1. “ Implementing a Public Health Approach to Drug Abuse and Mental Illness” Designing a National County Based strategy to significantly lower recidivism for juvenile/adult offenders and people in psychiatric crisis who find themselves homeless, in crowed emergency rooms, and inappropriately placed in jails. National Association of Counties (NACo) January 28-31, 2009 Lee County (Estero), Florida Leon Evans President, National Association of County Behavioral Health Directors; President and Chief Executive Officer The Center for Health Care Services Bexar County Mental Health Authority San Antonio, Texas [email_address]

2. "abject failure of our society to address critical needs for persons with severe mental illness" FAILED PUBLIC POLICY The Problem:

3. 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”.

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. Police and Sheriff's Deputies are upset because they have to deal with the mentally ill Frustration due to lack of known options and alternatives People in the MH system are scared to deal with folks in the Law Enforcement/Criminal Justice system People in hospital emergency rooms are overwhelmed Communication across systems: People who concentrate in vocational jobs aren’t focused on Housing Folks in housing don’t understand mental illness and need for vocational services Everybody's goal is different The Problem

10. 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.

12. The Problem gets worse: Poor and or reduced funding Scant, limited and rationed services Reduction of State Hospital treatment beds The Problem

13. Shortage of State Psychiatric Beds The Problem Severe Shortage of Psychiatric Beds Sounds National Alarm Bell Report finds US deficit of nearly 100,000 inpatient beds; result is increased homelessness, emergency room overcrowding, and use of jails and prisons as de-facto psychiatric hospitals. Critical bed storage (less than 12 beds per 100,000 population) Nevada‡ 5.1 Ohio 10.6 Arizona 5.9 South Carolina 10.6 Arkansas 6.7 Oklahoma 11.0 Iowa 8.1 Idaho 11.3 Vermont 8.9 Alaska 11.3 Michigan 9.9 Severe bed shortage (12–19 beds per 100,000 population) Florida 12.1 Colorado 16.9 Texas 12.1 North Carolina 17.1 Rhode Island 12.5 New Hampshire 17.2 Maine 12.6 California 17.5 Wisconsin 13.0 Tennessee 18.1 Hawaii 13.5 Georgia 18.5 Utah 13.8 Pennsylvania 18.9 West Virginia 14.2 Washington 18.9 Illinois 14.3 Oregon 19.2 Kentucky 15.6 Indiana 19.3 Massachusetts 15.8 Marginal bed shortage (35–49 beds per 100,000 population) South Dakota 40.3 Meets minimal standard (50 or more beds per 100,000 population) Mississippi 49.7 Source: TreatmentAdvocacyCenter.org Serious bed shortage (20-34 beds per 100,000 population) Louisiana 20.2 New Mexico 22.3 Nebraska 20.7 Wyoming 24.1 Montana 20.9 Connecticut 25.4 Missouri 21.5 North Dakota 25.9 Maryland 21.6 Minnesota 26.8 Kansas 21.7 New York 27.4 Alabama 22.1 New Jersey 32.4 Virginia 22.2 Delaware 33.8

16. 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,”

18. 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

20. Housing Source: Community Conversations Guide

21. Is funding all we need? Even if everyone had insurance, availability to pay for treatment, the people with mental illness would still not avail themselves with treatment Many providers deliver services, give bus tokens, incentives, call and remind about appointments, call family and still have a high no show rate; appointments and even medication is forgotten Without special supports, wraparound services, care coordinators, patient navigators this population wouldn’t get the kind of services or rehabilitation they need The Nature of Mental Illness

22. How about our Children? For troubled kids there is no early Intervention; treatment is fragmented Schools are challenged and ill equipped to handle kids with mental illness Columbine and others are places where no early identification and limited to no resources produced tragic results 67% to 70% of youth in the juvenile justice system have a diagnosable mental health disorder (Skowyra & Cocozza, 2006)

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

25. Meeting the Challenge What we know is what works in one community may not work in another community but you can take bits and pieces of what works in one into another, to rural or metropolitan areas we need to find a way to share that information and identify best practices What Works

26. Meeting the Challenge

29. Emergency Room utilization has dropped 40% since the inception of the Crisis Care Center. 40% of (7619 total seen at CCC) 3048 Persons diverted from the ER (in 2006 first year) X $1545 Cost Savings relative to ER Utilization $4,709,160 Source: Jean R. Setzer, Ph.D., University Health System Emergency Room Utilization (Medical Clearance) What Works

30. There are many more effective solutions in our States, in our Counties, and all across the Country ! What Works

31. Conclusion As elected officials and policy makers we must help drive the right solutions so taxpayers reap the benefit of efficient governance and persons with mental illness aren't criminalized and inappropriately placed in jails and prisons, emergency rooms and or our streets Create a National Commission which would involve elected officials who would oversee a unified and outcome driven solution Recommendation Call for Action

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