Facts & Issues: Adequacy Of Crisis & Emergency Mental Health Care In Travis County

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1 The LWVAA, at the May 16, 2007 Annual Meeting, authorized a local study of the adequacy of local mental health resources. A Mental Health Committee began meeting over the summer. The committee initially looked at the broad scope of mental health services and providers in Travis County, interviewing a number of health planners, state and local mental health care administrators, mental health associations and nonprofits as well as treatment professionals. Virtually all agreed that much needs to be done to improve prevention, diagnosis, and treatment, especially for individuals who do not have health insurance covering mental health and/or do not have personal financial resources to get treatment. The committee reached the conclusion that a full study of the adequacy of local mental health resources would take several years because the topic is so large and has so many components, and policies and funding are changing rapidly. Consequently, in this first year, we are focusing on the adequacy of crisis and emergency mental health care services in Travis County. Travis County judges, the Travis County Sheriff s Office and the Austin Police Department have all pointed out that there are significant gaps in mental health care resources in Travis County. In addition, the media has devoted considerable attention to the lack of adequate or appropriate services. This Facts & Issues provides information on the major governmental, private, and nonprofit mental health care providers. It also discusses the gaps in funding and services for emergency and crisis intervention and gaps in stabilization and follow-up treatment, whether provided in a hospital setting or elsewhere. MENTAL HEALTH PROVIDERS Travis County Healthcare District (TCHD) In 2004, Travis County voters approved formation of the Travis County Healthcare District to provide access to a full range of health care services and to consolidate health care functions previously shared by the City of Austin and Travis County. TCHD s mission is to promote the health and wellness of the residents of our community, especially the uninsured and underinsured. It is governed by a nine-member, appointed Board of Managers. The Board prepares, and submits its annual budget to the Travis County Commissioners Court. The Commissioners Court sets the District s tax rate annually. The TCHD s basic funding comes from local property taxes. Additionally, TCHD is able to leverage local dollars to draw down available federal funds and to leverage health care investments of community partners. The District funded inpatient psychiatric services at Seton Shoal Creek for eligible patients in the following amounts: FY2006 -$500,000 (six month period); FY $1,500,000; FY $2,300,0000. In addition, the District funds approximately $900,000 on an annual basis for integrated behavioral health services provided in the Community Health Centers and funds medications prescribed by the Austin Travis County Mental Health and Mental Retardation (ATCMHMR) for Community Health Center patients who are also patients of ATCMHMR. Community Health Centers The Healthcare District provides healthcare services for Travis County residents who are not eligible for other private or public insurance programs. TCHD has a primary care system that has been in place since the 1970s. The 14 clinics provide outpatient behavioral health services as well as primary healthcare, dental care, and HIV/AIDS treatment services for over 45,000 adults and children in Travis County. One of the reasons cited by many who supported the creation of TCHD in 2004 was the hope that the District would be able to support the provision of inpatient mental health services for uninsured or under-insured patients. By broadening the tax base for healthcare services from Austin to all of Travis County, proponents hoped that new and expanded mental healthcare services could be funded. However, at the time of the creation of the District, the City of Austin and Travis County transferred to the District the portion of their tax base dedicated to medical services only. A decision was made by both the City of Austin and Travis County not to transfer their respective tax bases for mental healthcare services to the District at that time. Therefore, the District has funded the expansion of mental health services it supports through the tax base it received for medical services. Copyright League of Women Voters of the Austin Area February

