The state of Texas has 2,477 hospital beds reserved for mentally ill patients, according to Joe Vesowate, the assistant commissioner for mental health and substance abuse services at the Texas Department of State Health Services.
Of those beds, 738 are reserved for "forensic patients," or those who have committed a crime but because of mental illness are not able to work with an attorney or participate in their own legal defense.
Those beds are full, Vesowate said.
As a result, hundreds of forensic patients wait to be transferred from city and county jails to an appropriate state mental health facility. Some wait as long as 70 days before they are evaluated or moved to a state hospital, he said.
Out of beds
That's a problem because city and county jails must bear the costs of care until they transfer the patients, Vesowate said.
That is a substantial unfunded mandate, and it could result in a serious legal challenge, according to Beth Mitchell, managing attorney for Advocacy Incorporated, a federally funded organization that advocates for the rights of Texans with disabilities.
"Yes, 240 people sitting in our jails waiting to be restored to competency--that is a lawsuit waiting to happen," Mitchell told a joint meeting of the Senate Health and Human Services Committee and the Senate Committee on State Affairs on August 23. "There have been other lawsuits, exactly the same type, that have found that that is a substantial deprivation of somebody's liberty, and [the courts] have required those states to increase funding in order to serve them appropriately in appropriate settings."
Mitchell said her organization might be forced to file a lawsuit if the state does not act.
Caring for forensic patients is a costly endeavor, Mitchell said.
"It costs $270 a day for a person in a hospital," she said. "To serve a mentally ill person in a jail it costs $130. That doesn't include $91 for your court costs, [and] your booking costs of $160."
Transportation costs to transfer a patient can add $400 to $500 more, she said.
Brazos County Sheriff Christopher C. Kirk said his county spends $150,000 to $200,000 a year on medication alone for forensic patients.
"Ten to 15 percent of our jail capacity, which is 546 beds and is over capacity, are MHMR [mental health and mental retardation] patients," Kirk said at the August Senate hearing. "In Brazos County in 2005, we transported 837 patients for 82,800 miles, and it took the full-time equivalent of two officers to do that. It's quite an impact on every county in the state."
A better way
Vesowate said there is a better, more inexpensive way to deal with forensic patients.
DSHS has asked the Texas Legislature for $82 million to fund what it calls a crisis services redesign. The project would put more funding into local crisis services.
The funding for forensic patients also would help the state better serve "civil patients"--those who have not committed a crime, said Sandy Skelton, CEO of the Texas Council of Community MHMR Centers.
"Each of the 40 MHMR hospitals has only so many beds," Skelton said. "Having more forensic patients puts more pressure on the civil beds. It is crowding out the civil capacity."
Funding for more beds would help, he said.
"If DSHS is successful [in getting the funding], that would go a long way to keeping people out of state hospitals. The number of state hospital beds per capita is very small--that's the primary problem. We have too few beds for a state the size of Texas."
Vesowate said the funding could allow local communities to offer 23-hour observation programs.
"It's cheaper for the county, and the patient's family can be present," he said. "Clearly a less-restrictive environment could be provided."
Mitchell said community-based programs can cost as little as $21 a day per person. They are cheaper and more effective, she said.
"The state spends very little on mental health services in the community," she said. "Instead we are increasing the use of emergency rooms, jails and state hospitals--the three most expensive services the state of Texas has."
The larger issue, Mitchell said, is about 72 percent of the people in Texas who need mental health services don't have access to them.
"People are not getting the services they need in the community," Mitchell said. "They are getting them in jails, where they stink. Jails don't have adequate staff to treat them. They are getting better, but they are still bare-bones, minimal."
A new review
Vesowate said DSHS is reviewing mental health crisis services in Texas. The review includes a survey that showed that 77 percent of law enforcement agencies and 71 percent of hospitals said patients had to wait more than an hour to meet with a crisis provider. During on-site reviews, 87.5 percent of patients did not get help within an hour.
Half of the local mental health authorities did not provide ongoing intervention until a crisis was resolved or the person was placed in the appropriate environment.
The report concluded that the state needs a new model for crisis mental health services. It recommended county, city and local authorities, courts, law enforcement agencies and school districts work together. It also said rural crisis care needs to be a priority.
"What we have to do is enhance the crisis services system so that all parts of the state have the work force and infrastructure to help folks with mental health or substance abuse problems," Vesowate said.
Community-based, 23-hour observation programs could eliminate costly trips to the 10 state hospitals spread across Texas, he said.
"That way we don't have to drive them from Bastrop County to Travis County, or even further out, from Bryan or Lee counties," he said.
Jail diversion programs should be a priority, Kirk said.
"Patients that have resources find help," he said. "Those that don't rely on us to help them, and sheriffs as a whole, believe that jail is not the appropriate place to hold mental patients and those that are in crisis."
Jail diversion programs have been successful and should be replicated across the state, he said.
Williamson County is home to one effective jail diversion program, according to district attorney John Bradley. The county has two jail diversion teams, one that works with police and another that works with MHMR and responds to non-criminal calls. The program costs about $500,000 a year, Bradley said.
"We have successfully diverted hundreds of people that we normally would have taken to jail," Bradley said. "And Williamson County, by spending this half-million dollars, has saved itself a million and a half dollars."
Mitchell said it would be easy to move care back to the communities.
"The state could say we must provide these services in the community for these people," she said. "Right now they are sitting there in jail waiting to get transferred. Some are abused by other inmates or they are in segregation cells, alone for 23 hours. That's got to be the worst thing you can do to them, have them sit there and listen to the voices in their heads."