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Right place, right time, right approach

November 15, 2011
by Dennis Grantham, Editor-in-Chief
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Texans collaborate to build a “model” jail diversion and crisis mental health system

By April 2000, when he was named President and CEO of Bexar County Mental Health Authority in San Antonio, Texas, Leon Evans had learned two very important lessons in four years of work as the director of community services for the Texas Department of MH/MR in Austin: “If it costs money, don't bother asking” and “Sometimes, you have to get the bureaucrats out of the way.”

In his many years as a behavioral health executive, Evans had long before realized that local organizations had the desire, the vision, and for the most part, the ability to do good work in their communities. So, as state director, he relished the chance to lead a contracting process that devolved state community services programs and funding into the hands of Texas' 37 regional mental health authorities from 1996 to 1999. His approach combined a simplified list of performance standards, an emphasis on technical assistance, and added incentives for providers who outperformed the field. The mantra: “Support those who support the consumers.”

In 1998, at an interagency meeting of state officials, Evans learned a whole lot more about just who many of those consumers were. Tony Fabelo, PhD, who then headed the Texas Criminal Justice Commission, said that for years the state had been incarcerating too many non-violent offenders, including a growing number with “severe” mental health or substance use disorders.

Most, Fabelo said, had been convicted of non-violent, substance-related felonies-often possession or DWI under the state's strict 1980s-era drug laws, which made possession of as little as a gram or two of illicit substances a felony. These drug offenders were a major component in swelling the Texas state prison population nearly six-fold between 1978 and 2004, a period that saw corresponding growth in the populations of the state's 273 county jails. A decade-long, $2.3 billion effort completed in 2002 tripled state prison capacity to more than 150,000 beds.

By the middle of the decade, as prison numbers continued to rise, Texas legislators were forced to confront the prospect of adding to what was already the world's largest prison system. At that point, the effort to make criminal justice and sentencing reforms picked up steam, even among tough-on-crime lawmakers. A study group, the Texas Commission on Offenders with Medical and Mental Impairments (TCOOMMI), validated Fabelo's earlier finding that state prison beds housed large numbers of non-violent and low-risk offenders.

About one in five had severe mental illnesses, said the TCOOMMI report, while more had less severe mental health problems that contributed to serious substance use disorders (SUDs). These, along with a growing number of aging inmates, were driving increased prison healthcare costs because, under Medicaid's “inmate exclusion,” state prison inmates lose access to benefits, making every aspect of prison medical care a state problem.

A vision for collaborative effort

As prison problems were seen to worsen at the state level, county and local officials had known about and felt the problem for years. Evans, who left state office in 2000 when he was hired to turn around Bexar County's troubled behavioral health authority, The Center for Health Care Services (CHCS), saw going in that he'd have little money to work with, but freedom to pursue some big ideas.

The first idea, central to everything developed since, was to blend, braid, and integrate funding streams from many small bureaucracies to stretch their value. Freeing those dollars and putting them to work would require a tremendous level of collaboration, coordination, and trust. So Evans and his CHCS team set about identifying potential partners and getting to work on the second idea: an effective program to divert mentally ill individuals from jail.

CHCS team members started a conversation with the San Antonio PD and the Bexar County Sheriff's Department. At first, talk of diverting any offenders was ridiculed. But by understanding, then addressing the issue in terms of real law enforcement concerns, CHCS staff began to make headway. SAPD police overtime exceeded $600,000 annually, primarily due to time lost by law officers who had to arrest, transport, and arrange disposition for non-violent mentally ill offenders. The Bexar County sheriff faced legal action for overcrowding at the County's 3,400-bed jail.

Therapeutic justice programs in Bexar County

Felony Drug Court

Misdemeanor Drug Court

DWI Court

Community Court

Veterans Court

Mental Health Court

Not Guilty by Reason of Insanity (NGRI) Court

Mentally Ill Offender Facility

Outpatient Competency Restoration

Community Reintegration Program

Involuntary Outpatient Commitment

Forensic Assertive Community Treatment

Outpatient Substance Use Treatment for Probationers

Veterans Jail Diversion Program

“Initially, the focus of our jail diversion efforts was in the area of the mentally ill,” explains Gilbert Gonzales, Diversion Program Director. “But we soon found that the real question-the real problem for police-is, ‘What is the most appropriate place for this detainee, based on the seriousness of the offense?’” Because hundreds of detainees per month were mentally ill, public intoxicants, or homeless, the cycle of arrest, incarceration, and medical care posed a huge drain on police, hospital, magistrate, and jail resources.