2006 APA Gold Award: Providing Jail Diversion for People With Mental Illness

Persons with mental illness are often jailed for nonviolent, victimless crimes. According to the National Alliance on Mental Illness, up to 40 percent of adults with mental illness will come into contact with law enforcement. And nationally, 16 percent of the jail population is incarcerated for offenses related to mental illness, mental retardation, or substance abuse. Of these, 60 percent to 75 percent were jailed for nonviolent offenses.

In response to the significant number of detainees and prisoners presenting with symptoms of severe mental illness, the Center for Health Care Services created the Bexar (pronounced "bear") County Jail Diversion Program. Since its inception in 2002, the program has sought to streamline the process of jail diversion to reduce the number of people who end up in jail as a result of behavioral problems caused in part by mental illness. The program has also sought to reduce the inappropriate use of emergency departments by this population. Today, the jail diversion program involves a dynamic community collaborative, increased access to care, continuity of care, and cost savings to the community.

Initial results show that from September 2003 to February 2006, 3,674 persons were diverted from jail, resulting in an estimated $3.8 million to $5.0 million in avoided costs within the county's criminal justice system.

In recognition of its innovative Bexar County Jail Diversion Program for persons with severe mental illness and substance use disorders, the Center for Health Care Services was selected as winner of the 2006 Gold Achievement Award in the category of community-based programs. The winner in the category of academically or institutionally sponsored programs is described on Original article: page 1524 . The awards will be presented on October 5 during the opening session of the Institute on Psychiatric Services in New York City. Each Gold Award winner will receive a plaque and a $10,000 prize made possible by a grant from Pfizer, Inc.

Intervention phases

In order to effectively divert offenders from jail and direct them into appropriate community services, the Bexar County Jail Diversion Program has identified and operationalized 46 separate and distinct intervention points in the current arrest-detention process in the criminal justice system. These intervention points were then divided into three phases. The first phase focuses on diverting persons with mental illness from the legal system, before they are arrested or booked into the county jail. This is accomplished by identifying and screening for mental illness, making recommendations to magistrates or judges, and providing options for treatment. The second phase of the diversion program focuses on identifying persons with mental illness who are already in the criminal justice system and recommending alternate dispositions, such as a mental health bond or release to a treatment facility. The third phase focuses on providing appropriate mental health and support services upon release from jail or prison.

Phase one

The first phase of the program involves prebooking diversions, and a crisis hotline is used to route calls for assistance and serve 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 (DMOT). This team—consisting of a mental health professional and a law enforcement officer trained in working with persons with mental illness—responds to calls from the community for assistance with persons with mental illness or mental retardation. The team is available at all times to respond to calls and is able to make on-site mental health assessments, consultations, and referrals. The actions of the DMOT often minimize the need for on-site arrests.

As another prebooking tactic, the program uses crisis intervention teams (CIT), which consist of police officers who have been specifically trained in working with persons with mental illness. These teams respond to calls in the field that may involve mentally ill consumers. By training officers to recognize and deal with people acting inappropriately as a result of mental illness, the Bexar County Jail Diversion Program hopes to direct consumers to the most appropriate treatment options, rather than automatically directing them to jail or the psychiatric unit of an emergency department.

The Bexar County's CIT training program consists of a 40-hour, week-long training course for law enforcement officers (state requirements are less than ten hours) and involves a broad range of community stakeholders and financial support from public and private organizations. Throughout the week, mental health professionals develop and act in role-play scenarios that must be successfully completed by officers. Participation of consumers, families, and members of the National Alliance on Mental Illness is an integral feature of this training.

Also, a mental health docket that combined data from ten criminal courts was reengineered. With the reengineering, the Center for Health Care Services became an integral part of the process by identifying and screening candidates before they arrived at the docket and by making recommendations as to appropriate placement and need for treatment. These changes have resulted in a significant reduction in the rearrest rate of misdemeanor offenders.

Phase two

The second phase of the diversion program focuses on identifying persons with mental illness who are already in the criminal justice system. To this end, the entire jail population is screened daily against a statewide database to determine which persons have accessed the mental health system in the past. This screening process identifies persons who are in potential need of intervention and assistance from mental health services.

In the second phase alternatives to jail for persons who are already in the system are explored. Persons with mental illness make up a significant proportion of the jailed population partly because inmates with mental illness serve an average of 15 months longer than those without mental illness for committing the same crime. Once incarcerated, these persons do not have access to adequate treatment and remain in the system simply because there is nowhere for them to go.

To help direct offenders to treatment, the program has established a residential step-down program, allowing judges a sentencing option that ensures that individuals go directly into treatment programs. The only one of its kind in Texas, the program consists of a 100-bed alcohol and substance abuse treatment facility and a 60-bed mental health facility, which allow persons to step down directly from jail into treatment.

Also, an involuntary outpatient commitment program was established within the civil probate court. Through a court-assigned mental health care professional, this program provides case management and continuity of care to persons who have been repeatedly incarcerated for minor crimes or who have come to the attention of law enforcement for health and safety reasons as a result of mental illness. This group of persons generally has their charges escalated because of the increasing number of offenses, and the intervention serves as a diversion from both jail and emergency departments, as it offers judges a sentencing option (commitment for 90 days, which can be renewed upon a physician's recommendation). When data were compared for the year before and the year after the first 14 participants entered the program, results showed that participants had a 79 percent reduction in the number of hospital bed-days (131 to 27 bed-days).

