Presentation made during the 2012 Latino Behavioral Health Institute Conference in Los Angeles, California.

1. Maximizing Efficiency and
Treatment Effectiveness al Estillo San Anto
Centers for Medicare and Medicaid Services
(CMS) Grant with
Diversion Initiatives Addressing Challenges
Of Mental Illness, Substance Use
and Homelessness
September 2012
Gilbert Gonzales
Juan Ramos
Director, Communications
Board Vice Chair
and Diversion Initiatives
The National Center for Behavioral Health
The Center for Health Care Services
Solutions
San Antonio, Texas
jramos.swkr@verizon.net
ggonzales@chcsbc.org
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2. 2

3. 3

4. The Centers for Medicare and
Medicaid Services (CMS) Grant
• Project Title: “A recovery-oriented
approach to integrated behavioral and
physical health care for a high-risk
population”
• Geographic Reach: San Antonio, Texas
• Funding Amount: $4,557,969
• Estimated 3-Year Savings: $5 million

5. Integration: Health and
Behavioral Health
• Will serve adults severe mental illness or co-occurring
mental illness and substance abuse disorders, at high
risk of chronic physical disease, through a CHCS multi-
disciplinary care team to coordinate behavioral, primary,
and tertiary health care.
• Project includes collaborations of leading hospitals,
doctors, nurses, pharmacists, technology innovators,
community-based organizations and patients’ advocacy
groups among others.
• The aim of this innovation award is to deliver better
health, improved care and lower costs to those enrolled
in Medicare and Medicaid, particularly those with the
highest chronic health care needs

6. 6

7. Why ?
 Poor communication
 Poor system design
 Silos
 No strategic
improvement plan
 Little use of prevailing best
practices
 Lack of leadership and overview 7

8. The Problem
The Problem gets worse:
Poor and or reduced
funding
Scant, limited and
rationed services
Reduction of State Hospital
treatment beds
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9. An Ounce of Prevention
Taxpayer Costs Avoided through Preventing
Crime
Criminal Behavior and Its Cost to Society
• 1.7 Trillion including victimless
crime – Perazzo 2002
• 674 Billion Federal, State and Local – Shapiro 1999
• 1.0 Trillion (2 million people incarcerated) – Adrienne
2005
Cost Avoided if One Criminal Career is Prevented
$ 976,217.81
• Average annual adult cost (2004) - $40,865
• Average annual juvenile cost (2004) - $32,888
Source: Dr. Victoria Reinhardt, An Ounce of Prevention presentation
9
To NACo, July 2008

10. The Case of Million MILLION-DOLLAR MURRAY
by MALCOLM GLADWELL
Dollar Murray The New Yorker Magazine, Issue of 2006-02-13
and 20, Posted 2006-02-06
“It cost us one million dollars not to do something about
Murray,”
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
“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.
10

11. Average Per Capita Spending
• In 1995, average monthly
spending per capita for clients
Community Based vs Institutional Cost Per Day
receiving services in Institutional,
"aged/disabled" home and $350 $320
community-based waivers $300
across all states with these $250
waivers was $485 per month. $200 Community
Institutional
$150
$100
Community, $42
• In contrast, average monthly $50
spending per Medicaid- $0
1
covered nursing home resident
was $2,426.14.
http://aspe.hhs.gov/daltcp/reports/costeff.htm
(per episode cost)
11

12. Collaboration: It’s an unnatural act between…
…two or more unconsenting adults.
12

13. Integrating and Strengthening
Community-Based Care
• Community-based services, that are readily accessible
and convenient, help in the early detection and
treatment of mental health problems.
• Will help to reduce the
need for hospitalization
and increase the chances
that patients can fully regain
their mental health and help
them to live and work
successfully
within the community.
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14. Community Care
Is better than Institutional Care
 Costs less than institutional care
 Is least restrictive
 Allows for greater
family involvement
 Produces better
outcomes
14

15. Community Mental
Health Philosophy
“You get better
outcomes when
treatment is
nearer to families,
jobs and
communities”. y
ph
so
ilo
Ph 15
Leon Evans

16. The Diversion Process
Point of Contact with CIT/Deputy 24/7 Crisis Emergency
Law Enforcement Mobile Outreach Services Transport to
Team Hospital
*Pre-Arrest Diversion
Referrals to
Community
Arrested Magistrate Post-Booking Diversion Providers
Court
Pre-Trial Bexar
Community-based
Diversion County Jail
Wraparound Care
Genesis Probation,
Incarceration, Treatment in lieu of
Parole Incarceration
Residential
Respite

