Continuity of Care Task Continuity of Care Task ForceForcePreliminary Recommendations
BACKGROUNDBACKGROUNDThe Texas State Psychiatric
Hospital system is nearing capacityWhile 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
TASK FORCE GOALSTASK FORCE GOALSExamine the overall continuum of
care for individuals with severe mental illness who move through multiple systems
Examine barriers to discharge for individuals in State Hospitals with extended lengths of stay
Make and prioritize recommendations to improve continuum of care and resolve barriers to discharge
TIMELINETIMELINEFour Task Force Meetings
◦February 5, 2010◦February 19, 2010◦March 26, 2010◦June 18, 2010
Final Report—August 31, 2010
Public ForumsPublic ForumsMarch 3rd, Czech Heritage Center, La
Grange, TXMay 7th, Rio Grande State Center
Auditorium, Harlingen, TX 12:30-2:00 PM
May 11th, Dallas County Health and Human Services Building, Room 627,Dallas, TX 12:30-2PM
May 21st, Big Spring State Hospital Auditorium, Big Spring, TX 12:30-2PM
May 27th, DSHS West Auditorium, Austin, TX 1PM-3PM
Global IssuesGlobal IssuesIs 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
Environmental Perspective: Environmental Perspective: Public Health EpidemicPublic Health EpidemicIncidence and prevalence of specific
diagnosesTrajectory of growing populationIncreasing numbers of uninsured and
underinsuredDecreasing capacity in the private
service systemAppreciation of behavioral health
disorders as chronic conditions, much like diabetes and hypertension
Potential for decreasing hospital bed capacity in the near future
Environmental Environmental PerspectivePerspectivePrimary care needs—need for
expansion of integrated careLack of residential alternatives to
hospitalization, including permanent supportive housing, is major barrier
Current service system doesn’t address significant overlap between Axis I, Axis II, Substance Use Disorders, Intellectual Disabilities, Head Injuries
Data DevelopmentData Development
Jail treatment prior to finding of incompetency
Individuals admitted > 3 times in 180 days
Individuals with > 5 forensic admissions in FY 2009
Outpatient Restoration of Competency Pilot Participants
Individuals with length of stay > 365 daysForensic commitment/re-commitment of
misdemeanants
Policy/Practice IssuesPolicy/Practice IssuesHousingCommunity supervision and medical
necessity—judicial expectations“Step-down” levels of careFunding for non-crisis servicesNeed for cognitive rehabilitative
servicesImproved communication between
courts and hospitals
Crisis
Person is seen by law enforcement
Is this a psychiatric
emergency?
Disposition per Law Enforcement
Contact Local Mental Health
Authority No Yes
Is the person a known consumer?
Yes
No
Medical status is known
Is there a known medical emergency?*
Disposition per Mental Health
Authority
No
Medical status is not known
Is there reason to suspect a medical
emergency?*
Medical treatment would be prudent to insure patient safety and safety in transport. **
Yes
Person is medically stable and safe for Law Enforcement transport?
Yes
No
Kept at hospital until stabilized
No
*The Peace Officer may use the following indicators to determine if a medical emergency exist:
1. Overdose2. Acute intoxication with alcohol or drugs.3. Chest pain4. Fluctuating consciousness.5. Stab wound, bleeding or serious injury.6. Seizure activity.7. Complications from diabetes 8. Injured in assault or fight9. Victim of a sexual assault10. Person is a resident of a nursing home or assisted living facility. Note: With the elderly, sometimes medical problems can cause symptoms that look like mental illness but are not. It's important to rule-out medical problems as the cause.
Psychiatric Emergency Flow Chart
Draft 4-23-10
Yes
**An inpatient mental health facility or amental health facility is not statutorilyauthorized to require a peace officer totransport a person in custody under chapter 573, Health and Safety Code, to a medical facility for a medical evaluation prior to taking that person to the mental health facility.
The opinion of Law Enforcement as to whether a medical emergency exist is final in the screening conducted with the Local Mental Health Authority.
Medical Clearance
Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermStatutory—46B
◦Clarify that maximum time commitment includes “time served” in jail from the date of booking
◦Include commitment expiration dates in court orders to facilitate communication between hospitals and courts
Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermStatutory—46B
◦Limit the maximum commitment period for misdemeanants to 90 days (civil commitment is alternative if criteria met)
◦Restore provisions in forensic expert reports about individuals not likely to be restored to competency in the for-seeable future to allow for better analysis and disposition of individuals with repeat forensic commitments
Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermStatutory—46B
◦Allow for voluntary jail treatment for 14-21 days prior to evaluation for competency to stand trial—with option for contest by defense counsel (involuntary treatment currently authorized under H&S Code 574.106 for certain individuals in jail settings
◦Clarify judicial authority under 46B.079(b)(2) (forced medications)
Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermStatutory—17.032
◦Link 17.032 provisions to Permanent Supportive Housing legislative appropriations request—create incentives throughout 17.032 to utilize PSH for misdemeanor defendants
Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermStatutory
◦Extended outpatient commitment for subset of outpatient commitment candidates
Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermMedical Clearance
RecommendationsPermanent Supportive Housing
for Misdemeanants with Conditional Release provisions
Alternative levels of residential care, including Assisted Living, for individuals with long term hospital stays
Preliminary Preliminary Recommendations:Recommendations:Short TermShort TermTraining
◦Judges◦Prosecutors◦Defense Attorneys◦Mental Health Professionals◦Law Enforcement◦On-Line peer consultation for judges,
defense attorneys, prosecutors◦Law Schools
Preliminary Preliminary Recommendations:Recommendations:Intermediate TermIntermediate TermClinical
◦Clinical competencies◦Professional development◦Salary analysis◦Peer support approach◦Trauma informed care◦Cognitive Rehab and appreciation of
co-morbidities in RDM◦Expanded time for testing,
assessment, record analysis
Preliminary Recommendations: Interim Studies?
◦ Mental Health Code
◦ Consideration of Medicaid Waiver
◦ Study of clinical issues for long term hospitalizations
◦ Improve data systems to better clarify issues around repeat forensic commitments and charges