1. 1 Community Care Based Services Leon Evans President and Chief Executive Officer The Center for Health Care Services Mental Health and Substance Abuse Authority Bexar County San Antonio, Texas levans@chcsbc.org Maximizing Efficiency and Treatment Effectiveness Diversion Initiatives Addressing Challenges Of Mental Illness, Substance Use and Homelessness Rapid City, South Dakota February 22, 2011 Gilbert Gonzales Director, Communications and Diversion Initiatives The Center for Health Care Services San Antonio, Texas ggonzales@chcsbc.org

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5. 5  Poor communication  Poor system design  Silos  No strategic improvement plan  Little use of prevailing best practices  Lack of leadership and overview Why ?

6. 6 The Problem gets worse: Poor and or reduced funding Scant, limited and rationed services Reduction of State Hospital treatment beds The Problem

7. 7 An Ounce of Prevention Taxpayer 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 presentation To NACo, July 2008

8. 8 The Case of Million Dollar Murray MILLION-DOLLAR MURRAY by MALCOLM GLADWELL The New Yorker Magazine, Issue of 2006-02-13 and 20, Posted 2006-02-06 News Release Emergency Departments See Dramatic Increase in People with Mental Illness Seeking Care Emergency Physicians Cite State Health Care Budget Cuts at Root of Problem American Psychiatric Association Hillarie Turner, 703-907-8536 June 2, 2004 hturner@psych.org Release No. 04-30 Sharon 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,”

9. 9 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)

10. 10 Collaboration: It’s an unnatural act between… … two or more unconsenting adults.

11. 11 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.

12. 12 Community Care Is better than Institutional Care  Costs less than institutional care  Is least restrictive  Allows for greater family involvement  Produces better outcomes

13. 13 Community Mental Health Philosophy “You get better outcomes when treatment is nearer to families, jobs and communities”. Leon Evans Philosophy

14. 14 Law Enforcement Detention/Jail CIT Judicial/Courts Magistrate, County, District Mental Health Public and Private Providers Crisis Care Center Jail Diversion Psychiatric and Medical Clearance Specialty Offender Services Community Dynamic Crisis Jail Diversion Information Exchange Police, Sheriff Probation, Parole Civil and Criminal Treatment Continuity of Care County City-wide EmergencyServices Community Collaborative Crisis Care Center Crisis Transitional Unit Crisis Hotline (Nurselink) CIT/DMOT SP5 Jail and Juvenile Detention Statewide CARE Match System County City-wide Entry Points System Level

15. 15 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:

16. 16 Show me the DATA !!!

17. 17 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

18. 18 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$1545 Cost Savings relative to ER Utilization $4,709,160 Source: University Health System Emergency Room Utilization (Medical Clearance) What Works

19. 19 Involuntary Outpatient Commitment Program Pre IOPC Program Post 79% Reduction in Bed Day Use, Post Program First Year Evaluation

20. 20 Texas Department of Criminal Justice MHMR Match Statistics October, 2007 C.I.D.ParoleProbationTotal Total TDCJ Population 152,66177,755432,359662,775 # of Care Matches*40,88319,76354,727115,373 % of Total Population26.78%25.41%12.65%17.40% *Represents all Clients served since 1985, including those whose diagnosis is no longer eligible for MHMR Source: Texas Correctional Office on Offenders with Mental and Medical Impairments

21. 21 Revocation Rates 2007 Federal Revocation Rate: 66% Two-thirds of returning prisoners are re-arrested for new crimes within 3 years or their release. Second Chance Act, 110TH CONGRESS REPORT to US HOUSE OF REPRESENTATIVES State Revocation Rate: Texas Felony Revocation Rate = 15.8% Top 5 Largest Community and Corrections Departments = 16.1 % Local Revocation Rate: Bexar County Mentally Impaired Caseload Department Probation Department = 8% Manos Diversion Program, CHCS = 6.2%

22. 22 Therapeutic Justice Partnerships with Bexar County Community Supervision and Corrections Dept. Two-100 Bed Substance Abuse Treatment Facilities (SATF-1 & SATF-2, 60 Bed Young Adult “boot camp” residential facility- Zero Tolerance) One- 60 Bed Dual Diagnosis Unit (MH/SA) Mentally Ill Offender Facility Outpatient Substance Abuse Treatment Program (lH 10) Dual Diagnosis Outpatient Substance Abuse Program (Palo Alto) Drug Court Treatment Services, Dual Diagnosis Drug Court Treatment Services, Mental Health Court Services, and Veteran Drug Court Services.

23. 23 Combined CCC and Restoration Documented and Immediate Cost Avoidance Cost CategoryCity of San AntonioBexar CountyDirect Cost Avoidance Public Inebriates Diverted from Detention Facility $435,435 $925,015 A. $1,983,574 $2,818,755* B. $2,419,009 $3,743,770 Injured Prisoner Diverted from UHS ER$528,000 $435,000 C. $1,267,200 $1,044,000 D. $1,795,200 $1,479,000 Mentally Ill Diverted from UHS ER Cost$322,500 $283,500 E. $774,000 $676,000 F. $1,096,500 $959,500 Mentally Ill Diverted from Magistration Facility$208,159 $179,833 G. $371,350 $322,300 H. $579,509 $502,133 Reduction in Competency Restoration Wait Time in Jail for Hosp Admission 0$255,055 $1,020,000 I. $255,055 $1,020,000 Reduction in Wait Time in Jail for Outpatient Competence/Wait Time for Restoration compared to Inpatient 0$137,898 $900,000 J. $137,898 $900,000 Reduction in Jail Time for Competency Restoration on Bond and on Return 0$385,522 $221,000 K. $385,522 $221,000 Total Year 1 Total Year 2 TWO YEAR TOTALS $1,494,094 $1,823,348 $3,317,442 $5,174,599 $7,002,055 $12,176,654 $6,668,693 $8,825,403 $15,494,096 Documented and Immediate Cost Avoidance, Two Year Analysis April 16, 2008 – March 31, 2010

24. 24 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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26. 26 The Center for Health Care Services Leon Evans, President/CEO The Center for Health Care Services Mental Health Authority 210 731-1300 www.chcsbc.org levans@chcsbc.org