e v a l u a t i o n r e p o r t august 2015 Texas Outpatient Competency Restoration Programs

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1 e v a l u a t i o r e p o r t august 2015 Texas Outpatiet Competecy Restoratio Programs

2 evaluatio report Texas Outpatiet Competecy Restoratio Programs C a t e Gr a z i a i M i c h e l e R. Gu z m á M i c h a e l Ma h o m e t a A l a Sh a f e r Prepared by: The Hogg Foudatio for Metal Health i collaboratio with the Departmet of State Health Services Recommeded Citatio: Hogg Foudatio for Metal Health (2015). Evaluatio Report: Texas Outpatiet Competecy Restoratio Programs. For additioal iformatio, please cotact: Lyda Frost, JD, PhD Director of Plaig ad Programs Hogg Foudatio for Metal Health lyda.frost@austi.utexas.edu (512) Ackowledgemets The Hogg Foudatio evaluatio team would like to thak the Departmet of State Health Services (DSHS) for its willigess to parter with the foudatio o learig from ad about the Outpatiet Competecy Restoratio (OCR) Program. We particularly wat to thak the DSHS OCR staff, especially the OCR program directors ad staff who took the time to fill out the surveys ad talk with us about their programs. We wat to ackowledge the time ad eergy take by Ms. Jeifer Swito ad Dr. Ala Shafer to provide us with iformatio ad data for the OCR programs. Dr. Courtey Heard, the curret OCR Program Director provided valuable feedback o the fial draft of the report. august 2015 Table of Cotets Executive Summary... 2 Itroductio... 3 Evaluatio Desig ad Methodology... 4 Backgroud... 4 Evaluatio Questios... 7 Process Evaluatio... 7 Program ad Participat Descriptios... 7 Methodology ad Aalysis... 7 Fidigs... 8 Outcome Evaluatio Participat Demographic Data Aalysis Program Outcomes at Pilot Projects Summary Recommedatio Refereces Our thaks to Dr. Michael Mahometa for providig his expertise i the area of statistical aalysis to this evaluatio project. We appreciate the time ad eergy of the Hogg Foudatio staff members who provided feedback o earlier drafts of this report ad who let their expertise to the project alog the way.

3 executive summary Competecy restoratio is the process by which defedats who have bee foud icompetet to stad trial (IST) are provided treatmet ad educatio so that they have a ratioal ad factual uderstadig of the legal proceedigs they will ecouter. Historically, competecy restoratio was provided i a ipatiet settig, but due to a shortage of psychiatric beds i Texas psychiatric facilities, the state bega to utilize outpatiet competecy restoratio i Texas operates twelve outpatiet competecy restoratio (OCR) programs, costitutig the largest iitiative of its kid i the coutry. Four pilot programs were created i , followed by seve ew programs i ad oe additioal program i These programs are located across the state ad served 1,061 idividuals as of the ed of FY The Hogg Foudatio for Metal Health has maitaied a strog iterest i idetifyig potetial beefits ad challeges of outpatiet competecy restoratio. While the state collected substatial data o the existig pilot programs ad has some positive prelimiary fidigs, further aalysis of this data was eeded. Therefore, i collaboratio with the Departmet of State Health Services (DSHS), the foudatio coducted a evaluatio of eleve of the twelve OCR sites. The evaluatio focused o the program desig ad implemetatio process for the eleve OCR sites i operatio durig the time of the assessmet, ad outcomes for the four pilot sites. More specifically, the goals of the evaluatio were to: Report o demographics of defedats participatig i each of the pilot projects; ad Make coectios, to the extet possible, betwee patiet characteristics, program activities, ad outcomes. The outcome evaluatio examied a sample of 644 participats who completed OCR services betwee Jue 2008 ad Jue Quatitative aalysis showed that prior hospitalizatios were a sigificat idicator i a defedat s likelihood to have a successful outcome, defied as beig restored to competecy or havig charges dismissed. Greater legth of stay i the OCR program cotributed to a higher likelihood of a successful outcome up to 21 weeks, but loger legths of stay were ot associated with beig restored to competecy. Resposes from 28 surveys collected from eleve programs, six site visits, ad umerous iterviews revealed that each program is uique, yet most implemet a similar model. Qualitative data revealed that program staff relatioships with their local courthouse had a large impact o their ability to serve cliets, with ewer programs havig somewhat more difficulty i developig those relatioships. I additio, commuity factors such as the availability of housig ad substace use programs, as well as a jail diversio program, played importat roles i the challeges ad successes OCR programs face. Coduct a process evaluatio usig qualitative iterviews of staff at the eleve sites, as well as with judges ad district attoreys, to clarify program desig ad idetify best practices ad implemetatio problems. Examie the program outcomes at the four pilot OCR projects i Travis, Bexar, Dallas, ad Tarrat couties. 1 The ewest program, Heart of Texas Regio MHMR Ceter, was ot icluded i this evaluatio. 2 Hogg foudatio for metal health a u g u s t

