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NTSPP Advocacy Bulletin January 2011:   Assisted Outpatient Commitment: Getting Beyond the Barriers to Appropriate Care ~ Considering a Solution to a Serious Problem

Why do some people with severe mental illness and/or addictions refuse appropriate treatment? Do they truly prefer to wander the streets and deteriorate in health and social functioning? As physicians we know that there are people who do not have the family or personal mental capacity to choose to obtain appropriate services, even if they were available to them.

Further, they cost society significant dollars in frequent hospitalizations, arrests, and jail time.

Assisted Outpatient Treatment (AOT) is a court-ordered treatment utilized by forty-four states (including Texas) and can be referred to as “Outpatient Commitment.” This court-mandated treatment is critical to save the lives and restore many individuals with persistent mental illness. Those individuals who have a history of medication non-adherence are in particular need of AOT.

The Evidence that it Works
In New York State, after five years of implementation of AOT, only 22% of those under AOT were hospitalized compared to comparable patients who were not court-ordered to receive treatment (including medications), with the result that 97% of the latter were hospitalized.

In a North Carolina study, intensive outpatient treatment without court-ordered services did not reduce hospital admission. However, when court-ordered services included three outpatient visits a month and use of appropriate medications for at least six months or longer, hospital admissions were reduced by 57% and those who were hospitalized had significantly fewer days in the hospital (Swartz et al., Can involuntary outpatient commitment reduce hospital recidivism? American Journal of Psychiatry, 156:1968-75, 1999).

Enacting Outpatient Commitment in Texas

Keep in mind that health care quality and safety ought to be of utmost importance in the minds of the legislators this cycle. Having considered the criticisms of coercion in treatment extensively, experts have concluded that “patient-centered care aims to promote patients’ engagement in their own treatment to the extent consistent with their abilities.” (Monahan et al., Mandated treatment in the community for people with mental disorders, Health Affairs, 22(5):28-38, 2003).

In Texas, outpatient commitment criteria are:

1) The presence of a severe and persistent mental illness;

2) If untreated, the person is likely to suffer from severe and abnormal mental, emotional, or physical distress and deterioration of the ability to function independently, leading to an inability to live safely in the community;

3) The person is unable to voluntarily and effectively participate in outpatient treatment (Summary for “State Standards for Assisted Treatment in Texas” as provided by the Treatment Advocacy Center, www.treatment advocacycenter.org).

AOT is largely underutilized in Texas, perhaps because families, medical personnel, and the courts are unaware of AOT and its utility. We are providing this information to you in the hope that your office can inform constituents should such a need arrive.

Concluding Request

We must get past the rhetoric to the judicious use of Assisted Outpatient Treatment (AOT) for those people who are relying on us to help them get beyond the imprisonment of their mental illness. Let’s not ignore them.

Postscript from the President to North Texas Legislators:

This is the second Patient Advocacy Bulletin forwarded to you as a North Texas legislator. Our first bulletin emphasized the inappropriateness of the use of jails and prisons in lieu of adequate treatment for severely and persistently mentally ill and addicted persons. This Bulletin describes a solution for some in the category of the severely and persistently mentally ill. It is our hope that you, as a Texas legislator, will attend to these issues and direct your staff to look more closely at what is happening in your particular community. We fear that there is indifference to these issues and urge you, as a Texas legislator, to initiate a process to correct inequities in funding for mental health services that exist across the state of Texas but which are particularly acute in the NorthSTAR service area, which includes the following counties: Dallas, Collin, Kaufman, Rockwall, Navarro, Ellis and Hunt.

We as members of the North Texas Society of Psychiatric Physicians are willing to answer questions concerning the treatment of the mentally ill and addicted and to provide further information per your request. We appeal to your interest in this topic not just because of the obvious cost savings that would be incurred if proper funding for adequate treatment were made available, but more importantly, we appeal to your conscience to help our citizens who are unable to help themselves.

