COLLABORATIONS THAT WORK: EXPLORING A RELATIONSHIP BETWEEN LAW ENFORCEMENT & MENTAL HEALTH Exploring the collaboration between the Houston Police Department and the Mental Health Mental Retardation Authority of Harris County.

Houston / Harris County Houston / Harris County Facts: Population of Houston: 2.1 million Size of Houston: 656 square miles Population of Harris County: 4.1 million Size of Harris County: 1,703 square miles Area Law Enforcement Agencies: 62 Harris County Jail population: 8,800 25% of people in jail receive psychiatric medications 7,500 Homeless at any given time 55% self-report mental illness

Historical Collaborations 1978: Mental Health Needs Council established by the County Judge as an advisory group to the Judge and Commissioners and still in operation today Membership includes over twenty organizations including professional associations, public providers, medical schools, and advocacy organizations Recommendations to county leadership have resulted in the establishment of Harris County Psychiatric Center (1986), the HPD Crisis Intervention Team (1999), and the Psychiatric Emergency Service (1999) at the Neuropsychiatric Center 1999 – 2004: Harris County approved funding for all major components of a comprehensive psychiatric emergency program

Comprehensive Psychiatric Emergency Program 1999: Psychiatric Emergency Services PES at the (Neuropsychiatric Center-NPC) 2002: Crisis Stabilization Unit (CSU) 2003: Mobile Crisis Outreach Team (MCOT) MHMRA Helpline 2004: Crisis Residential Unit (CRU) 2008: Crisis Intervention Response Team (CIRT) 2009: Chronic Consumer Stabilization Initiative (CCSI) 2011: CIRT Expansion to include Harris County Sheriff’s Office CPEP

Effective Collaborations Between CPEP PROGRAMS and LAW ENFORCEMENT

MCOT Mission / Goals The goal of the Mobile Crisis Outreach Team is to provide crisis intervention and relapse prevention services to individuals who are experiencing a mental health crisis and are unable to access treatment on their own or may be ambivalent about receiving mental health treatment.

CPEP COMPONENTS: Mobile Crisis Outreach Team (MCOT) Staffed with Psychiatrists, RN’s, Licensed Therapists, Case Workers, and Psychiatric Technicians Hours: 7A - 10P Weekdays (after hours covered by CIRT) Served ~2,800 in last twelve months; only 7% required hospitalization 60% had no prior jail, hospital or MHMRA crisis history Community based services include: Crisis Assessment, Crisis Intervention and Relapse Prevention Medication Services Individual Counseling and Brief Psychotherapy Case Management and Rehab Services Family Education and Support

Shared crisis calls Reciprocal referrals Collaborative trainings Ride alongs/MCOT Practicum Case staffings CIT administrative participation in MCOT rounds Incident debriefing Safety training Long history of collaboration Strengthened Third Party Credibility of clinicians with law enforcement CIT/MCOT Collaboration

MCOT by the Numbers referrals each month 7% are self-referred ~ 9-12% come from law enforcement cases open to MCOT at any given time 7 Master’s Level Licensed Clinicians, 9 Bachelor Level QMHPs, 3 RNs, 2 Psychiatrists, 6 Psychiatric Technicians

CPEP Components Psychiatric Emergency Service (PES) 24/7 psychiatric emergency room Staffed with psychiatrists, licensed social services, RNs and psychiatric technicians Served ~16,270 in past 12 months 912 were children/adolescents 421 were diagnosed with intellectual or developmental disabilities Over 5,580 were brought by law enforcement 50% were treated and did not require inpatient hospitalization

PES & LAW ENFORCEMENT Prior to PES, it took about 8 hours to hospitalize someone on an Emergency Detention Order (EDO) Often Officers spent their entire shift waiting to involuntary hospitalize someone Booking someone into jail took significantly less time so clients were often incarcerated in lieu of hospitalization to save time Currently, it takes an average of 45 minutes for law enforcement to involuntarily hospitalize someone at the PES on an EDO The Houston Police Department Mental Health Unit is also co-located at the PES

Law Enforcement to PES In the past 12 months the PES treated over 5,500 involuntary consumers brought in by law enforcement. This is an upward trend, compared to, 3,872 in 2008, 4,379 in 2009 and 5,365 in Eight percent were adolescents or children. Currently ~35-40% of total admissions to the unit are brought by law enforcement. Law enforcement take another ~3% from the PES on to jail after a brief psychiatric evaluation. These are generally consumers with a more serious charge who appear to have psychiatric symptoms. A brief assessment form completed in the PES is taken by the officer to the jail.