Phase three

The third phase focuses on preventing recidivism and arrests. For this phase, the program provides cognitive adaptive training (CAT) to consumers in their homes. For example, once patients with schizophrenia are discharged from detention or the hospital, CAT is provided to help them to resume daily activities in a community setting. The CAT program also employs persons with schizophrenia to help gain the trust and participation of persons with mental illness.

The Genesis Special Needs Offenders Program was created as another way to prevent recidivism. The program provides intensive case management, psychiatric services, and rehabilitation training for offenders who are on probation and parole. These services are provided in collaboration with local and state probation and parole departments.

Crisis Care Center

To provide law enforcement personnel enhanced access to services, the Crisis Care Center was opened in 2005. The center is open 24 hours a day and offers a more structured system of care by housing medical, psychiatric, and social work resources in one place. The center provides an average of 700 medical and mental health screenings per month. Not only has the center streamlined the screening process, but it also simplifies processes for evaluation, emergency treatment, disposition, and follow-up.

Before the Crisis Care Center was opened, law enforcement personnel had to deal with wait times of up to 12 hours when persons suspected of having minor legal infractions were evaluated by the hospital's emergency department. Now, wait times for screenings are just over an hour, thus saving the time of law enforcement.

Program staffing and funding

The jail diversion model is an integrated system of emergency departments, the court system, the mental health system, and probate courts. In addition to staff of partner agencies working in these systems, the Bexar County Jail Diversion Program employs 146 multidisciplinary staff, including physicians, nurses, licensed mental health professionals, benefit specialists, caseworkers, rehabilitation specialists, vocational and housing specialists, and records management personnel.

Funding for the Bexar County Jail Diversion Program—approximately $8.4 million annually—is provided through federal, state, and local support, Medicaid and Medicare, the University Health System, and CareLink.

Obstacles overcome

In many cases, the shortage of available funds and fractured and scattered resources are difficult problems for programs to overcome. Key to the success and leadership of the Bexar County Jail Diversion Program is the Medical Directors Roundtable, which meets monthly. The organizers of the roundtable brought representation from 22 city, county, and state law enforcement, judicial, and health care entities. Hospitals were also brought on board from the beginning, because of the high emergency department costs from recidivism. These representatives highlighted the mutual problems and frustrations that they faced and worked to find a common solution for all. The roundtable was also instrumental in finding and combining funding sources from all available resources.

In 2003 Texas faced a severe budget deficit resulting in an $8 million funding cut to the Center for Health Care Services. Despite this loss, the jail diversion program was successful in obtaining funds to enable it to continue, in part because it was clear how effective the program was. Small and major contributions were received from the federal government (three-year grant in the amount of $900,000), the state, local commissioners court, law enforcement agencies (dedication of $100,000 from drug seizure assets), and a host of provider entities, such as the National Alliance on Mental Illness, private hospitals, and an unrestricted grant from AstraZeneca Pharmaceuticals ($1.5 million).

Program effectiveness and quality assurance

The Bexar County Jail Diversion Program is outcome driven. As such, gathering and monitoring program data is a priority. The program documents all services and interventions. The Bexar County Jail Diversion Program follows the Texas Administrative Code in its procedures and program compliances. Best practices are in operation, such as Projects for Assistance in Transition From Homelessness (PATH), assertive community treatment, and crisis services. The Crisis Care Center maintains an active utilization review and utilization management process.

As part of the review process, the model employs a psychiatrist who is involved in the daily review of emergent cases and all activities of the crisis hotline, DMOT, and the Crisis Care Center. Also the DMOT calls the psychiatrist about every research case, directly from the scene. Staff also ensure quality improvement measures by tracking cases to completion and reviewing all state hospitalizations from the program.

Accomplishments

The program has been successful in providing humane and confidential care for persons with serious mental illness who are involved in the criminal justice system.

The accomplishments of the program have been acknowledged in many ways. The Substance Abuse and Mental Health Services Administration has featured the Bexar County Jail Diversion Program in its list of national model programs. Also, 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. Furthermore, mandatory state contract performance measures were adopted by the state and pulled directly from the standards of the Bexar County Jail Diversion Program.

Because of the success of the program, in 2003 it was a recipient of one of seven Target Capacity National Jail Diversion Program Grants. And in 2006 the Bexar County Program was the recipient of the National Council for Community Behavioral Healthcare award for service excellence.

Also, the favorable outcomes of the program led to legislation in 2005 by the 78th Texas Legislative session requiring the provision of state-approved jail diversion plans for all community mental heath centers.

The Bexar County Jail Diversion Program has been successful in integrating health care, law enforcement, and the judicial system to transform the way mental health services are delivered to offenders with mental illness with low-level offenses. In doing so, the program has reduced the recidivism of persons with mental illness by providing access to appropriate treatment. Giving persons with mental illness the opportunity to stay out of jail has enhanced public safety by freeing up jail beds for violent offenders and has provided humane and confidential care for persons with serious mental illness who are involved in the criminal justice system.