The document discusses the fragmentation and costs of the mental health system in the US. It notes that mental illnesses lead to unnecessary disability, unemployment, homelessness, school failure and incarceration. The annual economic cost of mental illness in the US is estimated to be $79 billion. About 20% of jail populations have a serious mental illness. There is a lack of coordinated services across systems like law enforcement, treatment, housing, etc. This leads to poor outcomes for those with mental illnesses.

1. Leon Evans, President and Chief Executive Officer The Center for Health Care Services, Bexar County Mental Health Authority San Antonio Texas www.chcsbc.org Systems of Care: Diversion Initiatives Criminal Justice Community Conversations December 2009 Bloomington, Illinois

2. President’s Freedom Commission On Mental Health Interim Report: “… the mental health delivery system is fragmented and in disarray…leading to unnecessary and costly disability, unemployment, homelessness, school failure and incarceration.” 2003 President’s Freedom Commission On Mental Health – Final Report “ In addition to the tragedy of lost lives, mental illnesses come with a devastatingly high financial cost. In the US, the annual economic, indirect cost of mental illness is estimated to be $79 billion”.

3. One in 100: Behind Bars in America Between 1987 and 2007, the national prison population has nearly tripled. Total Behind Bars - 2,319,258 SOURCE: Bureau of Justice Statistics; Pew Public Safety Performance Project, 2008 The Problem PRISON COUNT PUSHES UP

4. Community Wide Jail Diversion The Problem Criminalization of Mentally Ill Inappropriate Cost to Society 20% + in jail Increase use of emergency rooms Homelessness Public Safety Net Consumers at risk Law Enforcement at risk Public at risk The Problem

5. Poor communication Poor system design Silos No strategic improvement plan Little use of prevailing best practices Lack of leadership and overview Why ? The Problem

6. Poor System Design There’s no integrated Plan The Individual Vocational Services Employment Law Enforcement Treatment Housing Poor Communication The Problem Jails Emergency Rooms Medical Homeless Services

7. Mental illnesses are costly. The failure to treat them affects not only an individual’s overall health but the cost of health care, including costs that must be borne by public systems. 1 Mental illness is the leading cause of disability in the United States for people between the ages of 15 and 44. 2 The Global Burden of Disease study indicates that the burden of disease from mental disorders for countries like the U.S. exceeds that of any other health condition. 3 Mental illnesses and substance use disorders resulted in $193 billion in lost productivity in 2002. By 2013 this loss is estimated to rise to more than $300 billion. 4 (1,2,3,and 4 -Integrating Mental Health in Healthcare, The Bazelon Center) 75 to 90 % of people with psychiatric disabilities are outside the labor force in the US . Anthony and Bianch, 1987 The Nature of Mental Illness

8. Severe Mental Illness: the illness is devastating because of the illness a person can’t manage their own lives at onset, most people don’t understand mental illness, families don’t understand it and the person is rejected by the family and friends because of it many times the person starts self medicating with alcohol or drugs there is a lack of education and services because of the pain and suffering personal ties are cut

9. Homeless persons The Nature of Mental Illness People who are homeless frequently report health problems: 38% report alcohol use problems 26% report other drug use problems 66% report either substance use and/or mental health problems 39% report some form of mental health problems (20-25% meet criteria for serious mental illness) 26% report acute health problems other than HIV/AIDS such as tuberculosis, pneumonia, or sexually transmitted diseases 46% report chronic health conditions such as high blood pressure, diabetes, or cancer Source: National Resource Center on Homelessness and Mental Illness, 2004 People with SMI die 25 years early: People with serious mental illnesses served in the public system are dying 25 years early, on average, from a full range of preventable health problems such as heart disease and diabetes. (NASMHPD, 2006)

10. The Cost Costly for taxpayers Space is taken up which could be used for violent offenders It's just wrong In the U.S., the annual economic, indirect cost of mental illness is Estimated to be $79 billion. 2003 President’s New Freedom Commission on Mental Health

11. The Case of Million Dollar Murray MILLION-DOLLAR MURRAY by MALCOLM GLADWELL The New Yorker Magazine, Issue of 2006-02-13 and 20, Posted 2006-02-06 News Release Emergency Departments See Dramatic Increase in People with Mental Illness Seeking Care Emergency Physicians Cite State Health Care Budget Cuts at Root of Problem American Psychiatric Association Hillarie Turner, 703-907-8536 June 2, 2004 hturner@psych.org Release No. 04-30 Sharon Reis 202-745-5103 Cost “ in one study, it had been concluded that one homeless person can cost the City and County about $200,000 in one year”. Philip F. Mangano, Executive Director of the United States Interagency Council on Homelessness (USICH), May 1, 2007. “ It cost us one million dollars not to do something about Murray,”

