Travis County Commissioners Court
August 29, 2006
Item 19
Number 19 is is to receive follow-up report from Travis County mental health stakeholders group and take appropriate action. We heard a presentation a couple of week back about a mental health mobile treatment unit, and at that point some of the facts were not clear. And since we are moving on toward our budget markup and some of the facts have been -- some of the smoke has cleared, I thought it would be a good idea to have a follow-up report to the court.
>> good afternoon.
>> we have distributed some materials yesterday afternoon. Hopefully you received them. You have a several-page summary that shows the current status of the psychiatric emergency services proposal where we did have a few numbers outstanding, and we tried fill in the blanks. I'd just like to walk you through this quickly. We also did collect some additional information that the court had requested around current expenditures in Travis County related to mental health needs I might refer to it. And we have incorporated some of that information into this summary as well. You recall when we were here last we talked about the psychiatric emergency services proposal which had a number melments included in that. And that included the inclusion of a crisis unit, a mobile crisis outreach team, a housing -- a housing or respite component, and ea psychiatric emergencies component that would be co-located with the crisis stabilization unit as well as a component that addressed expansion services and other services that support or help to support individuals and keep them out of crisis. When will we were here left we were still developing and eval weight the various commitments of the mental health stakeholders group to this proposal. I'd like to briefly refresh our memories about the participants in the stakeholders group. You do have a one-page summary of the question that Commissioner Davis had asked and we submitted some background on the mental health stakeholders group. Just to refresh our memories again, this group began, the district convened a group in mid December of 2005 and we've been meeting every month since. The participants in the mental health stakeholder group include, of course, the district, myself as president and ceo as well as board chair and actually several of our board members. Judge Sam Biscoe and Commissioner Margaret Gomez have been participating. Travis County judge guy herman has been involved from the beginning. From stint we've had councilmember lee leffingwell and mayor pro tem betty dunkerley as well as the city manager and assistant city manager mike mcdonald. We of course have had Austin Travis County mhmr with us and that includes their executive director as well as their medical director. And we've had both the seton health care network as well as the st.david's foundation and saved david's -- st.david's health care system table. The goal was this group tofs create a proposal for the implementation of psychiatric emergency services for this community, which we of course many, many groups before us have identified as a very significant need. And in fact we have a couple of folks with us, sergeant hicks and judge o'engarden here today that would be pleased to talk about this proposal and how it might impact some of thenists their areas. -- the activities in their areas. Just to bring us back to the proposal and what missing at the time, we have in this summary provided you for each of the elements our current estimated cost and as well as the proposed commitments that we are aware of at this stage. For the crisis stabilization unit, the district has stepped forward and indicated it is willing -- of course, this does not come to full board policy and decision making, full board vote, but we have provided funz in our budget for the current year for inpatient psychiatric services which we've extended into the proposed fiscal 2007 fwowjt the provision of crisis stabilization services. Those services are current fly the form after contract with seton shoal creek, but are expected to evolve into a formal development of a crisis stabilization unit at seton shoal creek which he we would then take the dollars that we would have budgeted for the contract and troferd this function. We estimate that on an ongoing basis that cost could be between 1 fiscal year 1 and 1.5 million. We also have heard figures that that might be closetory it $2 million on an annual operating basis. The district is is -- has indicated its support of this -- of the operating costs for the cries stabilization unit as well as has indicated a willingness to provide capital funds to complement additional capital nawndz may be contributed by Austin Travis County mhmr to renovate the shoal creek facility to provide these services. In addition to the district's contribution to this and Austin-Travis County's contribution of capital, the seton network, of course, is contributing is both in kind and direct support of this function or this proposed function. They are bearing the operating costs of the assessment team to figure out exactly how to -- to reconfigure a portion of shoal creek to provide these crisis stabilization unit and crick emergency services -- psychiatric nj services. There will be (indiscernible) donated for this use and there are costs with the oversight of this project. There is a component that has yet to be quantified or even described yet and that is the involvement of the Austin medical education program, psychiatric edging indication program, which of course is also supported by seton. And we anticipate that thrbl more extended use is -- there will be more extended use of the psychiatry services. There is also a rapid design implementation retreat that's being held tomorrow