4 Itroductio I the crimial justice system, defedats are foud IST whe they are so fuctioally impaired as to lack the ability to cosult with their attorey or have a ratioal ad factual uderstadig of the legal proceedigs facig them. I this situatio, due process requires suspedig the legal process util a court fids the defedat competet to stad trial. Restoratio to competecy is the process used to provide treatmet aimed at improvig the defedat s fuctioal abilities to the legally-required level. Ipatiet competecy restoratio ca be costly. The average daily cost for ipatiet restoratio was $421 i Fiscal Year (FY) 2012 (Legislative Budget Board (LBB), 2013). Furthermore, whe a state hospital bed becomes available, it may be i a facility may hours away from the defedat s commuity. Safely trasportig the defedat to the facility ca require sigificat law eforcemet resources. Over the past several years, states have begu to fud alterative competecy restoratio programs, allowig both commuity-based, or outpatiet, competecy restoratio (OCR) ad jail-based competecy restoratio. I 2003, the Texas Legislature added articles to the Code of Crimial Procedure to allow outpatiet competecy restoratio (Texas Code of Crimial Procedure, 2015). While Texas was ot the first state to develop outpatiet competecy restoratio programs, the size of its programs is sigificat atioally. The Hogg Foudatio for Metal Health has maitaied a strog iterest i idetifyig potetial beefits ad challeges of outpatiet competecy restoratio. While the state collected substatial data o the existig pilot programs ad has some positive prelimiary fidigs, further aalysis of this data was eeded. Therefore, i 2012, i collaboratio with DSHS, the foudatio coducted a evaluatio of eleve outpatiet competecy restoratio sites. specifically, the goals of the evaluatio were to: Coduct a process evaluatio usig qualitative iterviews of staff at eleve curret sites, judges, ad district attoreys to clarify program desig ad idetify best practices ad implemetatio problems Examie the program outcomes at the four iitial pilot outpatiet competecy restoratio projects i Travis, Bexar, Dallas, ad Tarrat couties Report o demographics of defedats participatig i each of the pilot projects To the extet possible, make coectios betwee patiet characteristics, program activities, ad outcomes Coduct a basic cost compariso of ipatiet versus outpatiet OCR While this last item was origially a goal of the evaluatio, it was leared fairly early o i the project that the LBB was coductig a cost aalysis of OCR alog with other ipatiet competecy restoratio alteratives for their 2013 Texas State Govermet Effectiveess ad Efficiecy Report (GEER; LBB, 2013). Therefore, the reader is referred to the LBB report for cost aalysis iformatio. Coductig a more sophisticated cost aalysis was beyod the scope of this project, but it is ackowledged that a i-depth cost aalysis that compares the costs associated with both ipatiet ad outpatiet competecy restoratio services would be beeficial. The project focused o the program desig ad implemetatio process for the eleve outpatiet competecy restoratio sites i operatio durig the time of the evaluatio ad outcomes for the four pilot sites. More 3 Hogg foudatio for metal health a u g u s t

5 Evaluatio Desig ad Methodology Istitutioal Review Board Approval The Hogg Foudatio for Metal Health received Istitutioal Review Board (IRB) approval from DSHS to access ad aalyze the quatitative data utilized i the outcome evaluatio. Cliet-level outcomes from the four DSHS pilot sites were aalyzed. A IRB applicatio was submitted to the Uiversity of Texas at Austi s IRB for the process evaluatio portio of the project which cosisted of site visits ad iterviews with the four pilot programs as well as two ew programs, survey data collected from eleve sites, ad meetigs ad phoe calls with OCR program staff ad the DSHS OCR program director. The protocol was reviewed by the Office of Research Support, which determied it did ot meet the requiremets for huma subjects research. Therefore, IRB review ad oversight were ot required for the process portio of the evaluatio. Participats ad Procedures Qualitative data for the process evaluatio was collected through a survey, site visits, iterviews, ad meetigs. All sites participated i the survey, with a total of 28 completed surveys. I additio, site visits ad iterviews were completed at each of the four pilot sites ad a sample of two programs established i May of the ew sites that bega i 2012 were ot servig cliets at the time of data collectio; therefore, oly two were visited by the evaluatio team. A pre-determied set of questios were used at each visit; however, each site is distict. Site visits icluded meetig with multiple program staff, local judges, prosecutors, ad/or jail staff. The outcome evaluatio was coducted utilizig data from the four OCR pilot programs i Austi, Sa Atoio, Dallas, ad Fort Worth. The data set cosisted of 644 participats who completed outpatiet competecy restoratio services betwee Jue 2008 ad Jue 2012 at oe of the four sites. The participat records for this study were created by matchig data extracted from the state metal health database ad data submitted to the state by the four local metal health authorities (LMHAs or ceters) coductig outpatiet competecy restoratio. Outpatiet competecy restoratio service records were obtaied directly from the ceters. These records were the matched with state quarterly metal health assessmets, diagoses, mothly service records, ad hospitalizatios to create each cliet s research data record which cosisted of a iitial assessmet, demographic ad diagostic iformatio, prior hospitalizatios, service iformatio about outpatiet competecy restoratio, ad fial assessmet. However, because these data are collected for admiistrative rather tha research purposes, ot all cliets had complete data. backgroud I Texas, the restoratio process typically occurs i stateru psychiatric hospitals fuded primarily with geeral reveue. Curretly, Texas operates te adult psychiatric hospitals ad most receive both civil ad foresic commitmets. I FY 2012, 16,796 adults ad childre were served by oe of these hospitals, with 14 percet of those idividuals o foresic commitmets (LBB, 2013). A perso who is foresically committed usually has a loger legth of stay tha someoe who is civilly committed. I FY 2012, the average legth of stay for a perso who was civilly committed was 36 days compared to 120 days for a perso foud IST ad 227 days for a perso foud ot guilty by reaso of isaity (LBB, 2013). For this reaso, approximately 37 percet of all state hospital beds are allocated for foresic commitmets (LBB, 2013). Texas has a shortage of state psychiatric hospital beds for both civil ad foresic patiets, due i part to a uderutilizatio of alteratives to ipatiet commitmets. To protect their right to a speedy trial, defedats waitig for competecy restoratio may take priority over people civilly committed by a court or volutarily seekig 4 Hogg foudatio for metal health a u g u s t

