Dave Hnatow, MD

The statistics say it all. In 1955, approximately 560,000 Americans were receiving treatment for mental illness in state hospitals. Today, fewer than 55,000 people are being treated in state mental institutions. This process of deinstitutionalization along with the failure to provide treatment and supportive services to people with mental illness has overburdened emergency departments, crowded state and local jails, and left untreated patients to fend for themselves on city streets.

Across the country, people with mental illness and substance abuse are repeatedly cycled in and out of the criminal justice system. The 

 from the US Department of Justice estimate that more than 1.26 million mentally ill adults are detained in the country’s jails and prisons.

 Persons with mental illness are often jailed for nonviolent, victimless crimes. According to the National Alliance on Mental Illness, up to 40% of adults with mental illness will come into contact with law enforcement.

 And nationally 16% of the jail population is incarcerated for offenses related to mental illness, mental retardation, or substance abuse.

 Of these, 60% to 75% were jailed simply for bizarre behavior or nonviolent minor crimes, and yet they spend an average of 15 months longer in jail for the same charges than non–mentally ill prisoners. Too much of our mental health care is relegated to law enforcement and the criminal justice system, even to the extent that many jails and prisons are now the primary provider of mental health care.

Jails have a much higher percentage of homeless mentally ill than does the general community for many reasons. They were established to contain and control those in our population who commit criminal acts while they await adjudication, but they also have been used to contain and control the homeless, so much so that they now are the mental hospitals for the homeless mentally ill.

Emergency department visits for psychiatric conditions make up an ever-increasing share of all emergency department visits. 

 of emergency department visits were for mental health, substance abuse conditions, or both.

 Those patients were 2.5 times more likely to be admitted to the hospital than emergency department patients with other conditions. But there are fewer and fewer beds available for these patients. Nationally, there are about 26.1 

 per 100,000 patients, down from 29.9 in 2009, according to a report from the American College of Emergency Physicians.

 Leading experts say that roughly 50 beds per 100,000 are actually needed to meet the current demand. The result is that patients experiencing a mental health crisis are often boarded in the emergency department with limited or no psychiatric treatment for hours or days.

Patients with psychiatric complaints have a significantly longer duration of stay in the emergency department than patients with non-psychiatric complaints. 

 in the emergency department for psychiatric patients is associated with lower quality of care and further contributes to overall emergency department crowding. Without access to community mental health services, psychiatric patients increasingly rely on emergency departments for 

 and intermediate needs, including medication management services that can be delivered at a lower cost in the community.

The mental health care crisis is a community problem, and it requires a community solution. Some communities are trying to change this reality through programs that offer some nonviolent offenders a way out of incarceration, and a chance to improve their lives. Bexar County’s Center for Health Care Services (CHCS) is an organization dedicated to serving persons with mental illness, developmental disabilities, and substance abuse disorders. The CHCS has evolved into a dynamic community resource dedicated to health care integration and improving the mental health delivery system in San Antonio and Bexar County.

Leon Evans, president and chief executive officer of the CHCS, saw the county jail overcrowded with people in need of mental health treatment. He issued a challenge to community leaders in 2002 to develop a comprehensive system of care to address the inappropriate incarceration of nonviolent misdemeanor offenders and the inappropriate use of emergency departments by persons with mental illness.

Under the leadership of Mr Evans, the CHCS created the diversion program with a 3-pronged intervention plan:

• To identify persons with mental illness who might be vulnerable to arrest

• To recommend alternatives to jail for persons already in the criminal justice system

• To provide mental health and support services to prevent recidivism

The first phase of the program involves pre-booking diversions. A crisis hotline is used to route calls for assistance and serves as a point of coordination for all crisis and jail diversion services. All calls are recorded and tracked for follow-up.

Calls can be routed to the deputy mobile outreach team. This team consists of a mental health professional and a law enforcement officer trained in working with persons who have mental illness. The team is available 24/7 to respond to calls and is able to make on-site mental health assessments, consultations, and referrals.

As another pre-booking tactic, the program uses crisis intervention teams that consist of police officers who have been specifically trained in working with persons with mental illness. In the late 1980s, the Memphis Police Department devised a crisis intervention team consisting of officers who are trained in identifying and responding appropriately to the emotionally or mentally disturbed. Police officers are taught de-escalation techniques to calm individuals who may be agitated or aggressive. Instead of arresting them, police bring them to a mental health treatment center. The Memphis model has been adopted by other cities, including San Antonio, where police officers bring people to The Restoration Center. There, they can get mental health, medical, and substance abuse evaluations and treatment.

The Bexar County’s crisis intervention team training program consists of a 40-hour, week-long training course for law enforcement officers (state requirements are less than 10 hours). Throughout the week, officers and mental health professionals interact using role-play scenarios that must be successfully completed by officers. Officers learn techniques such as de-escalation techniques and how to identify an individual with mental illness.

The second phase of the diversion program focuses on identifying mentally ill persons already in the criminal justice system. The entire jail population is screened daily against a statewide database to determine who has accessed the mental health system in the past. This helps officers identify persons who are in potential need of intervention and assistance from mental health services.