Thank you very much. For further inquiries contact Edgar P. Nace, MD, at the following address:

Edgar P. Nace, MD
President NTSPP
12700 Hillcrest Rd,. Ste. 260  Dallas, TX 75230
972-716-9678 (phone)    972-789-9324 (fax) epnace@aol.com

The Advocacy Bulletin will be published periodically in order to inform legislators of mental health and addiction issues. We welcome comments and requests for information on specific topics. Contact NTSPP at: ntsppchapter@gmail.com

NTSPP  Advocacy Bulletin  December, 2010:   CAN WE AFFORD NOT TO SUPPORT MENTAL HEALTH INTERVENTIONS IN OUR CORRECTIONS SYSTEM?Did you hear about the recent study* finding that 10% of Texas prison inmates had serious mental illnesses (i.e., bipolar, major depression, schizophrenia, or psychosis other than schizophrenia)? Mentally ill prisoners are more than twice as likely to have repeated incarcerations compared to prisoners who are not mentally ill. Furthermore, the mentally ill are likely to have a longer sentence than the non-mentally ill.

In the coming session, difficult decisions need to be made regarding funding for the criminal justice, court system and public mental health system. In doing so, please consider the following representative fictionalized case scenario:

When Mr. Smith was picked up by police officers,he was off medications for several months and living on the streets. He began drinking heavily to subdue the voices in his head. When he eventually became paranoid and agitated, police officers took him to the emergency room to receive medications. His charges were dropped by the judge who heard his case in the adjacent mental health court and he was transferred to an inpatient facility, detoxified from alcohol, and observed on medications until he was stable enough to be discharged directly to an Assertive Community Treatment (ACT) Team.

If Mr. Smith was written off as someone who is not deserving of attention because he “drinks half the time” and if police officers did not recognize that he likely has a serious mental illness, he may have spent time in jail where he would get worse and perhaps commit further offenses.

Alternatives to incarceration include treatment centers for non-violent offenders (pre-booking) and mental health courts (post-booking) where non-violent mentally ill are placed in closely supervised treatment programs. According to the Texas Taskforce on Indigent Defense**, Mental Health Courts and Mental Health Public Defenders significantly reduce recidivism. In Dallas County, the six-month recidivism rate for people with schizophrenia with no mental health public defender was 18%, but with a mental health public defender, recidivism dropped to 5%. That saves money and saves patients undue suffering from restraint, confinement, or extended sentences.

Mr. Smith was assigned to an ACT Team; its services included illness management, recovery, and rehabilitation which kept him out of more costly state funded services. Because 20 to 25% of mentally ill prisoners will have a history of a violent crime and not be eligible for diversion, there is a need for alternative correctional facilities where those with mental illness can be vigorously treated and rehabilitated.

With our state budget shortfall, we should not neglect the cost-saving measures that are already in place that continue to save Texans money and provide appropriate treatment and diversion for mentally ill offenders.

Two things psychiatric physicians in North Texas request you to do:

1. Support diversion courts for the mentally ill to prevent them from getting caught up in the criminal justice system.

2. Support funding for mental health care providers and resources in the correctional system including rehabilitation and recovery services.

*Baillargeon J., et al. Psychiatric disorders and repeat incarcerations: the revolving prison door. American Journal of Psychiatry 2009; 166:103-109.

**Carmichael, et al. Representing the mentally ill offender: an evaluation of Advocacy Alternatives, Texas Taskforce on Indigent Defense. Office of Court Administration, April 2010.

The Advocacy Bulletin will be published periodically in order to inform legislators of mental health and addiction issues. We welcome comments and requests for information on specific topics. Contact NTSPP at: ntsppchapter@gmail.com.

From NAMI Collin County:

There will be a Town Hall Meeting for the North Texas Behavioral Health Authority (NTBHA) to gather information and input on the Public Sector Behavioral Health program (NorthSTAR) on Tuesday, March 9, from 6 to 8 PM at Custer Road Methodist Church.  The church is located on the west side of Custer Road north of Spring Creek and south of Legacy. 

