Diversion and Forensic Capacity: Presentation to the Senate Committee on Health and Human Services Mike Maples, Deputy Commissioner Lauren Lacefield Lewis, Assistant Commissioner Department of State Health Services June 16, 2016
Forensic Commitments Two forensic commitment types: Incompetency to Stand Trial Not Guilty by Reason of Insanity Incompetency to Stand Trial Code of Criminal Procedure, Chapter 46B Allows for inpatient or outpatient commitment for restoration to competency Return to the criminal justice system for trial Not Guilty by Reason of Insanity Code of Criminal Procedure, Chapter 46C Acquittal of charges Commitment to inpatient or residential care 2
Number of State Hospital Beds Total State-Supported Bed Capacity Has Declined over the Past Twenty Years 4,000 State Psychiatric Hospital Bed Capacity: FY 1994-2015 3,500 3,343 3,291 3,159 3,189 3,074 3,000 2,500 2,000 1,500 1,000 500 2,969 2,911 3,123 2,847 3,071 2,939 2,949 2,834 2,491 2,611 2,670 2,670 2,666 2,693 2,670 2,764 2,858 2,928 2,890 2,919 2,478 2,461 2,729 2,671 2,607 2,235 2,355 2,477 2,477 2,484 2,484 2,461 2,461 2,461 2,501 2,463 2,463 2,285 2,268 State Operated Psychiatric Hospitals Totals State Funded Psych Beds Totals Grand Total State Psychiatric Beds El Paso Psychiatric Center Legislative Authorization Waco Center for Youth Added Seven 3rd Party Beds Opened Montgomery County Mental Health Treatment Facility Reduced Capacity at Terrell State Hospital by 28 Beds Contract with Private Psych Hospitals Contract with UTHSC 220 220 220 240 240 240 240 240 256 256 193 193 193 193 182 209 209 303 397 427 427 456 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year Note: In fiscal year 2015, $20 million in additional funds will add approximately 94 additional contracted beds 3
Forensic Bed Capacity Forensic Functional Capacity: 1,211 Maximum Security Units: 256 Non-Maximum Security Forensic: 955 Civil Functional Capacity: 941 Maximum Security Units: 26 Factors Affecting Functional Bed Capacity Aging campuses and maintenance issues Building designs based on outdated models of inpatient care Workforce shortage Staff turnover in critical positions Specialized care for unique patients *Data is census information as of May 23, 2016, DSHS-MHSA Decision Support 4
Forensic Wait Lists Have Increased Since 2014 Forensic Waiting Lists for State Mental Health Hospitals: February 2006 - April 2016 Forensic (Non-Maximum Security) Maximum Security Total 450 400 350 300 250 200 150 100 50 0 5
The State Hospital Forensic Population Now Exceeds the Civil Population Civil vs. Forensic Patient Population of State Hospitals 2500 2000 1500 1000 2,054 500 Forensic 1,847 1,817 1,6311,667 1,5961,5571,520 1,4871,473 1,397 1,451 1,312 399 480 550 560 603 671 781 818 832 871 876 975 1,065 Civil 1,1971,244 1,226 1,127 1,118 1,098 0 Jan-01 Jan-02 Jan-03 Jan-04 Jan-05 Jan-06 Jan-07 Jan-08 Jan-09 Jan-10 Jan-11 Jan-12 Jan-13 Jan-14 Jan-15 Jan-16 6
Number of Patients Days Maximum Security Demand and Lengths of Stay are on the Rise Average Daily Census for MSU Not Guilty by Reason of Insanity Patients 250 Average Monthly Length of Stay for MSU Discharges 25 23 30 38 200 150 100 158.1 168.3 183.2 192.9 50 FY 2012 FY 2013 FY 2014 FY 2015 0 CY 2012 CY 2013 CY 2014 CY 2015 7
Key Trends: Impact of Different Commitment Types *fiscal year 2016 data is through February 2016 8
Key Trends: Impact of Different Commitment Types Average Length of Stay for Individuals with Multiple Disabilities Including Intellectual Developmental Disorders Average Length of Stay for Individuals Found Not Guilty by Reason of Insanity 1200 1200 1000 1000 1009 800 800 600 600 751 715 615 400 515 489 497 400 200 348 200 0 FY 2012 FY 2013 FY 2014 FY 2015 0 FY 2012 FY 2013 FY 2014 FY 2015 *fiscal year 2016 data is through February 2016 9
Current DSHS Efforts Critical State Hospital Repairs $18.3 million in appropriations for the FY 2016-2017 biennium Purchase of Private Psychiatric Beds $50 million in new appropriations for the FY 2016-2017 biennium Jail-Based Competency Restoration Procurement in process Staff Recruitment and Retention $1.4 million appropriation for targeted nursing increases Psychiatric Residency Stipend Program Patient Transition into Communities 10
Rider 73: Mental Health Peer Supported Re-entry Pilot $1 million for the 2016-17 biennium for the Mental Health Peer Supported Re-Entry Pilot Partnership with local mental health authorities and county sheriffs Certified peer support specialists to support successful transition into the community Pilot sites: MHMR Authority of Harris County Tropical Texas Behavioral Health in Edinburg MHMR of Tarrant County Collaboration with the Hogg Foundation for process evaluation Report is due to the Legislature on December 1, 2016 11