Law Enforcement at the PES

CIRT

Factors Contributing to the Development of the Crisis Intervention Response Team (CIRT) Increased number of CIT calls: 2007: 15, : 21, : 23,913 Nationally, it is estimated that 10% of all police calls involve an individual in a mental health crisis Two tragic outcomes in Houston involving individuals with mental illness Constantly improving relationship between MHMRA clinicians and Houston Police Department officers

Crisis Intervention Response Team (CIRT) Implemented in 2008 with 3 Teams, each consisting of one Licensed Master’s Level Clinician partnered with one CIT trained officer from HPD Respond in Ghost Marked patrol vehicles Respond to calls involving individuals exhibiting symptoms of mental illness and SWAT calls. In 2011 teams responded to over 6,330 calls and self- initiated over 1,000 calls. Less than 1% resulted in arrests; 28% taken to NPC. Expanded to 10 teams in 2010 Expanded to 13 teams in 2011 with the addition of (3) deputies from the Harris County Sheriff’s Office All 13 teams work together as one task force and respond to calls county wide

CIRT by the Numbers Total CIRT calls for 2012 (YTD): 3,188 Admits to NPC: 4,198 Admits to Ben Taub: 1,406 Admits to V.A.: 165 Other Area Hospitals: 154 Jail Diversions (by CIRT): 614

DEADLY ENCOUNTER May 6, year-old female with history of schizophrenia History of trespassing at police headquarters Made claims of laser beams being shot through her head, food being poisoned Numerous hospitalizations for mental illness Entered police headquarters with knife, stabbing herself in head while screaming for officers to kill her

DEADLY ENCOUNTER July 21, year-old male with lengthy history of schizophrenia Detained and committed by HPD 3 times in prior year Just released from HCPC 1 week prior to fatal encounter with police Stopped taking medication, deteriorated Mother called 911 after being turned away by HCPC Charged officers with pipe and told them “Shoot me”

Chronic Consumer Stabilization Initiative (CCSI)

WHAT IS CCSI ? The Chronic Consumer Stabilization Initiative (CCSI) is a collaborative effort between the Houston Police Department and The Mental Health Mental Retardation Authority of Harris County (MHMRA) CCSI was designed to identify, engage, and provide services to individuals who have been diagnosed with serious and persistent mental illness and who have had frequent encounters with the Houston Police Department

CCSI Overview CIRT Officers reported seeing the same individuals in crisis month after month even though they hospitalize them Clients consistently failed to engage in mainstream outpatient mental health treatment HPD identifies individuals with: Three (3) or more admissions to the Neuropsychiatric Center Excessive phone calls made to HPD by clients or others, on their behalf High utilizers of other public services (Fire Department/Ambulance, Hospital ER, etc.) Staffing: Four (4) case managers (15 clients each) One (1) psych tech One (1) HPD officer assigned as program liaison

CCSI PROGRAM GOALS Reduce the number of interactions with the Houston Police Department Identify unmet needs and barriers in the community Link and coordinate clients with needed mental health treatment and psychosocial services Provide support and education to the individual and their family members

PROFILE OF A CURRENT CCSI CLIENT Homeless 53 year-old male with history of schizophrenia and numerous hospitalizations for mental illness History of trespassing at police headquarters and downtown federal building Known for waving knives while screaming to be doing “GOD’S work” Shot a citizen, and subsequently shot by police. Charged with Attempted Murder, found to be insane and not convicted Charged with Robbery, sentenced to 37 months 23 Police contacts and 5 arrests prior to CCSI Added to CCSI Program in January contact with police and no arrests since being on the program Living in a Personal Care Home Taking medication regularly

Psychiatric Hospitalizations: 17 $ 31,840 Police Contacts: 23 $ 1,933 Incarcerations: 5 $ 112,165 Cost: $ 145,938 Psychiatric Hospitalizations: 1 $ 680 Police Contacts: 1 $ 202 Incarcerations: 0 $ 0 Cost: $ 882 before Chronic Consumer before CCSI after Chronic Consumer after CCSI A potentially productive and stable member of society Benefit CCSI Cost /Client: $ 4,633 + Cost (after): $ 882 $ 5,515 - Cost (before): $ 145,938 Cost Avoidance: $140,423 See Slide Notes for details of figures.

