Continuity of Care Task Force

1. Continuity of Care Task Force February 19, 2010

2. BACKGROUND • The Texas State Psychiatric Hospital system is nearing capacity • While 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

3. TASK FORCE GOALS • Examine the overall continuum of care for individuals with severe mental illness who move through multiple systems • Make and prioritize recommendations to improve efficiencies, access and quality • Examine barriers to discharge for individuals in State Hospitals with extended lengths of stay • Make and prioritize recommendations to resolve barriers to discharge

4. TIMELINE • Four Task Force Meetings • February 5, 2010 • February 19, 2010 • March 26, 2010 • April 16, 2010 • Four Public Forums • March 3, 2010, Czech Heritage Hall, LaGrange, TX • Individual Interviews • Meetings with Key Professional Groups • Final Report—September 30, 2010

5. Overview of First MeetingGlobal Issues • Is 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

6. Overview of First Meeting Discussion—Statutory Issues • 46B • Consideration of amendment of “immediate evaluation” to support 21 day referral program • Article 16.22/17.032 Code of Criminal Procedure • Why underutilized?

7. Overview of First Meeting Discussion—Statutory Issues • Forced Medication Provisions • Only being utilized in urban areas; impractical in rural areas • Three populations • Most simply take the medication once order is issued • Confusion/inconsistency about which court may order • Insufficient involvement of defense attorneys

8. Overview of First Meeting Discussion—Statutory Issues • Mental Health Code • Doesn’t reflect current system • Consider recommendation for interim study • Suspension rather than termination of SSI benefits while incarcerated

9. Overview of First Meeting Discussion—Policy/Practice Issues • Outpatient Restoration of Competency • Actually serving as case finders • Data about effectiveness • Outpatient Commitment • Continued resistance to use • Statutory or practice? • Medical Clearance • Ad Hoc Texas Council Committee

10. Overview of First Meeting Discussion—Policy/Practice Issues • Permanent Supportive Housing • Guardianship • Medication Formularies • Community Supervision and Medical Necessity • Residential Alternatives to Hospitalization • Funding for non-crisis services

11. TRAINING ISSUES • Judges • Growing acceptance of therapeutic jurisprudence • Need for training about interface of systems • Prosecutors • Dropping charges • Defense Attorneys • Competency raised too often, too soon? • Mental Health Professionals • Criminal justice perspective

12. Data Development • Clinical/demographic characteristics of most frequently and long term hospitalized • Other state models • Diversion statistics—Harris County • Practical value/outcomes of medical clearance • Charges filed in IST cases • State level formularies • Outpatient restoration of competency programs

13. DATA • Quick Fixes—National GAINS Center • Harris County RRCP Program • Criminal Offense Data • Demographic and Diagnostic Data

14. Quick Fixes - Examination • Increase fees for examiners • Court based examiners • “pre-competency” assessment • Inpatient stabilization prior to competency • Competency Courts (Nevada and Washington) • Jail based competency exams • Community based exams • Improve jail based treatment to prevent loss of competency • Expedite competency cases for quick disposition

15. Quick Fixes – Restoration • Admission triage • UR process to insure prompt return to court • Review of level of care and transfer to least restrictive setting • Time limits for competency based on level of crime • Competency restoration manual for examiners • Jail based competency restoration (Va. Tx.) • Expedite transfer of court/clinical documents • Video conferencing for hearings (Sell, status) • Community restoration

16. Quick Fixes - Return to Court • Competency Court manages process • Improve coordination: • Transport • Jail treatment • Prompt court hearings • Transition planning

17. Harris County Jail – 21 Day State Hospital Diversion Program Court Orders a Psychiatric Review on Consumer Eligible Active Referred to Court notified to seek other In Jail for No No No MHMRA Eligibility alternatives for evaluation Service? Consumer Center Yes Yes Yes Consumer seen by counselor and MD Non - Harris County Resident wit hin 3 days and Non Priority Population Meds prescribed Clinic physician sees within 3 days and begins Stabilization Results reported to Court commits to court for disposition Formal Client Rusk State Hospital No No May request formal Evaluation Stabilized Competent? for restoration of evaluation Completed competency. OR Hearing is reset Yes Yes Yes Court hearing Court notified within 20 days proceeds and sets date for hearing

18. Next Steps • Study of 2009 Wait List? • Hospital Issues? • Continuity of Care Communication? • Additional Data Development • Future Meetings • Other Stakeholders • Public Forums