2 Due to its limited funding and the need to make progress in many areas of unmet healthcare needs (e.g. hospital care, primary care, specialty care, dental care, etc.) the TCHD Board of Managers has stayed committed to its general policy to make incremental progress toward expanding health care in all areas of need. Additionally, since inception the Travis County Commissioners Court has shown a commitment to keeping the tax rate near its original figure. Overall, TCHD funding for mental health services in 2008 is over $3 million, and funding for all other health care services is approximately $80 million. Austin Travis County Mental Health Mental Retardation (ATCMHMR) In 1965 the State of Texas passed legislation authorizing local entities to establish community centers to provide services to people with mental illness and mental retardation. The ATCMHMR Center was established in The Center is neither a state agency nor a county department, but a publicly funded, nonprofit organization. The Center is authorized to receive funds from local, state, federal and other public and private sources. For FY2008, the Proposed Revenues for Behavioral Health Services is $14,857,777 with more than half of that amount, $8,416,000 coming from State Funds and $2,930,991 from Federal Funds. The mission of ATCMHMR is to improve the lives of people who experience mental, emotional or substance use disorders and intellectual and developmental disabilities and delays. The Center has played a pivotal role in collaborating with the Travis County Healthcare District to integrate behavioral and primary health care and increase efficiency in medication management. The Center s nine-member, volunteer Board of Trustees is appointed by the City of Austin (4), Travis County (4), and the Austin Independent School District (1). The board is appointed for two years and reflects the community it serves and represents. Members volunteer their time and skill at monthly meetings as well as various standing committee meetings, training sessions and fundraisers. The Center provides community-based services to adults and children with behavioral health disorders and intellectual/developmental disabilities who are deemed most in need. Behavioral Health Services are provided to individuals with a primary diagnosis of serious and persistent mental illness (schizophrenia, bipolar disorder and major depressive disorder) and substance use disorders. The system is designed to work with the individual in developing a plan for a continuum of care to address the full spectrum of behavioral health needs. Services are delivered through four networks and three support divisions located in more than 60 facilities and numerous sub-contracted entities across the city and county. Included are information and referral, psychiatric evaluation, 24-hour crisis intervention, medication support, inpatient treatment, employment and vocational services, care coordination, family support and respite care, housing, supported living and residential services. Also staff often provides mobile services in consumers homes, on the streets, or at other community sites. Single Point of Entry (SPOE) has been developed as a uniform telecommunications system linking all the divisions of the Center. It is available during business hours to direct prospective clients to the appropriate points of behavioral health, child and family services, and developmental disabilities programs. Intake appointments can be made through the use of an automated system. The staff will refer to other agencies when appropriate. For Fiscal Year 2006 Clients served in Adult Behavioral Health Services ,629 Crisis phone calls ,108 Request for services calls ,016 CRISIS SERVICES Crisis Services Redesign Plan (CSRP) In 2007, the Texas Legislature appropriated $82 Million for the FY biennium to improve the response to mental health and substance abuse crises in the state. The first phase focuses on ensuring Copyright League of Women Voters of the Austin Area February

3 statewide access to competent rapid response services, avoidance of hospitalization and reduction in the need for transportation. The first priority for funds allocated directly to Local Mental Health Authorities will be to ensure a minimum level of critical crisis services. As a result of the emphasis on Crisis and Emergency Services, a new division was recently created at ATCMHMR, which includes THE INN, Hotline, Mobile Crisis Outreach Team (MCOT) and Psychiatric Emergency Services. ATCMHMR has received $664,392 from Department of State Health Services (DSHS) and is recruiting additional staff to expand the Mobile Crisis Outreach Team and Crisis Hotline capabilities. The original funding of $400,000 from Travis County did not allow for 24/7 staffing for MCOT. The Center has also hired additional staff for the Crisis Residential Unit, THE INN. Mobile Crisis Outreach Team In collaboration with the Crisis Intervention Team of the Travis County Sheriff s Office and the Austin Police Department, the ATCMHMR Center has established MCOT to assist individuals experiencing psychiatric crisis. The Team has been trained to provide psychiatric assessment, psychiatric medical care, crisis counseling, and referral to community resources. Services can be accessed at or 472-HELP. Calls made to 911 are sent to the law enforcement Crisis Intervention Team. MCOT s first responder service is a major step in mental health crisis management; however, MCOT is limited in the available treatment options that can be accessed in a timely manner. Psychiatric Emergency Services (PES) This crisis intervention facility is open 24 hours a day, 