that will help us at a very detailed level design what the levels would look like at shoal creek. Out of this design we should have a better knowledge of what will be required for the standpoint of total resources both for personnel, for operating and how the space should actually be configured and therefore what the capital costs might be to develop this proposal. In terms of conditions of participation, of course from the district's per pekt perspective, and we discussed this last time, from the district's perspective in terms of committing fairly significant funds to the ongoing operating costs of the crisis stabilization unit, we see it very necessary that all elements of this proposal be in place. That we have a psychiatric emergency services that do function on a 24/7 basis, a true 24/#- 7 7 basis. That we do have the prevention services and the housing services as well as the services of the mobile crisis outreach team, that will prevent people from coming into crisis and coming into the system. Terms of the emergency services component of this, we do know that Austin Travis County mhmr has committed to transferring the funding that they are currently expending at the nadine jay center to relocate the psychiatric emergency services to shoal creek so it's co-located with the crisis stalization unit and they anticipate that they will be able to offer some additional fund fog the staffing that is required to make that a fully functional 24 shrsh 7 service. Now, again, out of the design work that will be done tomorrow and in the coming days and weeks we feel like we will have a better idea of what the total cost of that will be and we will continue to work with mhmr as well as other members of the stakeholders group to make sure we have sufficient funding to make that service what we think it needs to be. In terms of the prevention services, we did mention last time that st.david's health care system had granted over $800,000 in funds to develop meerj integrated type programs in 12 community agencies. So that will go a long way towards helping provide services in the comupts to people who are in care and keep them in care and stable. In addition, the district is -- has included in its proposed budget for fiscal year 2007 an additional $100,000 to further expand the emerge program and the federally qualified health center system. That will add additional behavioral health staff to provide more additional services to patients. Additionally we have funds that are targeted in our enhancement line item in the proposed 2007 budget that will allow us to consider further expansions of the emerge program that will be increases in the psychiatric services component of the program that would allow the clinics to treat a higher acuity of patients than they are treating now. So district is willing to consider that proposal during the year as it's further developed. Additionally the city of Austin -- this is another item that we did not have at our last meeting. The city was in process of evaluating the contribution that they could make wards the housing component of this plan, and I have been informed that councilmember leffingwell and mayor pro tem dunkerley will be bringing through the budget process for the city for 2007 a request to provide $1.3 million on funding for the housing facility that will augment the residential respite services that we have at nadine jay, which are 16 beds, and will be expended by Austin-Travis County mhmr to possibly 19 to 20 once the nadine jay psychiatric emergency services are relocated out of nadine jay over to seton shoal creek. So we will have an expansion of the nadine jay center as well as an additional facility for transitional housing. In addition, constituent indicates that they will continue with -- the city indicates that they will continue to work to determine a portion of the bond housing that will come to vote I believe in the fall that will help support housing for patients in crisis and coming out of crisis. Is you can see the figure we don't have today is the value of seton's contribution and that is essentially because diswroant all the components figured out yet, but we know what the elements are, but we have not been able to assign a dollar figure to them yet. So again the proposed component that was brought before the Commissioners court was for the funding of a mobile crisis outreach team, which was in the amounts of $400,000 a year. You had asked us last time some information about the current costs that were being expended by Travis County and I believe that you are in receipt of a memorandum that came from bill durfwerry from pbo that attempted to quantify both direct and allocated costs related to the various functions. I believe that the direct costs were somewhere in the neighborhood of 8.6 million and there was another similar amount bringing the total to about 14 million in term of direct and allocated. From that information, ms. Anna albegal from the Travis County health and human services department worked with the staff of pbo and others within the county to try to quantify -- I guess I might say the most directly accountable costs related to individuals that come through Travis County through their incarceration or -- either come through the courts or come through the jails with mental health conditions. And I believe --
>> was that amount also broke out, especially on the -- on the incarceration phase? If that was basically I guess taken out of the overall costs if it's to eliminate it where we don't have incarceration factor as far as the costs of that? Is that something that was also -- that was overall? Because it is a concern. I'm just wondering if that was part of the overall assessment as far as cost is concerned, was that also included?
