1. Bexar County Crisis Care Center Jail Diversion Presentation for 71st Annual NACO Conference & Expo Chicago Illinois August 4-8, 2006
Paul Elizondo, Commissioner Leon Evans Gilbert R. Gonzales
Bexar County, Precinct Executive Director, CHCS Director, CCC/Jail Div., CHCS

2. OVERVIEW Crisis Care Center Jail Diversion Initiatives
How the Program works
Summary Review

3. Public Safety Net
Crisis Care
Center
Jail Diversion
Initiatives

4. Crisis Care Center

5. The Center for Health Care Services
Crisis Care Center
The Center for Health Care Services
UTHSCSA, UPG
The Center For Health Care Services (CHCS)
The University Health System (UHS)
The University Physicians Group (UPG)
The University of Texas Health Science Center

6. The Vision
A Crisis Care Center (CCC) operating 24/7 providing medical and mental health screenings with six 23 hour holding beds.
The CCC would be located at the UHS downtown facility.
The patient would have a single diagnosis of mentally ill, mentally ill with medical problem, no diagnosis of mental illness but with medical problem. The patient may have a substance abuse diagnosis.

7. The Plan To Accomplish The Vision The University Health System
Provide space for the identified CHCS functions to be moved to the downtown facility for an annual lease cost of $1.
Provide additional staff to keep the Laboratory and X-ray functions open 8:00 pm to 8:00 am Monday – Friday and on week ends (funding to be determined).
Provide minor building modifications to accommodate CHCS functions (funded by CHCS).
Agree to co-location of CHCS Crisis Line and Nurse Triage Functions.

8. The Result

14. Emergency Psychiatric
Crisis Care Center
Emergency Psychiatric
Services Unit
Services – Medical Clearance
Psychiatric Services
Staff
Procedure to access services
Who to bring/ Who not to bring
Administrator on Call

15. Total Visits Medical Clearance = 129
CRISIS CARE CENTER
Aug 29th to Sept. 23rd, 2005
Total Visits = 605
Total Visits Medical Clearance = 129
Medical Eval only = 86
Needing XRay = 21
Needing Lab = 23
Needing Minor Procedure - 21
Psych and Med Eval = 27
Psych Only = 476, average 17 per day
Referred by Law Enforcement for Med Clearance = 88 or 68%
Referred by Law Enforcement for Psych only = 89 or 19%

16. Crisis Care Center Summary
Summary Stats
Sep – Dec 05
Average
Jan-06
Feb-06
Mar-06
Facility Total
2777
694.25
666
523
770
Psychiatric
2076
519
497
405
609
Express Med (Clearance)
701
175.25
169
118
161

17. Law Enforcement Law Enforcement Totals to Date Totals
Totals
865
SAPD
665
Med Eval Only 552
Med and Psych Evaluations 113
BCSO
200
Med Eval Only 186
Med and Psych Evaluations 11
Law Enforcement Man Hours Available for Re-allocation
Jan-06
Feb-06
Mar-06
960
639
940 49 28 80
Total
1009
667
1020
7 Month Averages:
SAPD = hours or ($42,192.50)
BCSO= hours or ($2,442.50)
Cost $50.00 per hour

18. Preliminary DATA (continued)
Crisis Care Center
Preliminary DATA (continued)
Then
Wait times for Medical
Clearance/ Screening at
UHS ER - 9 hours, 18 minutes.
Clearance/ Screening and
Psychiatric Evaluation is
between 12 and 14 hours.
WAIT TIME for LAW ENFORCEMENT
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 minutes .

19. Jail Diversion

20. Community Wide Jail Diversion The Problem
Criminalization of Mentally Ill
Inappropriate Cost to Society
20% + in jail
Increase use of emergency rooms
Homelessness
Public Safety Net
Consumers at risk
Law Enforcement at risk
Public at risk

21. Targeted Capacity Expansion (TCE) Grant for Jail Diversion Programs

22. “ If you’ve seen ONE jail diversion program,

23. Mental Health Screening Process at Local Jails
Based upon a random sample of 100 reports submitted
by local jails to TDCJ, the following observations were made:
Of the 100 inmate records reviewed, 15 or 15% had a
mental health diagnosis noted (10 had the same diagnosis
as that noted on the Client Assessment Registry, or CARE,
system);
Of the remaining 85, 29 or 34% were found on the CARE
system as current or former clients of MHMR, but no mental
health notation was indicated by the jail;
44% of the 100 were former or current clients of MHMR.