6 backgroud services. Noetheless, may defedats were beig detaied i jail for weeks or moths util a ipatiet bed became available. I 2007, a lawsuit was filed agaist DSHS o the grouds that IST defedats right to due process was beig violated if they spet a udue amout of time i jail without treatmet. A iitial rulig established 21 days as the maximum waitig period for defedats foud icompetet to stad trial to be admitted to a state hospital (Taylor Shearer v. Lakey, 2012). I May 2014, the rulig was overtured by the Texas Court of Appeals (Lakey v. Taylor Shearer, 2014). The umbers of foresic commitmets to state hospitals more tha doubled from 2001 to 2012 (399 to 940) (Health Maagemet Associates, 2011; LBB, 2013). At the same time, idividuals o the clearighouse waitig list also icreased. The clearighouse waitig list, comprised of idividuals foud IST but ot waitig for a maximum security uit, reached its peak i July 2010 at 334 idividuals, up from 56 i July 2008 (DSHS, 2013). I Jauary 2013, that umber was dow to 67. I 2012, the average time defedats spet o the clearighouse waitig list was 41 days (LBB, 2013). Prior to 2004, all defedats foud IST i Texas were committed to a ipatiet competecy restoratio program i a state hospital. I 2003, the Texas Code of Crimial Procedure (TCCP) (2015) was chaged to allow OCR. Uder the ew law, idividuals charged with a misdemeaor who are foud IST are required to be released o bail. The court is further required to sed IST idividuals released o bail to a outpatiet program if oe is available, as log as certai criteria are met, icludig that they are ot deemed a dager to others. 2 Idividuals with feloy charges may also be set to a outpatiet program, but the court is ot required to do so (Hohegarte, 2008; TCCP, 46B). I 2007, the Texas Legislature (80th Regular Sessio) eacted Seate Bill 867 to clarify the law ad promote a outpatiet optio for defedats who are i eed of competecy restoratio ad are ot a dager to others. I 2008, i respose to SB 867, DSHS lauched four pilot OCR programs i Travis, Bexar, Dallas, ad Tarrat couties. These four programs were iitially selected due to the variatio i their approaches. Each program primarily serves a sigle urba couty. I 2011, House Bill 1 (Rider 78; 82d Legislative Sessio) directed DSHS to develop five additioal OCR programs. However, the budget allocatio allowed for seve ew sites to be fuded the followig year. Adrews Ceter Behavioral Healthcare System, Commuity Healthcore, Emergece Health Network, Tri-Couty Services, Starcare Specialty Health System, Behavioral Health Ceter of Nueces Couty, ad Spidletop Ceter all received DSHS fudig for a OCR program i The ew sites relied heavily o guidace from the four origial pilots i developig their programs. Through coferece calls ad site visits, DSHS facilitated commuicatios across all programs, assistig ew sites i creatig programs that built o what was already beig doe across the state. However, due to a variety of factors, each OCR program remais distict. Table 1 presets iformatio o each of the eleve OCR programs. At the ed of FY 2013, OCR programs i Texas served a total of 1,061 idividuals. Although programs share best practices ad utilize similar compoets, each varies i its implemetatio. Differeces lie primarily i the programs ad services that itersect with OCR. For istace, the existece of jail diversio programs for idividuals experiecig metal health issues, the availability of affordable housig or supported livig, ad substace use treatmet programs ca alter the eviromet i which OCR is offered. I additio, each agecy admiisterig the program is uique, with differet structures ad scope of services. Fially, the relatioships OCR programs establish with their local courthouse ad the attitudes of judges ad prosecutors ca alter the way the OCR program fuctios. No evidece-based OCR program model exists to date, ad o oe model is used throughout the state but, rather, each tailors its program to the local cotext. 2 If a idividual is deemed IST ad there is ot a OCR program i the immediate area, the idividual may be admitted to a eighborig OCR program with judicial staff (e.g., judge, defese attorey, ad prosecutig attorey) approval. 5 Hogg foudatio for metal health a u g u s t

7 Table 1: Twelve Texas OCR Programs Agecy Name City / Couty Date of DSHS Fudig programmatic factors Austi Travis Couty Itegral Care Austi / Travis 2008 Residetial program for OCR cliets at the LMHA Crisis Respite facility with a strog partership with the Metal Health Public Defeder s Office. Ceter for Health Care Services Sa Atoio /Bexar 2008 Oe magistrate judge hadles all OCR program commitmets. Strog jail diversio program i the couty. MHMR Tarrat Couty Forth Worth / Tarrat 2008 A Couty Court at Law judge is primarily resposible for the bulk of commitmets to the OCR program. NorthSTAR / ValueOptios Dallas / Dallas, Rockwall, Ellis, Navarro, Colli, Hut, Kaufma 2008 Core OCR staff perso is a employee of Dallas Couty ad housed at the courthouse. Has access to the couty s electroic imate trackig system allowig earlier idetificatio of potetial cliets eligible for OCR. Starcare Specialty Health System 3 Lubbock/Cochra, Crosby, Hockley, Lubbock, Ly 2012 Provides metal health services i the jail: medicatio maagemet, court-ordered medicatio, ad jail-based competecy restoratio services (services ot provided via DSHS fudig). 4 Emergece Health Network 5 El Paso/El Paso 2012 Strog collaboratio betwee El Paso Psychiatric Ceter, the LMHA, the courts, ad probatio. Sigificat iput from probatio departmet is a uique program trait. Adrews Ceter Behavioral Healthcare System Tyler/Hederso, Rais, Smith, Va Zadt, Wood 2012 Bega offerig OCR before receivig fudig; peer compoet; law eforcemet works part-time for the program ad assists i completig site visits. Partership with local uiversity psychology departmet. Tri-Couty Services Liberty, Motgomery, Walker 2012 Strog partership with district court judge. Ceter has a array of foresic services offered. Behavioral Health Ceter of Nueces Couty 6 Corpus Christi/Nueces 2012 Strog parterships with couty ad district court judges, local bar associatio, district clerk. Residetial program with three cotracted beds at the LMHA crisis respite facility. Spidletop Ceter Chambers, Hardi, Jefferso, Orage 2012 Residetial program cotract with Wood Group Crisis Respite facility. Strog partership with probatio, as well as state metal health facilities. Commuity Healthcore Taylor/Bowie, Cass, Gregg, Harriso, Mario, Paola, Red River, Rusk, Upshur 2012 OCR staff have multiple roles at ceter such as cotiuity of care liaisos ad crisis respodets. Heart of Texas Regio MHMR Ceter 7 Bosque, Hill, McLea, Falls, Limestoe, Freestoe 2013 Oe fuded OCR positio, which is part of their Foresic Assertive Commuity Treatmet (FACT) team. Ceter has a array of foresic services offered. 3 Previously called Lubbock Regioal MHMR Ceter. 4 Starcare Specialty Health System is o loger providig jail-based competecy restoratio services. 5 Previously called El Paso MHMR. 6 Previously called MHMR Ceter of Nueces Couty. 7 This program was established after the evaluatio was coducted ad is ot icluded i this report. 6 Hogg foudatio for metal health a u g u s t