PROFILE OF A CURRENT CCSI CLIENT 51 year-old male with Major Depressive Disorder and numerous hospitalizations for mental illness Attempted suicide several years ago with a firearm, leaving him severely disfigured requiring extensive daily medical care Known to be reclusive in his apartment where he abused drugs and alcohol Has attempted to disarm at least 3 police officers verbally requesting suicide by cop 16 Police contacts and 2 arrests prior to CCSI Added to CCSI Program in December contacts with police since being on the program Attending doctor visits monthly Taking medication regularly

Psychiatric Hospitalizations: 9 $ 15,780 Police Contacts: 7 $ 588 Incarcerations: 2 $ 5,600 Cost: $ 21,968 Psychiatric Hospitalizations: 2 $ 1,360 Police Contacts: 3 $ 606 Incarcerations: 0 $ 0 Cost: $ 1,966 before Chronic Consumer before CCSI after Chronic Consumer after CCSI A potentially productive and stable member of society Benefit CCSI Cost /Client: $ 4,633 + Cost (after): $ 1,966 $6,599 - Cost (before): $ 21,968 Cost Avoidance: $15,369 See Slide Notes for details of figures.

Chronic Consumer Stabilization Initiative (CCSI) Successes Decreased the overall number of interactions between CCSI clients and the HPD by ~ 50% Decreased admissions of CCSI clients to Neuropsychiatric Center by ~ 30% Decreased admissions of CCSI clients to Harris County Psychiatric Center by ~ 37%

Chronic Consumer Stabilization Initiative (CCSI) Next Steps Achieved: Provide Medic-Alert bracelets to clients participating in the CCSI program Recent funding increase from City Council to fund 2 additional case managers Proposed: Collaborate with MHMRA Helpline to make scheduled phone calls to monitor former CCSI clients Dedicate a full time police officer position to the CCSI program Extend the Simmons Foundation Grant for

AWARDS AND RECOGNITION Recipient of the 2010 IACP Community Policing Award Finalist 2010 Herman Goldstein Award for Excellence in Problem-Oriented Policing Recipient of the 2011 Simmons Foundation Grant

Homeless Outreach Team (HOT)

HOT Mission Statement To improve the quality of life for all Houstonians by combining police and community resources in an effort to reduce the number of people who are living on the streets.

HOT Goals To help bridge the gaps that exist between the providers and the homeless in an effort to more efficiently utilize available resources.

HOT Statement regarding Collaboration with MHMRA Since the Homeless Outreach Team falls under the supervision of the Mental Health Unit, the team has benefited from the joint collaboration with the Mental Health Mental Retardation Authority. A full time case manager employed in the PATH program of MHMRA is assigned to our team. The case manager helps facilitate basic services by providing linkage to various resources in their agency.

HOT Team Houston Police Department established the Homeless Outreach Team in 2011 Team is made up of a Sergeant and 2 Officers from the Houston Police Department & a Case Manager from MHMRA with over 10 years of experience working with homeless individuals experiencing mental illness Team members travel the streets of Houston establishing relationships with homeless individuals with the common goal of getting them off the streets and into housing

HOT Team Next Steps Achieved: Acquired foundation grant to purchase a new transport van Proposed: Team expansion Increase community collaborations Expand City and County wide coverage

Ongoing Challenges for our Community and Harris County Comprehensive Crisis Services delivered in the absence of a comprehensive menu of ongoing Mental Health services accentuates the inadequacies of an over all MH delivery system. These inadequacies include: shortage of inpatient psychiatric beds limited outpatient services limited housing options difficulty engaging some chronic clients with history of non-compliance with treatment

Rewards/Benefits of Collaborations Able to make the most of our limited resources Able to provide the most immediate/accurate level of care to those referred to us maintaining the safety of both clients and staff Shared wisdom Ongoing Reciprocal Training

Contact Information Kim Kornmayer, LCSW Assistant Deputy; Crisis Services MHMRA of Harris County Ann MacLeod, LPC-S, NCC Program Director Crisis Intervention Response Team (CIRT) Chronic Consumer Stabilization Initiative (CCSI) MHMRA of Harris County Evelyn U. Locklin, MA, LPC Program Director Mobile Crisis Outreach Team (MCOT) MHMRA of Harris County Lawrence M. Pate Police Officer Houston Police Department Mental Health Unit