7 days a week and staffed with licensed clinicians and psychiatrists on call. MCOT or the Crisis Intervention Team may take individuals in crisis to be seen at PES. However, PES is not part of a hospital-based facility, and consequently many individuals are taken to hospital emergency rooms, most frequently University Medical Center at Brackenridge. Judge Guy Herman, the Travis County judge who handles psychiatric commitments, and other concerned people cite the lack of local inpatient psychiatric beds provided by public and private sources and the lack of a medicallybased model of psychiatric emergency services as our most pressing problem. Austin State Hospital (ASH) ASH is one of ten Texas Department of State Health Services mental health facilities. It was established in 1856 and the first patients were admitted in It provides psychiatric care to a 38-county region in Central Texas. ASH admitted more than 4400 patients in FY 2006 with about the same number of discharges, and it has an average daily patient census of 292. The focus of treatment is stabilization of acute psychiatric illness and return to the community. The average length of stay at the hospital is 18 days. Services are paid for through general revenue funds from the State of Texas, private payment, private third party insurance, as well as through Medicare and Medicaid programs. While Austin s population has experienced considerable growth, the number of beds available to Austin-Travis County was decreased from 110 beds to 63 in November, At that time the decision was made by MHMR to use local Emergency Room facilities until beds became available. Many patients upon release from ASH prefer to remain in Austin, rather than return to their home county. Inpatient service system capacity has not kept pace with the need. Seton Shoal Creek Hospital This private, nonprofit psychiatric hospital has 77 beds and serves children and adolescents as well as adults. Dual diagnosis patients are included. Sometimes older patients are diverted to Austin Lakes Hospital, formerly St. David s Pavilion, which has a geriatric focus. Of the total 77 operational beds, eight are funded through the TCHD for uninsured/indigent patients. In addition, when possible Shoal Creek will accept uninsured/indigent patients under their Charity Care program, however space is limited. Approximately 100 or more patients a month are turned away for lack of capacity. A typical census is a range of patients per day. Staff shortages (RNs primarily) limit the number of patients who can be treated. When Shoal Creek Hospital is full, patients are diverted to Emergency Room Services at other hospitals. Copyright League of Women Voters of the Austin Area February

4 Upon discharge, uninsured patients may have difficulty linking to follow-up care (psychiatrists, therapy, social services). Many bureaucratic hurdles make this process impossible to negotiate for people with mental illness. University Medical Center at Brackenridge (UMCB) Publicly owned, the UMCB is the only level II trauma center serving the Central Texas area with a 24-hour emergency department staffed by board certified emergency physicians. UMCB was leased by the City of Austin to Seton in 1995, bringing Brackenridge under the umbrella of Seton Healthcare Network. During a crisis many mentally-ill individuals are first seen in UMCB s Emergency Room. Patients are assessed medically upon admission, but there is not a psychiatrist on the ER staff. However, inpatient psychiatrists are available at times for consultation. Recently, the ER has increased the number of social workers and nurses as well as using 6 beds located away from the other ER beds to accommodate patients. These are not dedicated psychiatric beds but allow for more privacy. Due to the lack of other treatment centers, patients have stayed up to 5 days at the UMCB Emergency Room, but generally patients are discharged or moved within hours. Some patients who are not restrained actually leave the premises of their own volition. Dr. Ziebell, Medical Director of ER Services at Brackenridge, states that an increased number of inpatient beds is not the only solution. He points out that more respite care, aggressive case management and outpatient services could decrease the number of admissions to ER. Also there is a revolving door for many individuals at the ER and he cited that at least 3 individuals had over 90 visits in a three month span according to the Indigent Care Coalition. Current practice of law enforcement is to take individuals to the closest hospital. Because UMCB is a downtown hospital, it receives more ER patients than other hospitals. PLANNING & COORDINATION TO MEET THE CHALLENGES Mayor s Mental Health Task Force MMHTF In response to community concern over the challenges facing the Austin and Travis County residents with mental health needs, Austin Mayor Will Wynn created the Mayor s Mental Health Task Force in The Monitoring Committee (MMHTFMC) is a subcommittee of the ATCMHMR Center Board of Directors. The role of the MMHTFMC is to document and coordinate behavioral health services system