8 Evaluatio questios The evaluatio was divided ito two parts, a examiatio of the process of implemetig the OCR programs, ad a assessmet of outcomes thus far at the four pilot sites. The evaluatio questios for the process evaluatio icluded: What are the demographic characteristics of patiets i OCR? What cosideratios are take ito accout whe OCR staff deem someoe restored? Which treatmet ad educatio itervetios are beig utilized i the OCR programs at each site? What have bee some of the challeges to implemetig the programs? Which elemets have led to successful implemetatio of the programs? How do programs decide who is a good fit for the OCR programs? What appears to ifluece judges decisios about sedig a defedat to OCR (vs. ipatiet competecy restoratio)? The outcome evaluatio questios icluded: What are the characteristics of the idividuals who have participated i the pilot OCR programs i Texas? Which cliet characteristics, if ay, are associated with positive outcomes? Which pilot sites appear to be achievig the best outcomes? What legth of stay is associated with the best outcomes? Process Evaluatio of Eleve OCR Programs Program ad Participat Descriptios Through site visits, coferece calls, ad survey data, qualitative data was collected over the course of FY Evaluators were able to gather details about each OCR program across the state i existece at that time. I order to fully uderstad the differeces across sites, every OCR program was surveyed. However, high variatio ad a small umber of programs ad survey respodets makes it difficult to geeralize across programs. There were ie resposes from the pilot sites, ad 18 resposes from the sites added betwee 2011 ad 2012, from this poit o referred to as secod phase or phase two sites. This report serves to summarize fidigs, while attemptig to capture uique site differeces. Methodology ad Aalysis Site Visits Each of the pilot programs were visited i 2012 to gather more qualitative data, to iform the survey developmet, ad gai a i-depth uderstadig ito program operatios. Because the phase two programs had oly recetly bee established ad few were servig cliets, oly two of these sites were visited. Survey Developmet Themes that emerged from the six site visits served to iform developmet of the survey that was later distributed electroically to all of the programs. The survey was desiged to elicit iformatio about the opportuities ad challeges beig faced by the programs i developig ad implemetig OCR programs, ad other iput that may iform future OCR efforts at the state level. Each program participated i the survey, with betwee oe ad three respodets participatig from each site, resultig i 27 total respodets. Qualitative Data Aalysis Due to the complexity of each program site, qualitative data was aalyzed usig grouded theory ad case-orieted empirical sythesis (Jase, 2010). I this method, evaluators used prelimiary data (i.e. meetigs, site visits) to guide further data 7 Hogg foudatio for metal health a u g u s t

9 Process Evaluatio of Eleve OCR Programs collectio (i.e. survey) ad evaluatio questios. Relevat themes were idetified based o iitial qualitative data, selectig categories ad topics that were reiterated. I additio, categories that arose i the qualitative data that were ot pre-idetified were oted. Fially, all categories ad themes were aalyzed based o all qualitative data collected. The arrative portios of the followig sectio cotai iformatio from the data collectio efforts as a whole, while the figures specifically represet survey resposes. Fidigs OCR program developmet Although each OCR program is uique, competecy restoratio programs geerally cosist of three mai compoets: medicatio, competecy educatio, ad case maagemet. Survey resposes idicated that the four origial pilot sites had distict program developmet experieces compared to the secod phase programs. Oe pilot program director shared that the first four sites may have bee selected as pilots because they were so differet, with the hope that a program model might emerge from oe site. However, due to differeces i the commuities they serve, each program has remaied distict ad phase two sites were give autoomy i developig their program. Some program directors ad staff had the opportuity to visit a established OCR program i Florida, which utilizes a curriculum developed at Florida State Hospital. This model has bee distributed ad utilized by may Texas programs. However, oe program director explaied that policy differeces regardig Medicaid housig reimbursemets made Texas uique ad limited the applicability of Florida s model. That said, 56 percet of sites idicated that they used the Florida State curriculum i developig their program [Figure 1]. The Florida State model divides competecy restoratio ito two mai categories: a factual uderstadig of the law ad legal proceedigs, ad ratioal uderstadig ad decisio makig. Respodets who selected other idicated that advice from existig programs, the statewide i-perso OCR meetig, cosultatios from foresic psychologists ad restorative justice experts, meetigs with local judges ad prosecutors, ad iteret searches o best practices were some of the most helpful factors i desigig their program. Figure 1: Most Helpful Factors i OCR Program Developmet Cosultig with staff from DSHS Usig the Florida State curriculum as a model Participatig i OCR coferece calls Program staff s origial ideas about program desig Other Visitig other restoratio sites/facilities 0% 20% 40% 60% 80% 100% 8 Hogg foudatio for metal health a u g u s t