12. San Diego 529 high utilizers ran up a cost of $18 million dollars (2000-2003) including : $4 million for Emergency, Police, and Court $14 million for medical, ICU and surgery Impact San Diego SIP, Annals of Emergency Medicine, Vol 47, No.4:April 2006 15 chronic homeless inebriates (in eighteen months) cost $1.5 million The New Yorker Magazine, Million Dollar Murray, Issue 2006-02-13 and 20, 2006

13. The Case of Million Dollar Murray MILLION-DOLLAR MURRAY by MALCOLM GLADWELL The New Yorker Magazine, Issue of 2006-02-13 and 20, Posted 2006-02-06 News Release Emergency Departments See Dramatic Increase in People with Mental Illness Seeking Care Emergency Physicians Cite State Health Care Budget Cuts at Root of Problem American Psychiatric Association Hillarie Turner, 703-907-8536 June 2, 2004 hturner@psych.org Release No. 04-30 Sharon Reis 202-745-5103 Cost “ in one study, it had been concluded that one homeless person can cost the City and County about $200,000 in one year”. Philip F. Mangano, Executive Director of the United States Interagency Council on Homelessness (USICH), May 1, 2007. “ It cost us one million dollars not to do something about Murray,”

14. Texas Department of Criminal Justice MHMR Match Statistics October, 2007 The Problem *Represents all Clients served since 1985, including those whose diagnosis is no longer eligible for MHMR Source: Texas Correctional Office on Offenders with Mental and Medical Impairments 17.40% 12.65% 25.41% 26.78% % of Total Population 115,373 54,727 19,763 40,883 # of Care Matches* 662,775 432,359 77,755 152,661 Total TDCJ Population Total Probation Parole C.I.D.

15. Revocation Rates 2007 Federal Revocation Rate : 66% Two-thirds of returning prisoners are re-arrested for new crimes within 3 years or their release. Second Chance Act, 110TH CONGRESS REPORT to US HOUSE OF REPRESENTATIVES State Revocation Rate : Texas Felony Revocation Rate = 15.8% Top 5 Largest Community and Corrections Departments = 16.1 % Local Revocation Rate: Bexar County Mentally Impaired Caseload Department Probation Department = 8% Manos Diversion Program, CHCS = 6.2%

16. Collaboration: It’s an unnatural act between… … two or more unconsenting adults .

17. SATF-1 (100 bed Residential Treatment Program;Adult Males) an array of value added services are provided to include family education, GED preparation and testing, parenting education, and recovery support groups. SATF-2 ( 100 bed -50 bed Adult Female/ 50 bed Adult Male Residential Treatment) Zero Tolerance (60 bed young Adult ages 17-25 Residential Treatment) Mentally Ill Offender Unit (30 bed Adult Female/30 bed Adult Male Co-Occurring Residential Treatment Program) Bexar County Corrections & Community Supervision and The Center for Health Care Services programs; Residential Programs

18. Then (prior to Sept 2005) Wait times for Medical Clearance/ Screening at UHS ER - 9 hours, 18 min. Wait times for Medical Clearance/ Screening and Psychiatric Evaluation was between 12 and 14 hours. Now The wait time for Medical Clearance/ Screening at the Crisis Care Center is 45 minutes. Wait time for Medical Clearance/Screening and Psychiatric Evaluation is 60-65 minutes. Impact on WAIT TIME for LAW ENFORCEMENT What Works

19. Involuntary Outpatient Commitment Program Pre IOPC Program Post 79% Reduction in Bed Day Use, Post Program First Year Evaluation

20. Strategies for Success Don’t Let Them Go to Jail in the First Place Diversion in all appropriate settings Set up: Primary Diversion/Intervention Pre Booking services Cross match of jail population In jail screening/services Secondary Diversion/Intervention Post Booking services Intensive Outpatient Treatment for Probation/Parole (Genesis) Residential MH Services (MIOF) Continuity of Care Intensive Ongoing Case management Timely updates to Judges MH/Judicial Joint Staffing

21. Leon Evans, President and Chief Executive Officer, The Center for Health Care Services, Bexar County Mental Health Authority San Antonio, Texas For additional information contact: Leon Evans, Ph. 210 731-1300 Email: [email_address] Thank you ! www.chcsbc.org