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Community Care Based Services

Leon EvansPresident and Chief Executive OfficerThe Center for Health Care ServicesMental Health and Substance Abuse

AuthorityBexar County

San Antonio, Texas levans@chcsbc.org

Maximizing Efficiency and Treatment Effectiveness

Diversion Initiatives Addressing ChallengesOf Mental Illness, Substance Use

and HomelessnessCuyahoga County,

Cleveland, OhioApril 24, 2012

Gilbert GonzalesDirector, Communications

and Diversion InitiativesThe Center for Health Care Services

San Antonio, Texas ggonzales@chcsbc.org

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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 ?

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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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An Ounce of PreventionTaxpayer Costs Avoided through Preventing

Crime

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

• 674 Billion Federal, State and Local – Shapiro 1999

• 1.0 Trillion (2 million people incarcerated) – Adrienne

2005

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

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

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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 Care Emergency 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

“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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Average Per Capita Spending

• In 1995, average monthly spending per capita for clients receiving services in "aged/disabled" home and community-based waivers across all states with these waivers was $485 per month.

• In contrast, average monthly spending per Medicaid-covered nursing home resident was $2,426.14.

http://aspe.hhs.gov/daltcp/reports/costeff.htm

(per episode cost)

Community Based vs Institutional Cost Per Day

Community, $42

Institutional, $320

$0

$50

$100

$150

$200

$250

$300

$350

1

Community

Institutional

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Collaboration: It’s an unnatural act between…

…two or more unconsenting adults.

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Integrating and Strengthening Community-Based Care

• Community-based services, that are readily accessible and convenient, help in the early detection and treatment of mental health problems.

• Will help to reduce the need for hospitalization and increase the chances that patients can fully regain their mental health and help them to live and work successfully within the community.

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Community Care Is better than Institutional Care

Costs less than institutional care Is least restrictive Allows for greater

family involvement Produces better

outcomes

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Community Mental Health Philosophy

“You get better outcomes when treatment is nearer to families, jobs and communities”.

Leon EvansPhilosophy

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

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Law EnforcementDetention/Jail

CIT

Judicial/CourtsMagistrate, County, District

Mental HealthPublic and Private

Providers

Crisis Care CenterJail DiversionPsychiatric and Medical

ClearanceSpecialty Offender Services

CommunityDynamicCrisis Jail Diversion

Information Exchange

Pol

ice,

She

riff

Pro

batio

n, P

arol

e

Civil and CriminalT

reatment

Continuity of C

are

County City-wide

Emergency Services• Community Collaborative• Crisis Care Center• Crisis Transitional Unit• Crisis Hotline (Nurselink)• CIT/DMOT• SP5• Jail and Juvenile Detention• Statewide CARE Match

System County City-wideEntry Points

System Level

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• Jail Diversion Oversight Committee (34+ Community Agencies/Stakeholders)

• Community Medical Directors Roundtable

• Children’s Medical Directors Roundtable

• Bexar County Children’s Diversion School District Sub Committee

• Bexar County Children’s Diversion Child Protective Services Sub Committee

• Bexar County Children’s Diversion Juvenile Justice Probation Sub Committee

• Community Co-Location Coalition (29 Community Agencies including law enforcement entities meeting to address the homeless & public inebriate)

Stakeholder Collaboration via:

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Show me the DATA !!!

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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: University Health System

Emergency Room Utilization (Medical Clearance)

What Works

23Today2012 – The Bexar County Sheriff and San Antonio Police Chief mandate CIT Training

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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

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Involuntary Outpatient CommitmentProgram

0

50

100

150

# Bed Days Used

1 Yr Prior 132

1 Yr Post 27

State Hospital Bed Day Utilization Rate

PreIOPCProgram

Post

79% Reduction in BedDay Use, Post Program

First Year Evaluation

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CRISIS CARE CENTER• Crisis Line• Crisis Assessment• Mobile Crisis Outreach Team• Crisis Transitional Unit

7137 W. Military 645-1651

• Receives consumers from law enforcement 24/7

• Minor medical clearance • Call ahead preferred

210 225-5481• Can not take violent or

medically compromised individuals

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CIT Mental Health Detail• Mental health professional partners

with a CIT Officer together to respond on calls dealing with a psychiatric crisis.

• Team responds to high utilizer calls for the City providing follow up services to reduce the call volume.

• Goal is to put officers back into service for patrol as soon as possible.

– Reduce inappropriate incarcerations and costly emergency room visits.

– Offer quality training to law enforcement.

• Co-locate officer with the City unit and Sheriff Mental Health Unit for better collaboration and expedited call response

Dispatcher Training for 911 Call Takers and Dispatchers

• In 2007 - decided that dispatchers would also benefit from CIT Instruction and met with SAPD leadership to establish training.