We hope to see you all there!

Sharon DeBlanc
President NAMI of Collin County

OPEN TO THE PUBLIC  –  Regarding the Public Mental Health System in Dallas County (NorthSTAR)

DALLAS COUNTY  Behavioral Health System Redesign Task Force

Thursday, March 25, 2010  9:30 a.m.

Dallas County Health & Human Services Building    Hickman Conference Room (Room 627)
2377 Stemmons Freeway   Dallas, Texas  75207

Commissioner John Wiley Price, Chair  and Commissioner Maurine Dickey, Vice-Chair

Call to Order – 9:30 a.m.
Reports
(9:35 a.m.) Update on Parkland Study – Josh Flores
(9:40 a.m.) Update on Collin County Study – Dr. des Anges Cruser
(9:45 a.m.) Update on Transfer of Authority to NTBHA – Alex Smith
(9:55 a.m.) Update on NorthStar Psychiatrists Survey  – Dr. Ed Nace
(10:00 a.m.) Update on Goals of Project Transform – Ryan Brown

Legislative Advocacy Plan
(10:05 a.m.) – Legislative Report – Craig Pardue
(10:15 a.m.) – Review Advocacy Template – Janie Metzinger
(10:20 a.m.) – Discuss CJAB Legislative Agenda Item – Ron Stretcher
(10:25 a.m.) – Review/Assign Legislative Visits – Shay Cathey

Next Meeting Date: April 22, 2010

Adjournment

President’s Column from the Winter 2010 NTSPP Newsletter*

            The city of Seattle saved $4 million in hospital, jail and other public services after 95 homeless people moved into one housing project. These 95 people’s visits to hospitals and jails before had cost tax-payers nearly $8.2 million. Other facts concerning the wisdom of providing permanent supportive housing for the chronically homeless can be found in Kim Horner’s Dallas Morning News article of Sunday December 13, 2009. This article focuses on Dallas’s empty Plaza Hotel which a developer has been attempting to make available for permanent supportive housing. The state rejected this developer’s application for tax credits in March 2009, most likely because of neighborhood opposition. As a result, the twelve-story Plaza building remains empty and thousands of people in Dallas remain on the streets or in jail or emergency rooms, incurring costs of tens of millions of dollars, not to mention the human misery.

            Politics and bureaucracy seem to overrule humanitarian and common sense solutions. The American Heritage Dictionary defines bureaucracy as “administration of the government chiefly through bureaus or department staff with unelected officials”; “management or administration marked by diffusion of authority among numerous offices and adherence to inflexible rules of operation”; “an administration in which the need or inclination to follow complex procedures impedes effective action”. The dynamics of a bureaucracy can promote self-protection and self-serving behaviors at the expense of the actual mission of the bureaucracy.

            Can we as individual citizens and physicians, or as a small organization such as NTSPP, have some influence? I think we can but it does require patience, time and study of the issues. Should we not as a medical organization speak more loudly in the interest for permanent supportive housing? I hope that we will and I would welcome your thoughts on what NTSPP could do.

              Along similar lines, the possibility of the transfer of authority for mental health services may arrive in north Texas under the aegis of the North Texas Behavioral Health Authority. It is premature to assume that this is a done deal as the authority for mental health services resides in Austin in the Department of State Health Services. Several of us think it is critical that the authority be local, i.e. with the seven north Texas counties served by the NorthStar system. Should this transfer take place, it will be critical that the North Texas Behavioral Health Authority (NTBHA) have sufficient funds and personnel to do the job. NTBHA has a very strong board under the leadership of Judge Michael Chitty and has recently hired and effective executive director, Mr. Alex Smith. In my opinion, an additional positive step would be the creation of a NTBHA medical director’s position. This has existed in the past but not in recent years. Again, the issue of bureaucracy is relevant as the needs of the chronically and persistently mentally ill and addicted in the north Texas area needs to be a focus of concern and not issues of bureaucratic infighting. The Department of State Health Services allocates 38% of its $2,942,000,000 budget to mental health and addiction services. Yet, the Department of State Health Services does not have a psychiatrist with line authority. There is a psychiatrist on board but the position is more that of a consultant than one with authority to design appropriate services. If a psychiatrist or, more appropriately, several psychiatrists were to be included in the Department of State Health Services organization with real authority; it would behoove our professional organizations to consult with such psychiatrists and help assure that bureaucratic procedures do not impede what needs to be done for the individuals for whom the bureaucracy actually has been created to serve. 