10 Process Evaluatio of Eleve OCR Programs Establishig commuity parters ad itegratig programs ito the crimial justice system were reported as key compoets of program developmet. Iterviews coducted durig site visits revealed that OCR programs are established at the LMHA ad buildig relatioships with law eforcemet, the local courthouse, ad other parter systems ca take time. Relatioship buildig will be addressed further below. Although iitially the four pilot sites did ot share program developmet strategies, oce the phase two programs were authorized, all OCR programs bega to share iformatio more regularly. Commuicatio with other OCR program staff, either through idividual cosultatio or by participatig i coferece calls with all OCR programs, was cited as helpful i developig a program. Assessig idividuals fit for OCR Although there are legal, political, ad programmatic factors that ifluece placemets, the law states that defedats must be placed i the least restrictive eviromet (TCCP, 46B, 2014), which for some may be a OCR program. Competecy evaluators, judges, prosecutors, ad commuity metal health providers, may all have a opiio about what is appropriate for the defedat. However, as programs build relatioships with their local courthouse, program staff s opiio may also play a importat role i erollig defedats ito a OCR program. Therefore, oe goal of the evaluatio was to uderstad which factors ad tools OCR program staff cosider i decidig if a defedat is a good fit for OCR. Survey resposes are reported i Figure 2. Almost all respodets (96%) idicated that they used the crimial history of a defedat to decide if a potetial cliet is a good fit for OCR. I additio, respodets reported that they used cliical judgmet (78%); violece risk assessmets (both the HCR-20 8 [59%] ad the TTV 9 [19%]); ad prior hospitalizatios (67%) to help make 8 Douglas, K.S., Hart, S. D., Webster, C. D., & Belfrage, H. (2013). Historical Cliical Risk Maagemet-20, Versio 3 [Measuremet istrumet]. Metal Health, Law, ad Policy Istitute at Simo Frasier Uiversity. Distributed by ProActive ReSolutios. 9 Chesto, J., Mills, J. F., Kroer, D. J. (2014). Two-Tiered Violece Risk Estimates [Measuremet istrumet] Retrieved from et/publicatio/ _the_two_tiered_violece_risk_estimates_prelimiary_validity_of_a_dyamic_actuarial_approach_to_ Measurig_ad_Maagig_Violece_Risk Figure 2: Tools ad Iformatio Used to Decide if a Idividual is a Good Fit for OCR Crimial history Cliical judgmet Violece Risk Assessmet Prior hospitalizatios Other Fitess Assessmet Recidivism Risk Assessmet 0% 20% 40% 60% 80% 100% 9 Hogg foudatio for metal health a u g u s t

11 Process Evaluatio of Eleve OCR Programs Figure 3: Tools ad Iformatio Used to Decide Whe a Cliet has bee Restored A assessmet of the cliet s legal kowledge Cliical judgmet Other Ay of the followig Assessmet Tools: LSI-R (Recidivism Risk Assessmet), HCR-20 (Violece Risk Assessmet), TTV (Violece Risk Assessmet), FIT-R (Fitess Assessmet) 0% 20% 40% 60% 80% 100% that decisio. Respodets idicated that cliical judgmet icluded assessmet of history of violece, substace use, level of support, developmetal disabilities, metal health diagosis, ad likelihood to abscod. Respodets that selected other idicated that the defedat s charges, a screeig iterview, willigess to participate i the program, willigess to take medicatios, the competecy evaluatio, medical history, housig, ad family support were cosidered i decidig if a idividual is a good fit for the program. Although the pilot sites ad the secod phase sites reported usig similar idicators i assessig whether or ot a perso is a good fit for OCR, there was oe differece regardig prior hospitalizatios. Oly 56 percet of respodets from the phase two sites said they used prior hospitalizatios to decide if a cliet is a good fit as compared to 89 percet of respodets from the pilot sites. Assessig Idividuals Restoratio to Competecy Oce a defedat has bee erolled i the program, the competecy restoratio process may progress differetly for each perso. I some cases, oce a idividual is takig medicatios ad receivig legal educatio, restoratio to competecy occurs fairly rapidly. Others require more time ad a higher level of services ad care. Figure 3 shows what iformatio OCR program staff use to decide whe a perso is restored to competecy. Not surprisigly, most survey respodets (85%) idicated that the cliet s legal kowledge was used to decide whe someoe has bee restored. Similarly to how program staff make decisios about a defedat s fit for OCR, 59 percet of program staff surveyed idicated that they used their cliical judgmet to decide whe a cliet has bee restored. Respodets who selected other idicated that re-evaluatio by a foresic psychiatrist is aother tool to assess restoratio. That perso may or may ot be the idividual who coducted the iitial competecy evaluatio. The evaluatio also explored which cliet factors were perceived by OCR staff as havig a impact o a cliet s likelihood to be restored. Accordig to OCR program staff, the severity of a perso s metal health coditio was the most importat factor (89%), but their history of treatmet compliace (70%), support etwork (56%), ad substace use (41%) were also cosidered importat, as show i Figure 4. It is importat to keep i mid that these are perceived factors. Actual cliet-level factors related to the probability of restorig competecy were explored i the quatitative aalysis. 10 Hogg foudatio for metal health a u g u s t

12 Process Evaluatio of Eleve OCR Programs Figure 4: Factors Perceived to be Related to a Cliet s Ability to Restore Severity of metal health coditio History of treatmet compliace Support etwork Substace use Additioal commuity resources Crimial history High quality, affordable housig optios Number of hospitalizatios Severity of charge Other 0% 20% 40% 60% 80% 100% Factors Impactig the Success of OCR Programs Relatioships i the Courtroom OCR staff reported that as they built programs, relatioships with local judges were critical. At times, especially for secod phase sites, qualitative data revealed that establishig good relatioships with local judges ad prosecutors offices proved challegig. I fact, 44 percet of respodets from phase two sites highlighted the judges office as a major barrier to program success, while oe of the pilot sites selected this as a barrier. Site visits revealed that urba ceters where the pilot sites were created, Dallas, Fort Worth, Austi, ad Sa Atoio, already had some, if ot substatial, buy-i from judges whe the OCR programs came ito existece. Secod phase sites, o the other had, are geerally located i more rural areas, sometimes servig multiple couties. Iformatio from site visits ad meetigs with DSHS staff revealed that may of the phase two sites legal parters were iitially ufamiliar with, ad sometimes skeptical of, their local OCR programs. Oe survey respodet wrote, Judges ad DAs ofte have kee jerk reactios whe they hear the term outpatiet. Respodets from secod phase sites also highlighted judges cocers about the possibility of re-offese o the part of the defedat, ucertaity about the security of OCR sites, ad political motivatio. Whe asked about further traiig that would be helpful, more survey respodets from phase two sites requested support ad guidace i brigig judges o board. The importace of strog parters i the courtroom is echoed i survey resposes from the pilot sites. Sixtyseve percet of these sites reported that oe of the three most importat factors that impacted the success of their program was fidig a champio judge. As show i Figure 5, all sites seem to agree that a champio judge is a critical elemet to the success of a OCR program. Because these relatioships emerged as a factor that appeared critical to the success of OCR programs, the 11 Hogg foudatio for metal health a u g u s t