• Provided an abbreviated 12 hour CIT course for call takers and dispatchers in collaboration with CHCS

• The goal of this training is to increase safety by educating caller takers on essential intelligence gathering and dispatching a CIT Trained officer to the scene.

Partnered with Fire and EMS• As of 2007 SAFD has attended

every community training

• has become co trainers with joint PD and Sheriff’s Officers

• Have added a CIT component to their EMS In-service training.

• Partnering for Integrated training with Fire/EMS has extended numerous opportunities for growth:

– Officer and Fire/EMS better communication

– Safety

– Better utilization of resources

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TheRestoration Center

OpenedApril 15, 2008

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• Public Safety- Sobering Unit• Detoxification Facility• Community Court• Outpatient Substance Abuse Services

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Haven for Hope Homeless Facility CNN Video Clip

• http://www.diversioninitiatives.net/2010/07/haven-for-hope-cnn-video-just-before.html

“Texas officials hope a massive new facility will keep the homeless

out of jail, emergency rooms and re-integrated into society”.

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Haven for Hope Homeless Transitional Facility

www.havenforhope.org

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1,600

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Funding• Jail Diversion Planning and Oversight Committee - Judge Poly Jackson Spencer

• Changing the Law - Senate/House Bills Madla/Uresti,HB 2292 Mandated Jail Diversion

• SAMHSA Jail Diversion Grant

• Police Chief Ortiz Funding - Drug Bust Money

• University Health System Partnership- Care Link & New Generation Medications Program

• Texas Correctional Office on Offenders with Mental and Medical Impairments (TCOOMMI)

• Genesis Outpatient Services - Probation and Parole• Mentally Impaired Offenders Program-Probation • Substance Abuse Treatment Facilities (SATF I and II)

• Texas Crisis Redesign - $82 million State-wide

• Bill Greehey/Bexar County - Transformation Center

• Medicaid Administrative Claiming

• Medicaid Eligibility and Carelink Workers• Third Party Billing

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Cost Category City of San Antonio Bexar County Direct Cost Avoidance

 Public Inebriates Diverted from Detention

Facility 

 $435,435

 $925,015

 $1,322,685

 A.

 $1,983,574

 $2,818,755*

 $4,372,128

 B.

 $2,419,009

 $3,743,770

 $5,694,813

 

 Injured Prisoner Diverted from UHS ER

 

 $528,000

 $435,000

 $421,000

 C.

 $1,267,200

 $1,044,000

 $1,010,400

 D.

 $1,795,200

 $1,479,000

 $1,431,400

 

 Mentally Ill Diverted from UHS ER Cost

 

 $322,500

 $283,500

 $276,500

 E.

 $774,000

 $676,000

 $663,600

 F.

 $1,096,500

 $959,500

 $940,100

 

 Mentally Ill Diverted from Magistration

Facility 

 $208,159

 $179,833

 $126,893

 G.

 $371,350

 $322,300

 $191,125

 H.

 $579,509

 $502,133

 $310,018

 

Combined CCC and Restoration Documented and Immediate Cost AvoidanceYear One April 16, 2008 – March 31, 2009Year Two April 16, 2009 – March31, 2010

Year Three April 16, 2010 – March 31, 2011

Summary next slide

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Summary

BEXAR COUNTY DETENTION CENTERSYSTEM POPULATIONMONTHLY AVERAGES

(Main, Annex)

4222

3743

4133

40153987

3941 39464015

40814095

4171 4156

4094

38453807

3897

3981

4109

42634253

4040

3993

40624033

4066

3960

4079

4096

4084

4094

4095

41394173

4208 4261

4289

4225

4124

4158

4337

4272

4292

4197

421042544179 4193

4280

4357

43004300 4302

4053

4130

4001

4260

40284077

4231

4190

4017

379137903854

3982

3700

3800

3900

4000

4100

4200

4300

4400

JAN

FE

B

MA

R

AP

R

MA

Y

JUN

JUL

AU

G

SE

P

OC

T

NO

V

DE

C

SY

ST

EM

PO

PU

LA

TIO

N

2006 2007 2008 2009 2010 2011

On May 2011, there were 883 empty beds in the jail

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The End Result

• Comprehensive service for most in need• Increased availability of comprehensive

coordinated services• Reduced barriers to service access and

increase motivation with treatment compliance

• Employ evidence based practices known to be effective

• Utilization of system tracking and outcome based treatment

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The Center for Health Care Services

Leon Evans, President/CEOThe Center for Health Care Services

Mental Health Authority210 731-1300

www.chcsbc.orglevans@chcsbc.org