1. Continuity of Care Task Force February 19, 2010

2. BACKGROUND The Texas State Psychiatric Hospital system is nearing capacity While 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

3. TASK FORCE GOALS Examine 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

4. TIMELINE Four 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, TX Individual Interviews Meetings with Key Professional Groups Final Report—September 30, 2010

5. Overview of First Meeting Global Issues Is 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

6. Overview of First Meeting Discussion—Statutory Issues 46B ◦ Consideration of amendment of “immediate evaluation” to support 21 day referral program Article 16.22/17.032 Code of Criminal Procedure ◦ Why underutilized?

7. Overview of First Meeting Discussion—Statutory Issues Forced 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

8. Overview of First Meeting Discussion—Statutory Issues Mental Health Code ◦ Doesn’t reflect current system ◦ Consider recommendation for interim study Suspension rather than termination of SSI benefits while incarcerated

9. Overview of First Meeting Discussion—Policy/Practice Issues Outpatient 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

10. Overview of First Meeting Discussion—Policy/Practice Issues Permanent Supportive Housing Guardianship Medication Formularies Community Supervision and Medical Necessity Residential Alternatives to Hospitalization Funding for non-crisis services

11. TRAINING ISSUES Judges ◦ 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

12. Data Development Clinical/demographic characteristics of most frequently and long term hospitalized Other state models Diversion statistics—Harris County Practical value/outcomes of medical clearance Charges filed in IST cases State level formularies Outpatient restoration of competency programs

13. DATA Quick Fixes—National GAINS Center Harris County RRCP Program Criminal Offense Data Demographic and Diagnostic Data

14. 14 Quick Fixes - Examination Increase fees for examiners Increase fees for examiners Court based examiners Court based examiners “pre-competency” assessment “pre-competency” assessment Inpatient stabilization prior to competency Inpatient stabilization prior to competency Competency Courts (Nevada and Washington) Competency Courts (Nevada and Washington) Jail based competency exams Jail based competency exams Community based exams Community based exams Improve jail based treatment to prevent loss of competency Improve jail based treatment to prevent loss of competency Expedite competency cases for quick disposition Expedite competency cases for quick disposition

15. 15 Quick Fixes – Restoration Admission triage Admission triage UR process to insure prompt return to court UR process to insure prompt return to court Review of level of care and transfer to least restrictive setting Review of level of care and transfer to least restrictive setting Time limits for competency based on level of crime Time limits for competency based on level of crime Competency restoration manual for examiners Competency restoration manual for examiners Jail based competency restoration (Va. Tx.) Jail based competency restoration (Va. Tx.) Expedite transfer of court/clinical documents Expedite transfer of court/clinical documents Video conferencing for hearings (Sell, status) Video conferencing for hearings (Sell, status) Community restoration Community restoration

16. 16 Quick Fixes - Return to Court Competency Court manages process Competency Court manages process Improve coordination: Improve coordination: Transport Transport Jail treatment Jail treatment Prompt court hearings Prompt court hearings Transition planning Transition planning

17. Harris County Jail – 21 Day State Hospital Diversion Program 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 Courtcommits to Rusk State Hospital for restoration of competency. Non-Harris County Resident Non Priority Population Eligible for Service? In Jail Yes No Yes

18. 18 Next 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 Development Additional Data Development Future Meetings Future Meetings Other Stakeholders Other Stakeholders Public Forums Public Forums