>> yes. We would have to make some assumptions based on the data that we have, and it appears that pbo concurs that from the sheriff's office alone there is a cost of over $2 million related to services for inmates with severe mental health diagnoses. So that cost was assuming 268 inmates, and this is from pbo, there would be a cost of over $8,000 per inmate. So one would infer then that if we could prevoant those inmates -- prevent those inmates, those persons from actually becoming inmates, they're receiving services, before they become -- before they reach a point with their mental health care that they must become incarcerated for whatever reason, break the law or whatever that, that cost would be reduced by that person not being incarcerated. Often times we find that folks who are suffering from various mental health issues don't finish their medication or are unable to get into appointments to bet new medication, so therefore they self-medicate in other ways, with illegal substances or alcohol, those kind of things. And that is ultimately what leads to their contact with law enforcement.
>> we focused on I guess three your components because they seem to be most directly cal cue label, so to speak, because many of the costs that you incur are hard to quantify into an individual inmate basis. But if you look at the cost to the county attorney's office and the work loads associated with that and then you look at the cost that the sheriff's office are incurring relating to incarceration and treatment, which would include physical as well as mental health treatment, based on those three cost categories, thrfs timent thrafsd a -- there was estimate that had there was a direct cost to a single inmate of 11,500 per inmate. We can't make siewjses if that person doesn't come in you will automatically reduce your costs by that because that's not the way it works. You've got a is certain amount of fixed costs, but you do have a certain amount of vearlg costs so the extend you're paying for health care, if that person never 10ters your system, your -- never enters your system, you're not having that cost. If you do reduce the number of individuals in your system and having them treated elsewhere, that the resources that you're using to treat those that are most appropriately in your system will go a lot farther and be dedicated to that. So in terms of doing a rough estimate, we're looking at the expenditure of roughly 4 hun thousand dollars on -- $400,000 on this team. And you will recall that we do d. This team fairly conservatively seeing this as a pilot project. But if that team were able to avoid or divert 35 individuals from your system, then you essentially see a break jeefn point there in terms of that 11,500 collars in cost. That doesn't mean it's a direct savings to you.
>> there was another note here also have staff that probably the most immediate change, if you will, that we would see would be in the welfare checks that law enforcement are required to make when someone is concerned either through behavior or not being able to reach someone, and they call law enforcement to go out and determine that person's well-being or where we have neighbors who are witnessing baiferb that they have determined -- fwhaifer they have determined is inappropriate, so they have called for law enforcement to intervene. Those would be the types of calls based on either certain information gathered that could ultimately be referred to a team such as this. And so that would also be something else we could look at in terms of what the impact would be of having these particular staff in place.
>> I have several questions. To arrive at this 400,000-dollar estimate, we assume that four f.t.e.'s would be necessary. I'm trying to determine staffing costs as opposed to if there's a vehicle involved, some medical equipment. What is that break down? Do you recall?
>> the total cost for the four staff was estimated at 32 coup thousand -- 262,000. There was of course fringe related to benefits and overhead of another about 85,000. And then there was an administrative cost, and I would call it a guesstimate, an administrative cost factor that was applied. So the total estimated costs were about 347,000, and threfns an there was an administrative cost of three percent applied to that. I think that's a fairly variable number because part of it would depend on where we could house this team. It would probably be beneficial to house them as close as possible to the cit team. There is some question about whether there is it space available at ash or whether the cit team is located or in projection similar r. Proximity.the people aren't necessarily in a building all the time, they are theoretically out and moving.
