – 10 minutes • Wrap-Up – 5 minutes Total Time: 90 minutes