SAN ANTONIO — The plan was simple: instead of arresting the mentally ill for crimes, treat them for their illness.
Keep them out of the jails and emergency rooms and instead provide them with a one-stop shop where they can be treated with psychiatric care, counseling and rehabilitation. The plan in this Texas city was to help them heal.
This happened in 2008 when the Roberto L. Jimenez M.D. Restoration Center opened. Since that time, close to 50,000 people have been treated, saving the law enforcement more than 100,000 manpower hours that can now be spent on the streets, and saving taxpayers more than $50 million.
The center opened because of humane issues and not necessarily any financial ones that were plaguing the jails and hospitals. It came after Leon Evans was hired as president and CEO of the Center for Health Care Services in San Antonio. Previously he served as the director of community services for the Texas Department of Mental Health and Mental Retardation, and had become “aware of so many of these people becoming criminalized.
“There was a disconnect between the mentally ill and the community.”
And it is a connection leaders in Montgomery are working toward building in the Capital City.
“I can prove treatment works,” said Evans, the mastermind behind the center. “I do it through the criminal justice system. We focus our dollars on intervention points, catching these people before they end up in prisons and emergency rooms. We decided a person shouldn’t be criminalized if they have a mental illness.”
The Restoration Center, housed in a former job corps building, is an integrated clinic where people can receive psychiatric care, substance abuse services, general health care and transitional housing. There is a Sobering Unit, an Extended Observation Unit and a Detox Room. And there are programs including the “Mommies Program,” which treats pregnant women addicted to heroin, and more programs including a Crisis Care Center, an Injured Prisoners and Minor Medical Clinic, an Opioid Addiction Treatment Services and Outpatient Transitional Services.
It costs $100 million to operate annually.
“Leon is an icon in mental health,” said Jimenez, a psychiatrist and mental health care advocate. “He proposed this idea … where we had everything under one roof. It is truly a remarkable story.
“We’re the third largest county in the state of Texas, and the poorest county in the state of Texas. And yet, we’re able to do something that New York, Dallas, Chicago … it didn’t even dawn on them to do. It depended on relationships with city leaders, private businesses, military leaders, schools.”
The relationships were built with law enforcement, first responders and emergency rooms.
“But no good deed goes unpunished, which you need to remember in Montgomery,” Jimenez said.” We developed all of this, and guess what counties around us decided to do? They thought they’d send people to San Antonio. You have to be careful. Those are the things you learn. I think the main lesson is unless you have a charismatic leader who can bring every sector of the community together, it’s just not going to happen.
“Don’t kid yourself, it’s not going to be smooth. but over time, we’ve developed that trust.”
A case based on numbers
When Evans worked for the state, he became “painfully aware of the people going through the criminal justice system with severe mental illness, and that they were really there because they were untreated.”
Studies have shown, he said, that behavioral mental health is on the top of lists when looking at which diseases costs society the most in early death: bipolar, schizophrenia, major depression, post traumatic stress, personality disorders, alcoholism and drug use.
People in the U.S. with severe mental illnesses, he added, die at least 25 years sooner than the general population as they go untreated and undiagnosed.
“These people are dying early, but not from their mental illness,” Evans said. “Most go undiagnosed, and they start self-medicating with alcohol and drugs. Their illness is so debilitating so they don’t work, don’t have insurance, don’t receive care, don’t eat properly. All of these things compound their early death. So you’re dying of congestive heart failure, liver disease, diabetes …”
The problem, Evans said, is that the country used to think that 16 percent of people going to jail had mental illnesses, but “that’s because we never tested them. It’s more like 40 percent or maybe even higher. Most people are arrested for alcohol or drug-related offenses, and most of them have a mental health issue.”
The Sobering Unit
It is a voluntary program for those brought in by the San Antonio Police Department — and who are brought in on public intoxication-related incidents. Funded by the city of San Antonio — and costing $1.9 million a year — in the eight years it has been in existence, it has saved the city $50 million, said David Pan, director of Acute Care Services at Restoration Services.
It is meant to be a place where people can sleep on available mattresses until they are sober enough to leave.
“They can go to jail, or sober up,” Pan said. “There’s a lot of college kids here who go down to the Riverwalk and get drunk. They don’t really need to get arrested. They just need to … think about what they’re doing. So the police will bring them here.”
As Evans sees it: “There’s a reality check there, too. If you are next to some homeless person … that’s a wake-up call.”
The unit averages about 5,000 people a year, with peak times between 11 a.m. and 6 p.m. and 11 p.m. and 6 a.m. They stay between one hour and 12 hours, with between four hours to six hours being the average. They are processed in, vitals are taken, they drink water or Gatorade and sleep on mattresses until they are sober.