17. Civil and Criminal
System County City-wide System Level
Entry Points
Judicial/Courts
Magistrate, County, District
Probation, Parole
County City-wide
Continuity of Care
Police, Sheriff
Treatment
Law Enforcement Crisis Care Center
Detention/Jail
Jail Diversion Mental Health
CIT Psychiatric and Medical
Public and Private
Providers
Clearance
Specialty Offender Services
Emergency Services
• Community Collaborative
• Crisis Care Center
• Crisis Transitional Unit
• Crisis Hotline (Nurselink)
Dynamic • CIT/DMOT
Community
• SP5
Crisis Jail Diversion • Jail and Juvenile Detention
Information Exchange • Statewide CARE Match
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18. Stakeholder Collaboration via:
• Jail Diversion Oversight Committee
(34+ Community Agencies/Stakeholders)
• Community Medical Directors Roundtable
• Children’s Medical Directors Roundtable
• Bexar County Children’s Diversion School District Sub Committee
• Bexar County Children’s Diversion Child Protective Services Sub
Committee
• Bexar County Children’s Diversion Juvenile Justice Probation Sub
Committee
• Community Co-Location Coalition (29 Community Agencies including law
enforcement entities meeting to address the homeless & public inebriate)
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19. Show me the DATA !!!
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22. Top Ten CSCD’s with Most
Offenders Served and Recidivism
Rates 2012
35.0%
30.3%
30.0%
24.2%
25.0%
20.6% 21.3%
20.0% 17.7% 18.4%
15.0% 12.7% 13.6%
11.3%
10.0% 6.6%
5.0%
0.0%
r
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Ca
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23. Recidivism Rates for Top Five Community
Supervision and Correction Departments
2012
35.0%
30.3%
30.0%
25.0%
22.6% Bexar
20.6% Harris
20.0% Average
17.6%
Tarrant
15.0% Dallas*
12.7%
Travis
10.0%
6.6%
5.0%
0.0%
Bexar Harris Average Tarrant Dallas* Travis

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25. What Works
Emergency Room
Utilization (Medical Clearance)
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: University Health System
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26. Today 26
2012 – The Bexar County Sheriff and San Antonio Police Chief mandate CIT Training

27. Impact on WAIT TIME
for LAW ENFORCEMENT
Then (prior to Sept 2005) Now
• Wait times for Medical • The wait time for Medical
Clearance/ Screening at Clearance/ Screening at the
UHS ER - 9 hours, 18 min. Crisis Care Center is 45
minutes.
• Wait times for Medical • Wait time for Medical
Clearance/ Screening and Clearance/Screening and
Psychiatric Evaluation was Psychiatric Evaluation is
between 12 and 14 hours. 60-65 minutes. 27

28. 28

29. Involuntary Outpatient Commitment
Program
First Year
Evaluation 150
79% Reduction in Bed
Pre Day Use, Post Program
100 IOPC
# Bed Days
Program
Used
50
Post
0
State Hospital Bed Day Utilization
Rate
1 Yr Prior 132
1 Yr Post 27
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30. CRISIS CARE CENTER
• Crisis Line
• Crisis Assessment • Receives consumers
• Mobile Crisis Outreach Team
from law enforcement
• Crisis Transitional Unit
24/7
7137 W. Military 645-1651
• Minor medical clearance
• Call ahead preferred
210 225-5481
• Can not take violent or
medically compromised
individuals
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31. CIT Mental Health Detail
• Mental health professional
partners with a CIT Officer
together to respond on calls
dealing with a psychiatric crisis.
• Team responds to high utilizer
calls for the City providing follow
up services to reduce the call
volume.
• Goal is to put officers back into
service for patrol as soon as
possible.
– Reduce inappropriate
incarcerations and costly
emergency room visits.
– Offer quality training to law
enforcement.
• Co-locate officer with the City unit
and Sheriff Mental Health Unit for
better collaboration and expedited
call response

32. Dispatcher Training for 911
Call Takers and Dispatchers
• In 2007 - decided that dispatchers
would also benefit from CIT
Instruction and met with SAPD
leadership to establish training.
• Provided an abbreviated 12 hour
CIT course for call takers and
dispatchers in collaboration with
CHCS
• The goal of this training is to
increase safety by educating caller
takers on essential intelligence
gathering and dispatching a CIT
Trained officer to the scene.