planning and to fill unmet planning needs. The Monitoring Committee has identified six specific focus areas considered essential for a mentally healthy community: Schools and Youth; Criminal Justice Prevention/Diversion; Faith Based Activities; Safe, Affordable, and Accessible Housing; Access to Mental Health Services; and Community Awareness/Prevention. Access to Mental Health Services The Austin/Travis County community has faced a growing challenge in meeting the needs of individuals experiencing mental health crises. Individuals, families and community systems, e.g. criminal justice, hospital emergency rooms and law enforcement are negatively affected by the lack of capacity to meet these urgent needs. The need for psychiatric inpatient capacity and strengthened mental health crisis services is based upon factors evolving over more than a decade. A coalition began meeting in December 2005 when it became evident that erosion in state and national funding was unduly burdening resources in Travis County and leaving many citizens with no viable means of emergency psychiatric treatment. Psychiatric Emergency Services at ATCMHMR experienced a 48% increase in demand between October 2005 and October As of August 2007, the waiting list for behavioral health services at ATCMHMR stands at 540. Although many consumers receive medication through ATCMHMR, eligibility guidelines and the high cost of medication make access to medications difficult for some consumers. Recent state legislation has further impacted access by limiting the adult population that can be served by local mental health authorities and eliminating most mental health counseling services for adults in the Medicaid program. Copyright League of Women Voters of the Austin Area February

5 Other community challenges include providing mental health services for those who no longer qualify for access to Texas Department of State Health Services funded care through ATCMHMR because of recent eligibility restrictions. The Resiliency Clinic was funded with a grant from the Hogg Foundation for Mental Health to provide services for those who no longer meet the high priority population criteria. Unfortunately, when the grant that funded this clinic expired, the Clinic was not sustainable and thus closed. The Indigent Care Collaboration and St. David s Health Care System reflected that a total of 15,493 emergency room visits in Austin in 2005 were primarily due to behavioral health problems. Another challenge or delay in services results from the absence of legal commitment availability on weekends, evenings and holidays. Many communities have this available 24/7 for law enforcement as well as medical referral. Outpatient services are not the primary focus of this study on crisis intervention, but it is important to note the shortage of outpatient services, especially to low income/uninsured clients. This shortage has a direct impact on the increased need for crisis intervention and inpatient services. For many individuals, the point of entry and stabilization or resolution could have been met through earlier outpatient intervention, as a result possible crisis intervention and inpatient services could have been avoided. The MMHTF Monitoring Committee Report provides a wealth of information on providers in Travis County. The Website is According to the Crisis Services Redesign Plan, outpatient services are an example of enhanced services which may reduce crisis interventions and prevent admissions to a more restrictive level of care. Consequently such services would be considered for funding by the plan after the minimum level of services has been achieved. With inadequate funding for community based mental health services nationwide, it has been increasingly recognized that individuals with mental illness have been gravitating to the criminal justice system. Because Texas is among the lowest in the nation in per capita mental health funding, recent data has shown that Texas exceeds national averages in the number of individuals with severe mental illness in our jails and prisons. ATCMHMR Focus, Spring 2008 Criminal Justice Prevention/Diversion For individuals who are mentally ill and whose behavior has become aggressive or is deemed a public nuisance, a lengthy stay in jail is possible, and currently is likely. ATCMHMR Focus newsletter for Spring 2008 reports: While we have made tremendous strides in our jail diversion strategies, much remains to be accomplished. At any given time an average of 17-20% of those incarcerated have been seen at an outpatient clinic or diagnosed with a mental illness or substance use disorder translating to an average of 400 inmates in Travis County in any daily census. A human face was given to these statistics in an Austin American-Statesman article about a young man with bipolar disorder and schizophrenia who waited in the Travis County Jail for 121 days for a transfer to a psychiatric hospital. He was ruled incompetent to stand trial and a judge ordered that he be sent to a psychiatric hospital. In his case, there was a backlog of 40 inmates waiting for a transfer to a psychiatric hospital, and he waited in jail for three months before receiving treatment. Statistics from Mayor s Mental Health Task Force Monitoring Committee (MMHTFMC) 2005 Mentally Healthy Community Scorecard (Latest statistics available) # Law Enforcement Contacts with Mental Illness Clients Outcomes of Law Enforcement Contacts: Commitments (26%) Voluntary Admissions (14%) Arrests (5%) Other interventions (55%) Copyright League of Women Voters of the Austin Area February

