Joint Hearing of Senate Health and Human Services and Senate State Affairs

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Joint Hearing ofSenate Health and Human
Services andSenate State Affairs

• Joint Interim Charge 3
• August 23, 2006

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DSHS State Mental Health Hospitals

• Austin State Hospital
• 283 civil/ 24 adult forensic
• Big Spring State Hospital
• 74 civil/118 adult forensic
• El Paso Psychiatric Center
• 58 civil/16 adult forensic
• Kerrville State Hospital
• 18 civil/184 adult forensic
• North Texas State Hospital
• Vernon 0 civil/234 adult forensic
• Wichita Falls 241 civil/24 adult forensic
• Rusk State Hospital
• 245 civil/90 adult forensic
• Rio Grande State Center
• 55 civil/0 adult forensic
• San Antonio State Hospital
• 278 civil/24 adult forensic
• Terrell State Hospital
• 292 civil/24 adult forensic

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How do People Enter the System?

• Civil Commitments
• Criteria
• Presence of Symptoms of Mental Illness
  which result in Patients
• Danger to themselves
• Danger to others
• Who Gets Involved
• Magistrates/Peace Officers
• Adult Relatives and Guardians
• Admissions Physician
• Treatment Team
• Types
• Emergency Detention (24 hour)
• Orders of Protective Custody (30 day maximum)
• Court Ordered MH Services (90 day Temp/ 12 month
  Extended)

• Forensic Commitments
• Criteria
• Charged with or Convicted of Criminal Act
• Mental Illness or Instability
• Who Gets Involved
• Courts/Judges/Juries
• Admissions Physician
• Treatment Team
• Types
• Awaiting Adjudication
• Competency Restoration
• Post-Adjudicated
• Not Guilty by Reason of Insanity (NGRI)

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When do People Exit the System?

• Civil Commitments
• Treatment team determines the person is no longer
  an imminent risk to self or others and can safely
  be treated in a less restrictive setting
• An appropriate community placement exists

• Forensic Commitments
• Treatment team recommends when the person is
  competent to stand trial, or (for NGRI) the
  person is no longer an imminent risk to self or
  others and can safely be treated in a less
  restrictive setting
• Courts/Judges must approve discharges or changes
  in commitment status.
• State Hospitals and Local Mental Health
  Authorities have little control over the actual
  discharge of patients.

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Growth in Number of Forensic Patients
During 2005 and early 2006, the state hospital
system in Texas operated at levels exceeding
capacity. One driver of demand was an increasing
number of criminal code (forensic) commitments.
The forensic population now represents 30 of the
patients in state mental health hospitals.
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Average Lengths of Stay
The average amount of time forensic patients stay
at facilities is considerably longer than that of
patients who are at facilities on civil
commitments.
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Population Growth Compared to Funded State
Hospital Beds
Funding for State Mental Hospital Beds has
declined while the Texas population has grown
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State Mental Health Hospital Capacity

• In February 2006, the LBB approved 13.4 million
  in additional expenditures for state mental
  health hospital capacity. These funds were
  transferred from DSHS FY07 appropriations to
  FY06.
• As a result, statewide hospital system capacity
  was increased by 96 forensic commitment beds and
  144 civil commitment beds, for a total of 240
  beds.
• Currently, 194 of those beds are available for
  use. All 96 of the forensic beds are being fully
  utilized.
• 334 additional positions were required to fully
  staff the additional beds. As of July 28th, 239
  positions have been filled and the remainder
  should be filled by the end of August.

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State Mental Health Hospital Capacity

• Considerations
• Examine the commitment process to minimize state
  hospital stays for forensic patients
• Shorten the timeframe between patient restoration
  to competency and their return to court
• Ensure patient is returned to court as soon as
  clinically indicated
• Implement options for community-based competency
  restoration
• Requires community-wide engagement
• Provision of clinical services and supports are
  critical to success
• These models can significantly reduce total
  public costs and improve outcomes

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Crisis Services Redesign

• February 2006, DSHS established the Crisis
  Services Redesign Committee to develop
  recommendations for a comprehensive array of
  crisis services.
• Members of the committee include medical experts,
  citizen stakeholder groups, law enforcement
  representatives, county probate court judge
  representation, and county representatives, as
  well as individuals from professional
  organizations and provider groups.
• A redesign of crisis services will build on, and
  is a part of, the service improvements made by
  the evidence-based Resiliency and Disease
  Management program.
• A thorough review of the current crisis system
  was conducted, including holding public hearings
  around the state, reviewing current research and
  consultation with experts.

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Crisis Services Redesign

• The committee is considering a range of
  effective community-based interventions designed
  to intervene in and avoid crisis and the need for
  hospitalization, including
• 24-hour hotline
• Mobile outreach
• 23 to 48-hour hold capacity
• On-call psychiatric services
• Crisis residential services
• Respite
• In-home crisis resolution services

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Effective Treatment Models

• Prevention and early intervention
  servicesresearch shows that adverse experiences
  in childhood have long-term consequences (ACE
  study)
• Jail diversion
• Mental Health courts
• Drug courts
• Access to Recovery project

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Texas Access to Recovery Client Outcomes as of
8/1/06

• 92.99 Abstinent
• 66.47 Employed
• 93.90 Not arrested
• 99.00 Not homeless
• 88.71 Socially connected

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Return on Investment for Alternatives to
Incarceration
Substance Abuse and Crime Prevention Act
(SACPA-California) Total cost savings after
30-month follow-up period 173.3 million
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Youth in Texas at Risk for Juvenile Justice
Involvement
Parental Involvement with Criminal Justice
System
Becomes Parent
Youth Behavioral Problem
Juvenile Justice
CPS Youth
Youth Substance Abuse Problem
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The Challenge

• DSHS mental health services are only part of the
  public mental health system in Texas.
• Law enforcement, education, Medicaid, CHIP, the
  criminal justice system, hospitals and other
  entities all play major roles in treating Texans
  with mental illnesses.

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Considerations

• Better coordination of efforts, resources and
  funding
• Consistent application of evidence-based
  approaches
• Incentives to create diversion options
• Improved data sharing to demonstrate outcomes and
  savings