1. Joint Hearing of Senate Health and Human Services and Senate State Affairs Joint Interim Charge #3 August 23, 2006

2. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 20062 DSHS State Mental Health Hospitals + Austin State Hospital ++ + + + + + + Terrell State Hospital + Rusk State Hospital North Texas State Hospital (Vernon/Wichita Falls) Big Spring State Hospital Waco Center for Youth Kerrville State Hospital San Antonio State Hospital El Paso Psychiatric Center Rio Grande State Center + 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 Waco Center for Youth 78-bed residential treatment facility for youth

3. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 20063 How do People Enter the System? Civil Commitments Criteria Presence of Symptoms of Mental Illness which result in Patient’s: –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)

4. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 20064 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.

5. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 20065 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.

6. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 20066 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.

7. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 20067 Population Growth Compared to Funded State Hospital Beds Funding for State Mental Hospital Beds has declined while the Texas population has grown

8. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 20068 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 28 th, 239 positions have been filled and the remainder should be filled by the end of August.

9. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 20069 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

10. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 200610 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.

11. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 200611 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

12. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 200612 Effective Treatment Models Prevention and early intervention services— research shows that adverse experiences in childhood have long-term consequences (ACE study) Jail diversion Mental Health courts Drug courts Access to Recovery project

13. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 200613 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

14. SOURCE: SACPA Cost Analysis Report (First and Second Years); prepared by UCLA Integrated Substance Abuse Program; March 13, 2006. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 200614 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

15. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 200615 Youth in Texas at Risk for Juvenile Justice Involvement Parental Involvement with Criminal Justice System CPS Youth Youth Behavioral Problem Youth Substance Abuse Problem Juvenile Justice Becomes Parent

16. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 200616 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.

17. Senate Health and Human Services and Senate State Affairs DSHS Presentation August 23, 200617 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