6 Between 5/1/2005 and 12/31/2005, a total of 1,398 felony and misdemeanor cases were referred to specialist mental health attorneys. The criminal justice system has become a waiting room for mental health treatment, holding mentally-ill individuals until an under-funded and overwhelmed mental health care system can begin to treat them. Providing timely treatment for mentally-ill individuals who are in jail is one facet of the challenge of mental health care. Scarcity of funding, in a nutshell, is the basis of the very compelling challenges that mental health providers in both private and public sectors face in our community today. There is a real temptation to lay the burden of blame for this shortfall on the State, local government, hospitals, insurance companies or a lack of donor dollars. All of these entities certainly need to be involved in crafting a solution to the problem. But let s face facts: these institutions reflect the will of the people in the broader community. If we are seriously human, and seriously honest with ourselves, we must recognize that this is an issue worthy of broad support and come together to develop a system of care for those with severe mental illnesses. Jefferson Nelson, M.D. ATCMHMR Medical Director Guest Opinion, ATCMHMR, Focus, Spring 2008 Sources: Austin Travis County MHMR, Mobile Crisis Outreach Team (MCOT) brochure Austin Travis County Mental Health Mental Retardation Center, Directory of Services, 2006 Austin Travis County Mental Health Mental Retardation Center, Focus, Spring 2008 Mayor s Mental Health Task Force Monitoring Committee, Annual Report, 2006 Mayor s Mental Health Task Force Monitoring Committee, Behavioral Health Services System Mapping Report, 2006 Mayor s Mental Health Task Force Monitoring Committee, Mental Health/Criminal Justice Forum, Jan. 14, 2008 Travis County Health Care District, Report to the Community 2007 Mentally Ill People s Care Falling to Jail, Emergency Rooms in Austin, by Andrea Ball, Austin American-Statesman, Feb. 3, 2008, p. 1 Thank you to the many concerned public, private, and nonprofit officials and employees as well as concerned citizens who provided information to the LWVAA Mental Health Committee, and special thanks to: Austin Travis County Mental Health and Mental Retardation Center Seton Shoal Creek Hospital, Reenie Collins City of Austin, Council Member Lee Leffingwell Travis County Sheriff s Office, Sergeant Kitty Hicks, Crisis Intervention Travis County Probate Judge Guy Herman Travis County Healthcare District Patricia Young Brown, President & CEO Rose Lancaster, Board Member Mayor's Mental Health Task Force Monitoring Committee Chris Ziebell, MD, FACEP, Medical Director Emergency Services, University Medical Center at Brackenridge Marsha McCary, Ph.D Debbie Webb, Ph.D, Behavioral Health Services Division Director ATCMHMR Sherry Blyth, LCSW, Associate Director, Crisis Services Division Richard C. Neavel, PhD. LWVAA Mental Health Committee Judy Parken, Chair Shelly Baumgartner Susanna Bernat Rose Lancaster Nancy Neavel Phyllis Portnoy Susan Reid Susanne Slay-Westbrook Claudia Smith Betty Williamson Copyright League of Women Voters of the Austin Area February

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8 Mental Health Consensus Questions Would you support public funding to create, evaluate, or expand the following local mental health programs: A) First responder (law enforcement, mobile crisis, hospital staff) programs that include specially trained personnel. B) A crisis intervention and stabilization program, which would include a facility for in-patient care with appropriate staff. C) A mental health hotline and referral service to facilitate access to all levels of mental health services, regardless of ability to pay. D) A mental health outpatient program that would provide counseling and assertive case management i.e., assistance with housing, transportation, employment and other basic needs for recovering and chronic mental health patients. E) Long-term care for individuals requiring continued residential treatment. F) Staff training to implement programs based on current best practices. Please bring this with you to either the Day Unit Meeting at noon on Monday, March 10th at the Howson Library, 2500 Exposition Blvd. or the Evening Unit Meeting on Wednesday, March 12, 7:00 p.m., at the South Austin Senior Activity Center, 3911 Manchaca. If you are unable to attend either of the Consensus Unit Meetings, please fax this to the League office ( ) or mail it by March 13th to: LWVAA ATTN: Judy Parken 1011 W. 31st Street Austin TX Copyright League of Women Voters of the Austin Area February