24. CROSS-REFERENCE OVERVIEW OF CLIENT ASSESSMENT REGISTRY (CARE) MATCHES
(Total Offender Population: 628,343)
PROBATION: 59,612 (15%)
CID: 33,008 (22%)
PAROLE: 12,332 (16%)
TOTAL: 104,952 (17%)
Approximately 17% of the adult offenders under TDCJ’s supervision
were current or former clients of the public mental health system.
* CID = Criminal Investigation Division

25. “ Today’s Misdemeanants,
Tomorrow's Felon “

27. If No Programs Are In Place
Continued Increase/Overcrowding in Jail Population
Continued Increase/Overcrowding in Prison Population
Increased and Inappropriate Use of Emergency Rooms

28. Strategies for Success
Don’t Let Them Go to Jail in the First Place
Diversion in all appropriate settings
Set up:
Primary Diversion/Intervention
Pre Booking services
Cross match of jail population
In jail screening/services
Secondary Diversion/Intervention
Post Booking services
Intensive Outpatient Treatment for Probation/Parole (Genesis)
Residential MH Services (MIOF)
Continuity of Care
Intensive Ongoing Case management
Timely updates to Judges
MH/Judicial Joint Staffing

29. “If you want a partner,
you have to be a partner”

30. The Partnership The beginning City of San Antonio Mayor Ed Garza
Bexar County
County Judge
Nelson Wolf

31. Community Partnership
How We Started
Community Partnership
City Government
County Government
State Government
University – Local
Private Hospitals
Law Enforcement
Criminal/Civil Courts
Advocacy – NAMI
Consumers
San Antonio State Hospital
Mental Health Partners
The Jail Diversion Over-sight
Committee
The Jail Diversion Planning
& Advisory Committee
Community Medical Directors
Roundtable
Private Sponsorship
Aztrazeneca

32. GOALS
Establish a community-based partnership among stakeholders within the Judicial/Mental Health systems.
To implement a City/County wide model for the mentally ill and mentally retarded who may or has come in contact with the criminal justice system.
Establish a comprehensive Jail Diversion Program to reduce the number of individuals jailed because no alternative action or treatment was available.

35. The Diversion Process * Federal Grant Award
Point of Contact with Law Enforcement
CIT/Deputy Mobile Outreach Team
24/7 Crisis
Services
Emergency Transport to Hospital
*Pre-Arrest Diversion
Referrals to Community Providers
Arrested
Magistrate Court
Post-Booking Diversion
Pre-Trial Diversion
Bexar County Jail
Community-based Wraparound Care
Genesis
Probation, Incarceration, Parole
Treatment in lieu of Incarceration
Residential Respite
* Federal Grant Award

36. DMOT
CIT
PreTrial Svcs
Magistration
Genesis

37. Outcome In Bexar County Texas 3,764 persons suffering
from mental illness were diverted from inappropriate incarceration
(Sep 2004-March 2006).
# Diverted
FY Actual
FY Actual
YTD Actual
(six months)
FY05
*** mid year projection for FY06

38. The Model
The Bexar County Jail Diversion Model is a comprehensive, coordinated delivery network which is tasked with the identification, diversion from incarceration and treatment of the mentally ill for those persons who are placed or who are about to be placed within the criminal justice system. The model is symptom based and is designed to cover 46 specific intervention points within the mental health/criminal justice system.

39. Features of the Model Active partnership with all Early Intervention
stakeholders
Early Intervention
Early Screening and Assessment
Service Coordination at MH and
Judicial points of access
24/7 Crisis Center and Medical
Clearance access – One Stop
Targeted program data tracking

40. 2002 - 2005 The Path Deputy Mobile Outreach Team is established
Jail Diversion Planning Advisory Committee
met for one year
Mental Health Docket is expanded
Jail Diversion Over-sight Committee
established
Bexar County JD Model approved by JDPAC
78th Legislature in session/reorganization in
process – Jail Diversion Law
Crisis Intervention Training for Police/Sheriff
continues

41. The Path (cont.): Adult Crisis Services and Law Enforcement
Medical Clearance 24/7 - central location
established
County/City Wide consolidation of crisis services
and minor medical triage in process
Data on ER utilization and jail admissions for
misdemeanors tracked and showing decrease
Jail diversions show an eightfold increase
Expansion of Pre and Post Diversion programs
continue

42. CHCS Service Units within
the Model
The Deputy Mobile Outreach Team – Mental health professionals accompany an MH
trained Deputy Sheriff to calls from the community for assistance involving the mentally ill and the mentally retarded.

43. CHCS Service Units within
the Model
The Mental Health Docket – This docket is the combined efforts of the criminal courts, probation and mental health personnel to advise the court on consumer assessment, treatment and continuity of care. Court ordered referral is direct to intensive case management.

44. CHCS Service Units within
the Model
3. The Pre-Trial Services Program –The program obtains release from jail through a mental health bond (which can be obtained without cost to the consumer) and provides referral with transportation from the jail to designated treatment facilities. Reviews and assesses CARE
Match daily arrest activity with follow-up.

