Continuity of Care Task Continuity of Care Task ForceForceFebruary 19, 2010

BACKGROUNDBACKGROUNDThe Texas State Psychiatric

Hospital system is nearing capacityWhile total admissions and civil

commitments have decreased, the number of forensic commitments has increased

Forensic commitments generally involve longer lengths of stay

The increased number of forensic commitments and longer term patients has overcome the impact of decreased admissions

TASK FORCE GOALSTASK FORCE GOALSExamine the overall continuum of

care for individuals with severe mental illness who move through multiple systems

Make and prioritize recommendations to improve efficiencies, access and quality

Examine barriers to discharge for individuals in State Hospitals with extended lengths of stay

Make and prioritize recommendations to resolve barriers to discharge

TIMELINETIMELINEFour Task Force Meetings

◦February 5, 2010◦February 19, 2010◦March 26, 2010◦April 16, 2010

Four Public Forums◦March 3, 2010, Czech Heritage Hall,

LaGrange, TXIndividual InterviewsMeetings with Key Professional GroupsFinal Report—September 30, 2010

Overview of First MeetingOverview of First MeetingGlobal IssuesGlobal IssuesIs the increase in the number of

forensic commitments a positive or negative development? Both◦Lack of intermediate care options◦Better awareness

Recommendations will be challenging because of significant differences between urban and rural communities

Better mental health care and treatment for children and adolescents would be successful prevention approach

Overview of First Meeting Overview of First Meeting Discussion—Statutory IssuesDiscussion—Statutory Issues46B

◦Consideration of amendment of “immediate evaluation” to support 21 day referral program

Article 16.22/17.032 Code of Criminal Procedure◦Why underutilized?

Overview of First Meeting Overview of First Meeting Discussion—Statutory IssuesDiscussion—Statutory IssuesForced Medication Provisions

◦Only being utilized in urban areas; impractical in rural areas

◦Three populations◦Most simply take the medication

once order is issued◦Confusion/inconsistency about which

court may order◦Insufficient involvement of defense

attorneys

Overview of First Meeting Overview of First Meeting Discussion—Statutory IssuesDiscussion—Statutory IssuesMental Health Code

◦Doesn’t reflect current system◦Consider recommendation for

interim study

Suspension rather than termination of SSI benefits while incarcerated

Overview of First Meeting Overview of First Meeting Discussion—Policy/Practice Discussion—Policy/Practice IssuesIssuesOutpatient Restoration of

Competency◦Actually serving as case finders◦Data about effectiveness

Outpatient Commitment◦Continued resistance to use◦Statutory or practice?

Medical Clearance◦Ad Hoc Texas Council Committee

Overview of First Meeting Overview of First Meeting Discussion—Policy/Practice Discussion—Policy/Practice IssuesIssuesPermanent Supportive HousingGuardianshipMedication FormulariesCommunity Supervision and

Medical NecessityResidential Alternatives to

HospitalizationFunding for non-crisis services

TRAINING ISSUESTRAINING ISSUESJudges

◦Growing acceptance of therapeutic jurisprudence

◦Need for training about interface of systems

Prosecutors◦Dropping charges

Defense Attorneys◦Competency raised too often, too soon?

Mental Health Professionals◦Criminal justice perspective

Data DevelopmentData DevelopmentClinical/demographic characteristics of

most frequently and long term hospitalized

Other state modelsDiversion statistics—Harris CountyPractical value/outcomes of medical

clearanceCharges filed in IST casesState level formulariesOutpatient restoration of competency

programs

DATADATAQuick Fixes—National GAINS

Center

Harris County RRCP Program

Criminal Offense Data

Demographic and Diagnostic Data

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Quick Fixes - ExaminationQuick Fixes - Examination Increase fees for examinersIncrease fees for examiners Court based examinersCourt based examiners ““pre-competency” assessmentpre-competency” assessment Inpatient stabilization prior to Inpatient stabilization prior to

competencycompetency Competency Courts (Nevada and Competency Courts (Nevada and

Washington)Washington) Jail based competency examsJail based competency exams Community based examsCommunity based exams Improve jail based treatment to prevent Improve jail based treatment to prevent

loss of competencyloss of competency Expedite competency cases for quick Expedite competency cases for quick

dispositiondisposition

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Quick Fixes – RestorationQuick Fixes – Restoration

Admission triageAdmission triage UR process to insure prompt return to UR process to insure prompt return to

courtcourt Review of level of care and transfer to Review of level of care and transfer to

least restrictive settingleast restrictive setting Time limits for competency based on Time limits for competency based on

level of crimelevel of crime Competency restoration manual for Competency restoration manual for

examinersexaminers Jail based competency restoration (Va. Jail based competency restoration (Va.

Tx.)Tx.) Expedite transfer of court/clinical Expedite transfer of court/clinical

documentsdocuments Video conferencing for hearings (Sell, Video conferencing for hearings (Sell,

status)status) Community restorationCommunity restoration

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Quick Fixes - Return to Quick Fixes - Return to CourtCourt

Competency Court manages Competency Court manages processprocess

Improve coordination:Improve coordination: TransportTransport Jail treatmentJail treatment Prompt court hearingsPrompt court hearings Transition planningTransition planning

Harris County Jail – 21 Day State Hospital Diversion Program

No

No

No

Court Orders a Psychiatric

Review on Consumer

Consumer seen by counselor and MD within 3 days and Meds prescribed

Active MHMRA Consumer

Referred to Eligibility Center

Clinic physician sees within 3 days and begins Stabilization

Client Stabilized

Court notified within 20 days and sets date for hearing

Results reported to court for disposition May request formal evaluation OR Hearing is reset

Court notified to seek other alternatives for evaluation

Formal Evaluation Completed

Competent?

Court hearing proceeds

Court commits to Rusk State Hospital for restoration of competency.

Non-Harris County Resident Non Priority Population

Eligible for Service?

In Jail

Yes

Yes

No No

Yes

Yes

Yes

Yes

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Next StepsNext Steps

Study of 2009 Wait List?Study of 2009 Wait List? Hospital Issues?Hospital Issues? Continuity of Care Communication?Continuity of Care Communication? Additional Data DevelopmentAdditional Data Development Future MeetingsFuture Meetings Other StakeholdersOther Stakeholders Public ForumsPublic Forums