To assist these non-violent, often repeat offenders, an early release-to-treatment program was formed with the help of community corrections resources. Offenders who meet program criteria may be released from jail into long-term residential treatment (typically 90 to 180 days) at 2 local facilities: the 60-bed Mentally Ill Offender Facility or the 150-bed Substance Use Offender Facility. Judges may also exercise a third option: ordering an individual’s involuntary commitment to intensive outpatient treatment in lieu of prison time.

The third phase focuses on preventing recidivism. The county’s Genesis re-entry program identifies and supports re-entering offenders considered to be at high risk for recidivism. The program provides cognitive adaptive training to patients in their homes. This program works to prevent re-arrest by providing cognitive training and employment opportunities to mentally ill individuals in their communities after they have been discharged from a jail, hospital, or mental health treatment facility.

The Bexar County community has adopted aggressive steps to stem the course of events leading to incarceration for persons with mental illness and substance abuse. The Bexar County jail diversion program was established to divert individuals from inappropriate incarceration and inappropriate use of emergency departments while providing evaluation and treatment to reduce recidivism. This program was designed to bridge as many of these service gaps as possible. Results have demonstrated a significant reduction in the re-arrest rate of misdemeanor offenders. Specific actions have been taken to ensure emergency department utilization is kept as low as possible. Treatment before and after incarceration is achieved through an extensive partnership with 

In conjunction with the jail diversion programs, the CHCS established The Restoration Center. The facility is staffed by mental health and medical professionals 24/7, so police officers have a place to take individuals other than to jail or the emergency department for psychiatric, medical, and substance abuse evaluations. The Restoration Center houses a number of units that work in tandem to provide needed services. These units include the crisis care center, the deputy mobile outreach team, the San Antonio police department mental health unit, the public safety (sobering) unit, the detox unit, the minor medical unit, and CenterCare (outpatient integrated primary care/behavioral health clinic).

The crisis care center provides walk-in screening and assessment services, a secure law enforcement area for detained mentally ill persons, and 18 beds for 23-hour stabilization and/or transfer to a residential or more appropriate setting. It is staffed by medical, psychiatric, and social work professionals. Open to the public and to law enforcement, the crisis care center receives 500 to 700 individuals monthly who otherwise would have been taken into custody and incarcerated, sent to emergency departments, or admitted to state psychiatric facilities.

The role of the Bexar County’s deputy mobile outreach team is to direct individuals to the most appropriate clinical treatment setting with the least possible delay. The deputy mobile outreach team is activated when a face-to-face, on-site evaluation is required. In consultation with a psychiatrist, a decision is made whether immediate treatment is needed and where it should be provided.

The San Antonio mental health unit consists of specially trained, uniformed police officers who respond to calls when mental illness is suspected. Trained by mental health professionals, this unit is charged with safely resolving conflict and transporting the person in crisis to an appropriate mental health treatment facility; the individual is placed on emergency detention for further psychiatric evaluation, or jail if necessary. The officers are particularly well informed about the availability of mental health services and community resources.

The public safety (sobering) unit provides an innovative substance-abuse treatment program. The unit is set up to receive public intoxicants 24/7. These individuals are brought by law enforcement for evaluation and treatment instead of being taken to jail or sent to a local emergency department. The public safety unit admitted over 7000 public inebriates over the past year-the majority of whom were diverted from the jail. The sobering unit is a safe, supportive environment where publicly intoxicated people can get sober and be directed to other community services. They spend an average of 5 hours on the unit during which they are assessed medically by an emergency medical technician. They receive a minimum of 15 to 30 minutes of brief intervention using motivational interviewing techniques to engage them to enter substance abuse treatment (detox) within the same facility. Over a 6-month period, this relatively simple intervention, open to police and the public, saved the county $5.1 million and the city $1.4 million in legal and hospital costs.

Residential detoxification is the first phase of treatment and provides a safe, humane withdrawal from substance dependence. These men and women have frequented the local emergency departments and jails. They are in need of extended detoxification and have additional medical/psychiatric issues and/or a non-supportive living situation, which often necessitates admission to a 24-hour residential detoxification program. During the past year, 2232 individuals received services in the detox unit. Of these, 57% were treated for alcohol dependence, with the remaining individuals presenting with other drug dependencies. Detoxification alone will not result in long-term sobriety, but detoxification in conjunction with outpatient care can result in 

 of patients being alcohol and drug free 5 years after treatment.

 notes, “Length of stay in treatment has been found to be a significant predictor of positive post-treatment outcomes, such as decrease in unemployment and crime.”

 For these reasons, people are encouraged to engage in the intensive outpatient counseling program while they reside in structured sober living at the in-house recovery program on the Haven for Hope campus. The program has proved effective. About 70% of those who graduate from the center’s 90-day residential program for substance abuse are living and working independently a year later.

The minor medical unit evaluates and treats injured individuals who are under arrest but have not been to the magistrate’s office. They are brought in by law enforcement before being taken to jail for evaluation and treatment instead of being sent to a local emergency department. During the past year, 852 injured detainees were treated in this unit. These individuals needed some type of minor medical care and clearance before being booked into the jail. In the past, the arresting officer would have taken them to the public hospital’s emergency department to obtain medical evaluation, treatment, and clearance. Due to overcrowding of the public hospital, most officers waited between 8 and 10 hours to obtain medical care for their detainee.