>> I'm visualizing a medical ground transportation unit for the team. Where do we get sna.
>> it's really just vehicles involved because these -- remember also that the -- they don't always go out as a team.
>> here's -- my question's real simple wrvment is is that cost? -- where is that cost?
>> there are cost of vehicles and laptops, minor equipment, but the way we understand this works from the other areas in houston and san antonio, there's not special equipment that's required. These are people getting in their cars and going to where the crisis is. They may go one at a time, they may go two at a time, they may accompany law enforcement.
>> so we can implement a mobile unit for about $400,000.
>> yes, sir. And that includes a crift, two licensed -- psychiatrist, two licenses counselors and a nurse on that four-person team.
>> okay. At our last meeting the county judge did ask a question that is if we had two or three thousand dollars, would it be better to use that money to fund this team or to hire two additional psychiatrists and reduce the waiting period that a lot of mental health clients now face. And the answer given to me at the meeting by those more in the know than I was that given the totality of circumstances right now the mobile unit makes more sense. Is that snriew.
>> yes, I would agree with that. And it's not to say that those increase in psychiatrists would not be very well utilized in reducing the wait lists, but this mobile crisis outreach team is also designed to get at a part of the population that is harder to reach and harder to maintain and are not necessarily individuals that would come into a system that had increased crick capacity. -- psychiatric capacity. So our approach to this has been on a continuum and we believe that the focus on the mobile crisis outreach team can probably have the largest impact right now on law enforcement as well as up the use of crisis services. And we think that potentially has a larger bang for your buck so to speak. But I would add to that, judge, that you are absolutely correct that there are additional resources needed in the existing system to keep people in to care and to try to repre vent those crisis. Absolutely.
>> and I raise the question because we've implemented four or five mental health pilot programs during the last 18 months. Fanned they work as well as we hope, there will an steady plow of mental health clients released to the free world, expedited through our why system, but if they have to wait three, four, five months to get an appointment, what we have been told is without medication, case management, shelter, these same individuals end up bhak in our cuss -- back in our custody, which in our view is exactly opposite what we -- we are working for. If we look at the different elements of the strategy that the stakeholders looked at and arrived at, how important, how critical is the mobile treatment unit?
>> I think it's very critical. I think that if we do not have the mobile crisis outreach team in place, either very close to -- and we have this implemented or soon to follow, I think we will have people cycling into the crisis service. I think we would build the service and they will come and they will come. So the objective has been to see that the mobile crisis outreach team has come out of crisis redesign work group that will be issuing its report sometimes in the coming months. But taking their lead on best practices, they've indicated that this team is a big component to the function. Without it you do end up with a significant gap. To your point, judge, I think we have to continue to make progress in beefing up the services that exist now, including psychiatric services just as you said so that we're getting people into care and keeping them in care and keeping nem stabilized. I think what we struggle with is where is is it most appropriate at this point in tame to put -- in time to put the building blocks in place after system that then we can then hopefully grow over time once each component is there. To me it's like building a house. If don't have each of the bricks of this continuum in place, then I think we're just pushing it to one side or the other. We're either going to be pushing back into the inmate health arena or we're going to be pushing into the crisis services and inpatient beds.
>> two or three more things by me and I'll be done. When Commissioner ghoaz Commissioner Gomez and I began teangd the meetings werks didn't know where we would end up, but then the more informed we became about how scbant the problem is and what additional pieces we need to put in place in our community. As we looked around, the other urban communities of Texas have similar things in place. Secondly, I think the other members were in the same position we were in, but as the conversations continued and the strategies sort of evolved, different partners picked up different pieces. And some of these pies are a whole lot larger than the ones we're asked to consider picking up. I think it's fair for us to play a role because these are Travis County residents and we do stand to benefit if the programs work as we expect them to. Now.