13 Process Evaluatio of Eleve OCR Programs Figure 5: Most Importat Factors Impactig Success of Overall Program Idetifyig ad/or fosterig champio judge(s) Gettig the support of the district attorey (DA) Buildig good relatioships with law eforcemet/jail Developig a good reputatio for restorig cliets Establishig a metal health docket/court Icreasig commuity awareess aroud OCR Other 0% 20% 40% 60% 80% 100% evaluatio team aimed to lear how effective relatioships were formed. For programs that felt they had a positive relatioship with their local judge, sittig i their courtroom was reported as the most effective strategy (71%) followed by meetig with the judge idividually (58%), usig cost-beefit argumets (50%), ad sedig judges materials about OCR (46%) [Figure 6]. Respodets who selected other idicated that Figure 6: Most Effective Methods of Establishig a Good Relatioship with Local Judges Sittig i judge s court room Settig up idividual meetigs Usig cost- beefit argumets Sedig judge materials about OCR Attedig commuity meetigs Workig with someoe i the DA s office to advocate for Other Coectig to a judge i aother area who is a OCR Parterig with a advocacy group 0% 20% 40% 60% 80% 100% 12 Hogg foudatio for metal health a u g u s t

14 Process Evaluatio of Eleve OCR Programs Figure 7: Factors that Ifluece a Judge s Decisios about Sedig Defedats to OCR Severity of charges Recommedatio of competecy evaluator Relatioship with OCR program Number of past arrests/crimial history Political reasos Recommedatio of someoe else Other 0% 20% 40% 60% 80% 100% group discussios with judges ad the sheriff s departmet, as well as buildig relatioships with judges staff ad public defeders, were also effective. Respodets also idicated that a umber of factors ifluece a judge s decisio about sedig a defedat to OCR. The most importat idicator, accordig to survey resposes, was the severity of charges (85%), followed by the recommedatio of the competecy evaluator (67%), the judges relatioship with the OCR program (63%) ad the defedat s crimial history (52%). See Figure 7 below. Respodets who selected other idicated that cocers about re-offese ad treatmet compliace were additioal factors. The political climate of a couty also affects the OCR program. Fiftee percet of survey respodets idicated that political reasos were a factor ifluecig judges decisios about whether to sed someoe to a OCR program (=4) [Figure 7]. Whe asked to specify, resposes icluded cost aversio, electio year pressure, ad headlie phobia. Based o the fact that OCR is less expesive tha ipatiet competecy restoratio (GEER, 2013), this first factor may be based o misiformatio. Housig Oce defedats are erolled i a OCR program, certai factors may pose a challege. For istace, may cliets erolled i a OCR program do ot have stable housig. Quatitative data from the four pilot sites idicated that 28 percet of OCR participats were experiecig homelessess. Across all sites, 59 percet of survey respodets idicated housig was a challege for their program ad it was the oly challege that a majority of respodets idetified. However, whe the survey resposes from the pilot sites ad secod phase sites were compared, the housig challeges appeared to be more of a issue for the origial sites. Oly 39 percet of respodets from phase two programs listed housig as a challege compared to100 percet of respodets from the pilot sites. See Figure 8, ext page. 13 Hogg foudatio for metal health a u g u s t

15 Process Evaluatio of Eleve OCR Programs The differece betwee resposes from the pilot sites ad the secod phase programs may be partially explaied by the fact that at the time the data as collected, most ew sites had served very few cliets ad may ot yet have experieced challeges with housig. Housig also varies widely by locatio ad some commuities may have housig optios that others do ot. For istace, site visits revealed that there are some rural couties that do ot have ay group homes, a housig optio ofte used by OCR programs whe available, while three OCR programs have a residetial compoet ad ca offer o-site housig to cliets. Although the availability of housig optios is ofte outside the cotrol of OCR programs ad may be limited i some areas, DSHS reports that programs have always bee ecouraged to utilize their fuds to pay for housig costs for OCR program participats. 10 However, eve if housig optios are available, crimial backgroud checks create a serious barrier for OCR program participats. I thikig about importat factors that affect housig, 78 percet of survey respodets idicated that the stability of the housig optios is oe of the most importat factors to cosider. Survey respodets idicated that other challeges iclude the defese cousel watig their cliets to receive time served (accomplished by goig to jail or a ipatiet settig), a lock-em-up metality, bias toward ipatiet treatmet, lack of family support, cliets ot receivig a competecy evaluatio, willigess ad desire to participate, ad absece of a metal health court. Substace use Aother challege OCR programs reported is servig defedats with co-occurrig substace use disorders. Forty-oe percet of survey respodets reported that substace use was oe of the most importat factors i a cliet s ability to regai competecy. For some programs, this meas that substace use ad the defedat s willigess to receive treatmet help determie whether that perso is a good cadidate for OCR. Survey resposes revealed that substace use assessmets are used as part of staff s cliical judgmet i determiig if they are a good fit for the program. Additioally, although OCR programs have the ability to 10 C. Heard, persoal commuicatio, July 20, Figure 8: Biggest Challeges to Implemetatio Lack of housig optios for cliets Other Lack of substace use disorder treatmet available to cliets Judge s office perspective o OCR Defese attoreys perspective o OCR 21 day maximum jail time is ot eough time to set up services Servig multiple couties ew site pilot site all sites Servig cliets with feloy charges DA s office perspective o OCR 0% 20% 40% 60% 80% 100% Note: Missig bars idicate o survey respodets selected that optio as oe of the top three challeges. 14 Hogg foudatio for metal health a u g u s t