33. Partnered with Fire and EMS
• As of 2007 SAFD has attended
every community training
• has become co trainers with
joint PD and Sheriff’s Officers
• Have added a CIT component to
their EMS In-service training.
• Partnering for Integrated
training with Fire/EMS has
extended numerous
opportunities for growth:
– Officer and Fire/EMS better
communication
– Safety
– Better utilization of
resources

34. The
Restoration Center
Opened
•
April 15, 2008
• Public Safety- Sobering
Unit
• Detoxification Facility
• Community Court
• Outpatient Substance
Abuse Services
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35. Haven for Hope Homeless Facility
CNN Video Clip
“Texas officials hope a massive new facility will keep
the homeless
out of jail, emergency rooms and re-integrated into
society”.
• http://www.diversioninitiatives.net/2010/07/haven-for-hope-cnn-video-just-before.html
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36. Haven for Hope Homeless Transitional Facility
36
www.havenforhope.org

37. 1,600
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40. Funding
• Jail Diversion Planning and Oversight Committee - Judge Poly Jackson Spencer
• SAMHSA Jail Diversion Grant
• Changing the Law - Senate/House Bills Madla/Uresti,HB 2292 Mandated
Jail Diversion
• Police Chief Ortiz Funding - Drug Bust Money
• University Health System Partnership- Care Link & New Generation
Medications Program
• Texas Crisis Redesign - $82 million State-wide
• Bill Greehey/Bexar County - Transformation Center
• Texas Correctional Office on Offenders with Mental and Medical
Impairments (TCOOMMI)
• Genesis Outpatient Services - Probation and Parole
• Mentally Impaired Offenders Program-Probation
• Substance Abuse Treatment Facilities (SATF I and II)
• Medicaid Administrative Claiming
• Medicaid Eligibility and Carelink Workers
• Third Party Billing
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41. Combined CCC and Restoration Documented and Immediate Cost Avoidance
Year One April 16, 2008 – March 31, 2009
Year Two April 16, 2009 – March31, 2010
Year Three April 16, 2010 – March 31, 2011
Cost Category City of San Antonio Bexar County Direct Cost Avoidance
Public Inebriates Diverted from Detention $435,435 $1,983,574 $2,419,009
Facility
$925,015 $2,818,755* $3,743,770
$1,322,685 $4,372,128 $5,694,813
A. B.
Injured Prisoner Diverted from UHS ER $528,000 $1,267,200 $1,795,200
$435,000 $1,044,000 $1,479,000
$421,000 $1,010,400 $1,431,400
C. D.
Mentally Ill Diverted from UHS ER Cost $322,500 $774,000 $1,096,500
$283,500 $676,000 $959,500
$276,500 $663,600 $940,100
E. F.
Mentally Ill Diverted from Magistration $208,159 $371,350 $579,509
Facility
$179,833 $322,300 $502,133
$126,893 $191,125 $310,018
G. H.
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Summary next slide

42. Summary
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43. BEXAR COUNTY DETENTION CENTER
SYSTEM POPULATION
MONTHLY AVERAGES
(Main, Annex)
4400 4357
4337
4292 4300 4302 4300
4280 4289
4300 4260 4263
4253 4272
4222 4231 4225
4254 4210 4208 4261
4193
SYSTEM POPULATION
4179
4200 4173 4171 4158
4156
4130 4139 4197 4190
4109 4133 4124
4095 4095 4094
4079 4084 4081
4100 4062
4094 4053 4040
4096 4028 4033
4015 4017
4077 4066
3987 4001 3993
4000 3981 4015
3960
3941 3946
3982
3897 On May 2011, there were 883
3900
empty beds in the jail 3845
3807
3854 3790 3791
3800 3743
3700
FEB
DEC
MAY
SEP
APR
JAN
MAR
JUN
AUG
OCT
JUL
NOV
2006 2007 2008 2009 2010 2011

44. The End Result
• Comprehensive service for most in need
• Increased availability of comprehensive
coordinated services
• Reduced barriers to service access and
increase motivation with treatment
compliance
• Employ evidence based practices known
to be effective
• Utilization of system tracking and outcome
based treatment
44

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46. The Center for
Health Care Services
Leon Evans, President/CEO
The Center for Health Care Services
Mental Health Authority
210 731-1300
46
www.chcsbc.org
levans@chcsbc.org