45. CHCS Service Units within the Model
Involuntary Outpatient Commitment Program - On site court assigned case manager liaison monitors IOPC and works directly with Judges
5. Magistration Screening Program – Addresses the assessment and referral needs of the magistrate before booking and incarceration.

46. CHCS Service Units within
the Model
The Crisis Intervention Teams (CIT) – Officers trained by Law Enforcement and Mental Health Personnel via a 40 hour curriculum including role play demonstrations. Attends weekly operational
meetings with MH and Community Stakeholders

47. Annual National CIT Conference Columbus, Ohio

48. National Award for Service Excellence Banquet, April 10th 2006 Orlando Florida

49. CHCS Service Units within the Model
7. Not Guilty By Reason of Insanity Program (NGRI) -
Targets consumers who have been found to be not guilty by reason of insanity and no longer a danger to self or others. Intensive case management services are offered.
Regular contact with the committing court is also maintained to substantiate compliance with services. Staff act as a liaison between the client, the court, the hospital system and the outpatient treatment team.

50. CHCS Service within the Model
8. Cognitive Adaptive Training -
CAT is a psychosocial intervention that concentrates on
re-structuring a patient’s physical environment in ways
that promote desired behaviors (e.g. taking medications,
dressing appropriately, keeping clinic appointments).
CAT involves establishing environmental supports in
the patient’s home or work environment and organizing
the environment to cue and sequence adaptive behavior.

51. CHCS Service Units within
the Model
9. The Genesis Special Needs Offenders
Program – This unit provides intensive
case management, psychiatric services
and rehabilitation training for
offenders on probation and parole in
collaboration with local and state
probation and parole departments.
Provides treatment for 60 (MI) and
100 bed (Substance Abuse) residential
units operated by Bexar County
Probation Department

52. POST DIVERSION CLINICAL EXPANSION Palo Alto
Combined Substance Abuse and MH Services
Prison
Client Court
Ordered
Parole
Substance Abuse
Treatment Facility
100 Clients
10 Staff
Genesis
203 Clients
16 Staff
Pasos
75 Clients
6 Staff
Manos
100 Clients
8 Staff
Omega (AppleWhite)
65 Clients
13 Staff *
Probationers within SA Treatment Unit
Probation
Probationers within
Mentally Impaired Facility
Genesis - TCOOMMI
Funding
Source
Bexar County Treatment Facility
Treatment Alternative to Incarceration Program
Omega – TCOOMMI, CJAD, CHCS
Funding
Source
Manos - AstraZenica
Pasos – Department of Justice

53. CHCS Service within the Model
10. Research - Measuring the Potential Economic and Societal Benefits
Interim results of the program show over 1,700 diversions from jail incarcerations during state Fiscal Year 2004, potentially resulting in an estimated range of $3.8 million to $5.0 million dollars in avoided costs within the Bexar County Criminal Justice System.
Jail diversion programs have been shown to have positive impacts on decreasing incarceration time for the severely mentally ill, while increasing access to, and utilization of, comprehensive psychiatric services.
Due to the organized structure of the Bexar County Jail Diversion Program and the thoroughness of the concurrent data collection process, a unique opportunity exists to measure the actual societal cost-benefit derived (in city, county and state dollars) from the jail diversion program in the near future, with continuance of the program.

54. Bexar County Jail Diversion Economic Analysis 2006
Conducted by RTI International
Dr. Alex Cowell is principal investigator
Also working with Dr. Nahama Broner and Mr. Arnie Aldridge
Considerable help from
Leon Evans, CEO CHCS
Dr. Edwardo Sanchez, Commissioner Texas Department Of State Health and Human Services
Multiple city and county organizations
Funded by the National Center for Behavioral Health Solutions

55. Study Motivation Legislators, providers, and stakeholders need to know
What resources does BCJD need?
Which agencies provide these resources?
To what degree can criminal justice costs be reduced?
Does BCJD make fiscal sense?
Requires external and independent research
Credibility with legislators
Credibility with stakeholders
Credibility with academic peers conducting similar evaluations

56. Study Objectives
Using comprehensive data with a quasi-experimental design, the study will
Analyze the costs of pre- versus post-booking diversion
Measure cost shifting between the health care and criminal justice systems
Calculate the cost effectiveness of BCJD for improving mental health and criminal justice outcomes
Calculate the net benefit of BCJD

57. The Path Leads to:
Measure Program impact on outcomes – City, County, State and Federal
Increase Stakeholder input to evidence based services
Expand service capacity through collaborative partnerships
Continue educational efforts with target groups within community and the judicial/mental health systems
Engage Legislators, propose legislative change where needed
Engage in program evaluation and dissemination

58. Thank you ! Leon Evans, Executive Director, The Center for Health
Care Services San Antonio, Texas
For additional information contact: Gilbert R. Gonzales, Ph