16 Process Evaluatio of Eleve OCR Programs pay for substace use treatmet, 30 percet of survey respodets idicated that the lack of available substace use treatmet programs was oe of the three biggest challeges they faced i implemetig the OCR program. Perhaps because of this, oe survey commet proposed that locked substace use treatmet facilities would make a world of a differece. Feloy charges The severity of a defedat s charges plays a sigificat role i the competecy restoratio process. Eighty-five percet of survey respodets idicated that severity of charges is oe of the most importat factors that a judge cosiders i decidig whether to sed a defedat to OCR. Survey resposes idicated that may judges are cocered about safety ad risk; judges may be hesitat to be resposible for allowig a idividual with a feloy charge ito the commuity. Furthermore, accordig to oe judge, because prosecutors are ofte uwillig to drop a feloy charge, the judge has little choice but to cotiually exted the OCR commitmet if a defedat is urestorable. Coversely, if the charges are dropped, the court o loger has legal authority to force treatmet compliace. Iterview iformatio gathered durig site visits idicated that cliets with feloy charges ca be a complex ad challegig populatio to serve. Although may misdemeaor charges are dropped oce a cliet is complyig with OCR program requiremets, prosecutors are ulikely to dismiss a feloy charge. For cliets with more complex issues, such as Alzheimer s disease, traumatic brai ijury (TBI), or developmetal delays, feloy charges preset a uique challege. These cliets are ulikely to be restored ad are also ulikely to have their charges dropped, leavig them i a limbo of sorts. Some program ad DSHS staff have cocluded that these idividuals are ot a good fit for OCR. At the same time, some OCR programs have served cliets with feloy charges successfully. Therefore, for defedats with more severe charges, it becomes especially importat to idetify their metal health eeds up frot to determie if they are a good fit for OCR. Each OCR program may face uique challeges i servig idividuals with feloy charges due to the wide variatio i local cotext. For istace, jail diversio programs have a sigificat impact o people experiecig metal health problems who are brought to jail ad charged with a crime. I some couties where there is a strog jail diversio program, OCR program staff share that far fewer idividuals with metal illess are charged with misdemeaors. While this is the iteded outcome, it also meas that those couties OCR programs may serve more idividuals with feloy charges. For istace, i oe couty with a strog jail diversio program, 52 percet of the OCR cliets have feloy charges, the largest amog all OCR programs. Legal Factors Affectig OCR Programs Whe asked to describe what chages to Chapter 46B of the TCCP survey respodets felt would facilitate OCR participatio, resposes maily cetered aroud two themes: beig give time credit for OCR ad OCR beig a stroger first optio. Resposes are preseted here regardless of their legal correctess. Time Credit Oe theme that emerged from the survey commets was the desire to have time spet i OCR cout as time served o the cliet s charges, should he or she be foud guilty ad seteced to cofiemet. As the law curretly reads, the court oly credits cofiemet i a metal health facility, residetial care facility, or jail (Article 46B.009). Oe respodet commeted that, The attoreys like their cliets to go to a hospital so the cliet ca get time served o their charges. Oe respodet suggested this laguage, A court setecig a perso covicted of a crimial offese shall credit to the term of the perso s setece the time the perso is cofied i a metal health facility, ordered to a outpatiet competecy restoratio program, residetial care facility, or jail.... While two of the OCR sites are residetial programs, they are ot locked facilities, ad cliets participatig i those OCR programs do ot receive credit for time served. OCR as First Optio. Commets from the survey respodets stress that OCR should be the first optio ad hospitalizatio the last. Oe participat commeted that all idividuals who have bee charged with a low 15 Hogg foudatio for metal health a u g u s t

17 Process Evaluatio of Eleve OCR Programs level misdemeaor should be ruled out of OCR, first, before a ipatiet optio is cosidered. This respodet suggested that if judges, prosecutors, ad attoreys had to say why a outpatiet treatmet program would ot work, the the umber of defedats beig referred to OCR versus ipatiet would icrease. Oe survey participat expressed that the court should have to sed a IST defedat to OCR if the LMHA ad the foresic psychiatrist agree that outpatiet restoratio best meets the patiet eeds. Other respodets stated: Amed 46B to read that OCR should be the default judgmet for a IST ad ipatiet hospitalizatio should be used oly whe OCR is ot available ad/or is ot suitable for the defedat. I also recommed that TCCP Article 46B.071 be revised to read: O a determiatio that a defedat is IST, the court shall: (1) commit the defedat to a facility uder Article 46B.073; or (2) release the defedat o bail uder Article 46B.072; ad shall (3) order the defedat released o bail to participate i a outpatiet competecy treatmet program, rather tha ipatiet treatmet, if a outpatiet competecy restoratio program is available to the defedat ad is appropriate for the defedat as defied i Art. 46B Hogg foudatio for metal health a u g u s t