Rider 66: Harris County Jail Diversion $10 million for the 2016-17 biennium for the Harris County Jail Diversion pilot program Program goals: Reduce recidivism rates Reduce frequency of arrests Provider services Mental Health and Substance Use Disorder Treatment Permanent and Temporary Housing Peer Support Assistance with Basic Needs Rehabilitation Transportation Vocational/Education Care Coordination Health Services Report due to the Legislature by December 1, 2016. 12
Rider 70: Jail Based Competency Restoration $1.7 million to conduct a jail-based competency restoration pilot Pilot goal: Treatment to restore competency to individuals in county jails, rather than in psychiatric facilities or in community-based settings Services: Mental health and co-occurring substance use disorder treatment Legal education for individuals found Incompetent to Stand Trial Timeline Texas Administrative Code rules finalized in January 2016 Procurement currently in negotiations Reports due to the Legislature each fiscal quarter 13
Crisis Services Primary DSHS-funded crisis services include: Mobile crisis outreach teams, 24-hour hotlines, crisis respite/residential, crisis stabilization units, extended observation, residential treatment centers (youth) The 84 th Legislature provided an additional ~$13 million per year to expand/enhance crisis services. This funding has been utilized to contract for additional crisis services, including: Crisis respite units Rapid Crisis Stabilization Beds Mental Health Deputies Veterans Resource Centers Law Enforcement Liaisons Substance Abuse Treatment at Crisis Residential Units Crisis Intervention Response Team Crisis Peer Support Services 14
Rider 80: Crisis Facility Review A comprehensive review of DSHS-funded crisis and treatment facilities Stakeholder involvement to identify best practices and barriers to effective service delivery Local Mental Health Authorities Disabilities Rights Texas Texas Council of Community Centers Report due to the Legislature by December 1, 2016. 15
Patient Support for Decision Making and Transition Services The Patient Support for Decision Making and Transition Services has an open enrollment procurement open. DSHS anticipated responses from several Texas Certified Guardianship providers These respondents would cover Austin State Hospital, San Antonio State Hospital, and Rusk State Hospital, the three State Hospitals with the highest number of referrals to the program A provider forum will be held in July 2016 to provide additional information to these and other potential respondents 16
State Hospital Workforce: Recruitment and Retention Factors leading to workforce shortage include: Noncompetitive salaries Poor facility conditions Aging workforce in several areas Increasing acuity and violence of population served DSHS was appropriated $5.6 million for staff recruitment and retention: Funds appropriated provide pay increases to Nurses and LVNs based on geographic areas ($2.7 million/biennium) and increased PNA pay by 2 percent ($2.9 million/biennium) Funds continue to support 15 residency slots through DSHS contracts with Texas medical school departments of psychiatry to purchase resident and supervisor time DSHS is evaluating university partnerships, including potential benefits to State Hospital recruiting and retention 17
SB 1507: Joint Committee on Access and Forensic Services Required development of: A bed day allocation methodology for distributing beds for voluntary, civil, and forensic patients throughout the state A bed day utilization review protocol that includes a peer review process Recommendations for the creation of a comprehensive plan for the coordination of forensic services Regular committee and subcommittee meetings with stakeholder input 18
SB 1507: Joint Committee on Access and Forensic Services (cont.) Bed Day Allocation Recommendations Allocation of beds based on poverty-weighted population No penalties or sanctions Consideration of incorporating factors related to acuity and the availability of local resources Bed Day Utilization Review Protocol Recommendations Focus on data collection and analysis Layered peer review process Pilot in limited areas before statewide implementation Plan for Coordination of Forensic Services Continued meeting of forensic subcommittee to refine recommendations 19