CHCS also operates Prospect Courtyard, a safe sleeping area, within the Haven for Hope campus, which is the city of San Antonio’s $110 million transformational homeless center. The 37-acre campus is dedicated to interrupting the revolving door that sends homeless people from the streets to jails or emergency departments and back again. The essentials for breaking the cycle are not readily available inside the legal system. Long-term mental health treatment, counseling, job training, clothing, and housing as well as continuing substance-abuse treatment are needed to break the cycle of homelessness.

John was in his 20s when he was found by police in a bamboo marsh pit under a city bridge and arrested for trespassing and failure to identify himself. He grew accustomed to being in court, so even when he was not in trouble, John would simply show up unannounced and sit patiently waiting to speak with Judge K with whom he had developed a relationship. Often, John, who was homeless, was referred to the crisis care center (CCC), but he always refused to stay and never saw a doctor. One day, acting through the newly established community court, Judge K called the jail diversion program manager, who assigned a case worker to escort John to the CCC. Arrangements were made ahead of time with the CCC by the jail diversion team to ensure John would be seen immediately, which would prevent the anxiety that caused him to refuse treatment in the past. In coordination with the CHCS, which operates the Jail Diversion Unit, John received medication and was assigned a treatment case manager. John’s diagnosis was schizophrenia; he was finally stabilized. Since then, through efforts of the case manager and the judge, who maintain open lines of communication with John, he has been encouraged to remain in a stable living environment and receive outpatient mental health treatment.

The program has been successful at providing humane and confidential care for persons with serious mental illness who are involved in the criminal justice system. A total of 13,367 calls were handled by the crisis helpline in the past 6 months. Within a 12-month period during 2014 to 2015, 6000 individuals were screened, referred to, or provided with crisis services. Ten thousand people utilized sobering, medical detox, medical clearance, and intensive outpatient drug abuse services.

In the past 5 years, CHCS services documented direct savings of $50 million for local governments through jail diversion, consumer engagement, and treatment. Treatment is more cost-effective than jail. The costs associated with incarceration are high. Overcrowding at the Bexar County jail has not only been reduced, but the jail now routinely has a surplus of approximately 800 beds. Jail stays for mentally ill detainees, once 5 times longer than those for other detainees, have been dramatically reduced thanks to rapid access to treatment and better access to competency restoration services. Recidivism among non-violent offenders referred to treatment is below 10%. Available county and state prison capacity is better utilized to house more violent, high-risk offenders.

The accomplishments of the program have been acknowledged in many ways. The program was adopted by the State of Texas Department of Health Services as the model for implementation of jail diversion programs throughout the state. The Substance Abuse and Mental Health Services Administration has featured the Bexar County Jail Diversion Program on a list of national model programs. The program is recognized at the national level by the US Department of Substance Abuse and Mental Health Services Administration as one of the top jail diversion programs in the country. And, the program has received the National Excellence in Service Delivery Award from the National Council for Community Behavioral Healthcare and the American Psychiatric Association’s Gold Award for community program innovation in 2006. Many medical directors from mental health organizations and emergency departments from across the country have visited and toured the integrated system of care that brings together law enforcement, psychiatric crisis services, drug-abuse services, primary and acute medical care, and residential treatment.

In addition to Bexar County, a number of communities have developed crisis services for their community. A few examples include Buncombe County in North Carolina, Yellowstone County in Montana, Hennepin County in Minnesota, and King County in Washington. Each demonstrates collaboration and partnership with law enforcement to help divert individuals with mental illnesses from the justice system and into the services they most need.

The Bexar County jail diversion program in conjunction with the Restoration Center offers an example of how a joint effort involving the medical, legal, and mental health communities can help more mentally ill people get the care they need with less drain on both law enforcement and emergency department resources. Managing mental illness at the community level can keep the mentally ill out of jail and out of the emergency department as illustrated by the success of the comprehensive collaborative program in San Antonio.

Today, the jail diversion program involves a dynamic community collaborative, increased access to care, continuity of care, and cost savings to the community. A great deal of progress in making psychiatric and medical services more accessible has been made. Yet none of this progress would have been possible without the incredible level of community support, collaboration, and generous commitments of passion and time from many medical and non-medical citizens of Bexar County.

It is significant that the criminal justice system and mental health system often serve the same individuals. The creation of carefully structured partnerships involving criminal justice and mental health professionals within well-organized jail diversion programs has provided the treatment needed for recovery and has enabled the mentally ill to return to productive lives. Mental illness is treatable, and even for those with serious mental illness, recovery can be achieved. The entire community reaps the benefits of a united criminal and health care system.

Dr Hnatow is an emergency medicine physician who also serves as the Medical Director for the Restoration Center, Center for Healthcare Services in San Antonio, TX.

 US Department of Justice. Mental health problems of prison and jail inmates. 2006. 

http://www.bjs.gov/content/pub/pdf/mhppji.pdf

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