1. Continuity of Care Task Force Preliminary Recommendations

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 Examine barriers to discharge for individuals in State Hospitals with extended lengths of stay Make and prioritize recommendations to improve continuum of care and resolve barriers to discharge

4. TIMELINE Four Task Force Meetings ◦ February 5, 2010 ◦ February 19, 2010 ◦ March 26, 2010 ◦ June 18, 2010 Final Report—August 31, 2010

5. Public Forums March 3 rd, Czech Heritage Center, La Grange, TX May 7 th, Rio Grande State Center Auditorium, Harlingen, TX 12:30-2:00 PM May 11 th, Dallas County Health and Human Services Building, Room 627,Dallas, TX 12:30- 2PM May 21 st, Big Spring State Hospital Auditorium, Big Spring, TX 12:30-2PM May 27 th, DSHS West Auditorium, Austin, TX 1PM-3PM

6. 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

7. Environmental Perspective: Public Health Epidemic Incidence and prevalence of specific diagnoses Trajectory of growing population Increasing numbers of uninsured and underinsured Decreasing capacity in the private service system Appreciation of behavioral health disorders as chronic conditions, much like diabetes and hypertension Potential for decreasing hospital bed capacity in the near future

8. Environmental Perspective Primary care needs—need for expansion of integrated care Lack of residential alternatives to hospitalization, including permanent supportive housing, is major barrier Current service system doesn’t address significant overlap between Axis I, Axis II, Substance Use Disorders, Intellectual Disabilities, Head Injuries

9. Data Development Jail treatment prior to finding of incompetency Individuals admitted > 3 times in 180 days Individuals with > 5 forensic admissions in FY 2009 Outpatient Restoration of Competency Pilot Participants Individuals with length of stay > 365 days Forensic commitment/re-commitment of misdemeanants

10. Policy/Practice Issues Housing Community supervision and medical necessity—judicial expectations “Step-down” levels of care Funding for non-crisis services Need for cognitive rehabilitative services Improved communication between courts and hospitals

11. Medical Clearance

12. Preliminary Recommendations: Short Term Statutory—46B ◦ Clarify that maximum time commitment includes “time served” in jail from the date of booking ◦ Include commitment expiration dates in court orders to facilitate communication between hospitals and courts

13. Preliminary Recommendations: Short Term Statutory—46B ◦ Limit the maximum commitment period for misdemeanants to 90 days (civil commitment is alternative if criteria met) ◦ Restore provisions in forensic expert reports about individuals not likely to be restored to competency in the for-seeable future to allow for better analysis and disposition of individuals with repeat forensic commitments

14. Preliminary Recommendations: Short Term Statutory—46B ◦ Allow for voluntary jail treatment for 14-21 days prior to evaluation for competency to stand trial—with option for contest by defense counsel (involuntary treatment currently authorized under H&S Code 574.106 for certain individuals in jail settings ◦ Clarify judicial authority under 46B.079(b)(2) (forced medications)

15. Preliminary Recommendations: Short Term Statutory—17.032 ◦ Link 17.032 provisions to Permanent Supportive Housing legislative appropriations request—create incentives throughout 17.032 to utilize PSH for misdemeanor defendants

16. Preliminary Recommendations: Short Term Statutory ◦ Extended outpatient commitment for subset of outpatient commitment candidates

17. Preliminary Recommendations: Short Term Medical Clearance Recommendations Permanent Supportive Housing for Misdemeanants with Conditional Release provisions Alternative levels of residential care, including Assisted Living, for individuals with long term hospital stays

18. Preliminary Recommendations: Short Term Training ◦ Judges ◦ Prosecutors ◦ Defense Attorneys ◦ Mental Health Professionals ◦ Law Enforcement ◦ On-Line peer consultation for judges, defense attorneys, prosecutors ◦ Law Schools

19. Preliminary Recommendations: Intermediate Term Clinical ◦ Clinical competencies ◦ Professional development ◦ Salary analysis ◦ Peer support approach ◦ Trauma informed care ◦ Cognitive Rehab and appreciation of co- morbidities in RDM ◦ Expanded time for testing, assessment, record analysis

20. Preliminary Recommendations: Interim Studies? ◦ Mental Health Code ◦ Consideration of Medicaid Waiver ◦ Study of clinical issues for long term hospitalizations ◦ Improve data systems to better clarify issues around repeat forensic commitments and charges