            I believe we, as citizens and physicians as well as a relatively small professional organization, can play a constructive role if we are willing to relate to these issues and interact with the entities which carry the responsibility. What is your point of view?

                                                                        Edgar P. Nace MD,  President NTSPP,   NTSPPpresident@gmail.com

*Note:  All psychiatrists and psychiatrists in training  in the Dallas Area for whom we have email addresses  receive the complete newsletter by e-mail.  Didn’t receive one?  Send your name with degree and email address to NTSPPchapter@gmail.com. 

SHELTER: Thursday 4 pm

Laundry started pick up today & will be on Tues & Thurs 1800-1900 hrs

Laundry drop off will be Mon & Weds 0830-1000 hrs

Houston has asked us to hold off sending folks back for now – so we will have company into next week

FEMA requires registration before moving into hotels that FEMA selects, and

FEMA requires their number & picture ID for moving

Medical clinic will transfer from MRC to PMH HOMES medical staff with operation 1000-1400 hrs

Mental Health will move to a 12 hour shift daily

EMS will continue 24/7 daily

Meds pick up will be 1600-1800

OEM update:

The State call had a different emphasis today. It was on transitioning people back to their homes or to hotels and apartments if they don’t have anything to go home to. There will be a big meeting with FEMA after the call to work out funding details. Another call will be held this afternoon to explain the process. Also, the State has buses ready to fan out as soon as the damaged counties are ready for folks to return. We have heard that Harris County and Houston may be open, but we are waiting on official confirmation.

We had 930 folks in the shelter overnight. We were able to consolidate the other Dallas shelters into one; and appreciate the help from DISD and DART in moving people. FEMA has set up a table to register them so they should be ready to move to hotels as soon as that program is announced today. Other social services are welcome to set up in the Library; contact Kjerstine Nielsen at 214-670-7809.

The Dallas Fire-Rescue Team has been released and will return to the City this afternoon. They did a great job with search and rescue in the Orange County and Bolivar Peninsula areas. The Debris Team working in Houston continues their work. They are now asking for “load and haul” assistance more than tree cutting, so our Park Dept may be called on to help with that. Mary Nix is talking with the Houston contingent as we speak.

Hopefully more later on the transition to hotels or bus repatriation to the southern areas.

FEMA info Dr. Barnes sent:

 3 Areas Points:

#1. Hotel/Motel Program:

Good for 30 day period beginning first day of Implementation – until October 14th.

Can be extended after that time.

1-800-621-FEMA

 #2. State Critical Needs Incidental Program

Funding up to $500 for incidentals

60 day period and not be extended

1-888-766-3258

#3. Emergency Food Stamp program – HHS: 1-877-541-7905

Card may also be used on hot, ready to eat foods, not normally allowed under federal rules

TexasBenefits.com

www.HHSC.state.tx.us (emergency food stamps)

If they are already on stamps and in the affected area, then they will be automatically reloaded.

Apply by : October 17th.

* The attachment shows the Houston Estimated Time for Completion of Substantial Restoration.

Dave

Dave Hogan, LCSW, DAPA

Crisis Intervention Manager

Environmental & Health Services

City of Dallas

1500 Marilla, 2DN

Dallas, TX 75201

(214) 670-4225 phone

(214) 957-6902 cell

(214) 670-4669 fax

david.hogan@dallascityhall.com