If there is a warrant out on someone, they are not left there. And if more care is needed than just rest and hydration, a physician’s assistant or a crisis assessment is performed that helps people get linked to services.
“A lot of them actually think we’re family, as often as we see them,” said Manuel Molina, a licensed chemical dependency counselor who works in the unit on 12-hour shifts.
“We do get a lot of college kids and tourists who don’t belong in jail and don’t need a ticket and to taint their record,” Molina said. “We don’t reject anybody. A lot of times they want to negotiate (leaving). Technically, they can leave whenever they want. So I redirect and negotiate and it seems to work sometimes for an hour or more.
“I ask them to talk again, to drink more water. They’re under the influence so they’re redirectable like children. It’s a dance.”
The five-to-seven-day program is primarily for those who don’t have insurance. Texas didn’t participate in the Affordable Care Act, so “we still have if not the highest, then one of the highest, of uninsured people in the country.”
The room is funded by the state department of health services – the FY 2017 budget is $1.9 million – and are general revenue dollars appropriated by the state Legislature from tax revenue. The DSHS reimbursement rate is $224 per patient per day.
“We also accept Medicaid reimbursement but the Texas Medicaid rate for inpatient detox is only $138 per patient per day,” Pan said. “We have a few third-party insurance agreements, but generally refer people with insurance to other private providers.”
He said the center tries to reserve the 28 detox beds for the large number of people requesting services who do not have benefits of any kind.
Those who arrive are assigned a licensed chemical dependency counselor, and are then treated for alcohol, opioids and benzo, or benzodiazepine, a class of psychoactive drugs typically used to help people reduce anxiety, prevent panic disorders, relax muscles or promote sleep.
Extended Observation Unit
Along with the crisis walk-in center, this 48-hour observation unit costs about $5 million a year and is primarily a crisis stabilization unit with the average person staying about 20 hours. Certified by the state health services, it is staffed by psychiatrists and licensed practical nurses.
“Almost anything, we can address,” Pan said. “We have mental health assessors, licensed mental health professionals. About half the time they can resolve the crisis issue immediately. About half the time, people come in and go into our extended observation. It’s crisis stabilization, a hospital diversion program, rather than them go into a psychiatric bed. It saves the taxpayers thousands of dollars.”
This budget for the unit includes the EOU and the licensed mental health professionals who provide mental health assessments for crisis walk-in customers and people brought in by law enforcement. Funding comes from a variety of sources including general revenue, Medicare, Medicaid and private insurance billing.
“We also receive about $1 million from the University Hospital system, the county hospital for Bexar County,” Pan said. “University Hospitals is a taxing entity and pays for three beds in the 16 bed EOU for patients who come or are brought to the UHS emergency department and are in need of crisis stabilization rather than inpatient hospitalization.”
Mental health, stigma, outreach
“(The) stigma is so bad now so when you hear about mental illness what do you think about?” Evans asked. “You think about the (Jared Lee) Loughner kid who shot the congresswoman (Gabrielle Giffords). You think about the kid who shot all the babies at Newtown. You think about the (Washington) Naval Yard shooting. The kid that shot everyone in the theater in Aurora. Young people, that’s all they hear, too.
“So when you get that first diagnosis, you run. You don’t accept it. It’s very difficult. But most of these people don’t know what’s wrong. They feel weird, and when they drink or use drugs, they feel better. That leads them down the wrong path.”
And most mental health authorities across the nation don’t deal with this population, he said.
“These folks don’t knock on our door,” he said. “These people don’t realize that they are sick. They are depressed, so they are drinking, smoking dope, or they are using drugs. They don’t think something is wrong with them to the point that they’ll seek treatment.”
They do frequent emergency rooms, though. In San Antonio, a high utilizer program allows for medical records to show up across the board in hospitals.
And when someone shows up “inappropriately” in an emergency room three or more times in a quarter and that have a mental illness diagnosis, they are placed in a specialized program to engage them in treatment.
“We’ve had a 50 percent reduction in people using the emergency rooms at a savings of several millions of dollars,” Evans said.
He notes that opening the Restoration Center came after Bexar County considered building an additional 1,000 beds around 2001 to 2003. But because of the jail diversion project, the county never built them, and the Bexar County Jail now has about 1,000 vacant beds from original inventory.
“One of the things I’ve been trying to promote is how you pay and what you count drives behavior,” he said. “Most health insurance and most Medicaid pay for what I call ‘card services.’ They pay for inpatient and outpatient services.
“If we would develop some specialized programs like crisis respite, intensive case management, short-term residential treatment – some things like that that are some of the things that we do here, then these people become a lot more functional, and wouldn’t be in that vicious cycle … and they live much longer and you can go on and on and on.”