>> put this on my sheet as a discussion item, but I also realized we would have the cushion today. This would be a markup discussion item. So we can look at this as we look at the others, but I think if we're going to do it, this is the time. The other thing now is my position is that if we fund this, we would fund it on a pilot basis for the first year like the others are doing, and make the call one year later about whether we continue this or redirect those resources. This is one of those areas that we sort of -- I won't say we ignored for years, but we didn't do as much as we probably should have. And so we're now trying to do catchup. And the thing that brought it to our attention two or three years ago was when smk banged us -- when somebody banged us against the head with the number of inmates in our custody who have mental health issues. And I don't know -- I always knew the number was large, but I never knew it was as large as the numbers we were given by our folks. And all the other evidence that has surfaced recently has confirmed those numbers. One day it's 200, the next day it's 400. So that's why we funded the other pilot initiative try to deal with the situation.
>> judge, would it be okay at this time to ask judge hohengarte in in. Hohengarten?
>> I would be happy to hear from them.
>> I don't want to take your time if you don't need to hear from me. I would like to say that the Austin Travis County mental health jail diversion committee supports this, and when we initially began working on this issue, the hospital district hadn't hired consultants and hired the stakeholder group and so forth. When they did it was very helpful because it pulled out and it allowed us to focus on what happens when it's in our system and diversions once they are in the system. I think it's important for us to fund this package to go forward because to the extent that it minimizes what we need to do on the other end, it's important to have it in place first in a way. And these owe soaferl of the items -- several of the items that were included were included in the presentation we made back in June of '05 for recommended best practices funding for mental health. The crisis tailization, the psychiatric services, the mobile crisis outreach team is similar to a fact team in some ways and I think we've educated y'all about that many times. So I support this because I think it will make a difference. One other cost that wasn't included was all the court costs in s in terms of expenditure of time, attorneys' fees and so fortsz. There certainly is a cost to that in the criminal justice system as well. I also brought -- because we're asking you to spend money, I wanted to let you know of some recent things that I think we have a good chance of receiving that don't cost you any money. And that is -- and I know judge Biscoe is aware of these. We applied for a -- to be a test site for a computer program that helps you estimate cost savings generated by mental health jail diversion. The hospital district has hired consultants to come in and put together a package. That's behaving wlai the learning site does. And we've also continued to educate our own for free basically about how to handle mental health cases in the court system so that we can do a better job of that. You just knowing this is here in case you ever need to consult it and knowing that we're trying to work on ways to bet resources to the community, we're doing a lot without spending any money, but this is necessary to accomplish what we need to accomplish.
>> okay, thank you. We always can use one more memo or report. Anybody else?
>> [one moment, please, for change in captioners] think that we're.
>> the thing that probably resonates the most with me, trish, is when you say we really don't need to do this as sort of an island. We can't have one of it and then kind of sitting around waiting, when is the next group funding their deal. I know when we talked a few weeks ago the deal was okay, proposed commitments. That to me doesn't necessarily mean, you know, we want you all to sign up for the commitment and I'm going to try to get this proposed, turned into what you all said you're going to do. I know that--
>> in the September meeting, I mean, all of us would have gone through our budget process. So then we will know what's been approved and what has not.
>> all right.
>> is this kind of predicat predicated on that come September, everybody that has a stake in this thing bellies up to the bar and says, you know, turn it from a proposed to it's in the budget.
>> yes.
>> otherwise we have the ability to kind of rethink, right?
>> that's my intention.
>> uh-huh.
>> that meeting is September 18.
>> okay.
>> and that is the goal.
>> don't vote today, though. Doing mark-up. Thank you all very much.
>> thank you.
>> thanks, tom.
>> don't forget judge hohengarten's visit.
>> that's the rating that the judge gave us. More r?ck cracing reading from the--recreationing reading.
>> I moved it from my desk to yours.
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Last Modified:
Wednesday, August 30, 2006 12:28 PM