18 Outcome Evaluatio of Four Pilot OCR Programs Participat Demographics The quatitative research sample cosisted of 644 participats who completed outpatiet competecy restoratio services betwee Jue 2008 ad Jue The typical participat was a 38 (SD = 13) year old Black (46%) or White (32%) sigle (87%) male (72%) diagosed with schizophreia (63%) or bipolar disorder (21%) ad whose crimial charge was ot a feloy (60%). A substatial umber of participats were homeless (28%). Detailed descriptive statistics for the sample are displayed i Table 2. Statistics i the table are based o the fial subject cout of 589 that resulted from data cleaig (described later i this sectio). Table 2: Participat Demographics austi bexar dallas tarrat total Overall 120 (20.4%) 94 (15.9%) 237 (40.2%) 138 (23.4%) 589 Restored (Depedet Variable) Yes 97 (80.8%) 88 (93.6%) 169 (71.3%) 86 (62.3%) 440 (74.7%) No 23 (19.2%) 6 (6.4%) 68 (28.7%) 52 (37.7%) 149 (25.3%) Ethicity Other 6 (5%) 0 (0%) 12 (5.1%) 4 (2.9%) 22 (3.7%) Black 39 (32.5%) 26 (27.7%) 159 (67.1%) 48 (34.8%) 272 (46.2%) Hispaic 16 (13.3%) 51 (54.3%) 18 (7.6%) 10 (7.2%) 95 (16.1%) White 59 (49.2%) 17 (18.1%) 48 (20.2%) 76 (55.1%) 200 (33.9%) Married Married 4 (3.3%) 10 (10.6%) 6 (2.5%) 5 (3.6%) 25 (4.2%) Not Married 116 (96.7%) 84 (89.4%) 231 (97.5%) 133 (96.4%) 564 (95.8%) Feloy Yes 53 (44.2%) 49 (52.1%) 86 (36.3%) 37 (26.8%) 225 (38.2%) No 67 (55.8%) 45 (47.9%) 151 (63.7%) 101 (73.2%) 364 (61.8%) Previous Hospitalizatio 0 Istaces 47 (39.2%) 47 (50%) 109 (45.9%) 77 (55.8%) 280 (47.5%) 1 Istace 16 (13.3%) 17 (18.1%) 44 (18.6%) 21 (15.2%) 98 (16.6%) 2 Istaces 13 (10.8%) 15 (16%) 21 (9%) 11 (7.9%) 60 (10.19%) 3 or more 44 (36.7%) 15 (16%) 63 (26.6%) 29 (21%) 151 (25.64%) Schizophreia Yes 72 (60%) 50 (53.2%) 176 (74.3%) 65 (47.1%) 363 (61.23%) No 48 (40%) 44 (46.8%) 61 (25.7%) 73 (52.9%) 226 (38.37%) Bipolar Disorder Yes 39 (32.5%) 23 (24.5%) 33 (14%) 40 (29%) 135 (22.92%) No 81 (67.5%) 71 (75.5%) 204 (86%) 98 (71%) 454 (77.08%) Major Depressive Disorder Yes 1 (.08%) 5 (5.3%) 24 (10%) 8 (5.8%) 38 (6.45%) No 119 (99.17%) 89 (94.68%) 213 (89.87%) 130 (94.20%) 551 (93.55%) Legth of Stay (Weeks) Mea SD N Hogg foudatio for metal health a u g u s t

19 Outcome Evaluatio of Four Pilot OCR Programs Data Aalysis Quatitative data was aalyzed by a Uiversity of Texas at Austi statistical cosultat. Although the origial evaluatio questios were much broader, a iitial aalysis yielded few sigificat relatioships due to limitatios i the sample ad complexity of program compoets. Therefore, the evaluatio questios were arrowed. A series of logistic regressio models were ru to aswer the research questios: 1. What are the characteristics of the idividuals who have participated i the pilot OCR programs i Texas? 2. Which cliet characteristics, if ay, are associated with positive outcomes? 3. Which pilot sites appear to be achievig the best outcomes? 4. What legth of stay is associated with the best outcomes? Data obtaied from the state metal health database 11 cotaied codig idicatig the outcome of the cliet; Restored, Dismissed, Not Restored, Abscoded, or Exteded Commitmet. The categories were defied as follows: Restored - Idividual was restored to competecy. Dismissed - Charges agaist idividual were dismissed. Not Restored - Idividual was ot restored to competecy. Abscoded - Idividual did ot follow through with OCR program. Exteded Commitmet - Idividual is cotiuig i the program per a judge s order, eve though the OCR team does ot feel that competecy is achievable. For the purpose of the logistic regressio models, origial outcomes were grouped ito two possibilities: Successful (origially coded as Restored or Dismissed) ad Not Successful (origially coded as Not Restored, Abscoded, or Exteded Commitmet). Various demographic measures were cosidered for iclusio ito the models. Model selectio followed the guidelies of Hosmer ad Lemesow (2000), icludig those idepedet variables that were sigificat as idividual predictors of the outcomes. After selectio criteria, the mai logistic regressio model cotaied a total of te predictors: ethicity, married (yes/o), feloy charge (yes/o), istaces of previous hospitalizatio, total legth of stay i the program, schizophreic diagosis, bipolar diagosis, major depressio diagosis, ad site locatio of the program. Data was cleaed for ease of use i the model. Participats were assiged to oe of four ethicity groups: White, Black, Hispaic, Asia/Other. The umber of istaces of hospitalizatio prior to etry ito the program was also recoded: zero istaces, 1 istace, 2 istaces, 3 or more istaces. The total legth of stay (LOS) was recorded for each subject ad reported i weeks. Log-term participats (loger tha oe year) were excluded, givig a fial subject cout of 589. The average legth of stay was weeks (SD=12.28). Program Outcomes at Pilot Projects The program outcomes at the four iitial pilot outpatiet competecy restoratio projects i Travis, Bexar, Dallas, ad Tarrat couties were examied. Logistic regressio was used to compare the sites, while cotrollig for the icluded participat characteristics. Results idicate good model fit, likelihood ratio (LR) chi-square (df=15) = 96.80, p < 0.05; Pseudo R2 = See Table 3 (ext page) for results of each icluded coefficiet. 11 The Cliet Assigmet ad Registratio database is a maiframebased cetral cliet registratio database for ipatiet ad commuity metal health services. 18 Hogg foudatio for metal health a u g u s t