Initiative Eases Mental Health Burden in EDs

September 2009

By Heidi Splete
Elsevier Global Medical News

Managing mental illness at the community level can keep the mentally ill out of jail and out of the emergency department, illustrated by the success of a collaborative program in Bexar County, Tex.

Jail diversion programs have been in place in the United States for decades, but they have increased in the past few years, according to a 2004 policy report on the Bexar County program.

Dr. HnatowThe Bexar County Jail Diversion Program offers an example of how a joint effort involving the medical, legal, and mental health communities can help more people get the care they need with less drain on both law enforcement resources and ED resources, according to Dr. David Hnatow.

Jail diversion steers mentally ill individuals into the mental health system, and it can ease the burden on overcrowded EDs, Dr. Hnatow, a San Antonio emergency physician, said in an interview.

Dr. Hnatow also chairs a local community medical director round table, which has been a sounding board for the mental health initiatives in the county.

Bexar County has a high concentration of homeless people who are mentally ill and regularly commit petty crimes, Dr. Hnatow said.

The Center for Health Care Services created the diversion program in 2002 with a three-pronged intervention plan in mind: identifying persons with mental illness who might be vulnerable to arrest, recommending alternatives to jail for persons already in the criminal justice system, and providing mental health and support services to prevent recidivism.

To help identify vulnerable individuals, a law enforcement officer and licensed counselor go into the community in a mobile outreach effort to assess those at risk and determine what help they might need before a crisis occurs.

The jail diversion effort includes a week-long training course for police officers, in which they learn crisis management techniques such as active listening and how to talk to a person with schizophrenia.

The second phase of the program provides alternatives to jail for persons who have been arrested. Individuals are screened for mental health problems, and they may be able to go directly to treatment programs instead of to jail.

In 2005, the county established a Crisis Care Center, staffed by mental health and medical professionals 24/7, so police officers have a place to take individuals other than to jail or the ED for a psychiatric evaluation, said Dr. Hnatow. "Putting a psychiatrist and a medical provider in the same room seemed like a good idea," he said.

The crisis center manages approximately 800 cases a month, an average of five of which end up being transferred to an ED, Dr. Hnatow noted.

"Our promise to law enforcement would be that they would have a 30-minute or less turnaround time" when they brought individuals to the center, he said. That's a big improvement over a 12-hour wait in the ED, he added.

The program also works to prevent rearrest by providing cognitive training and employment opportunities to mentally ill individuals in their communities after they have been discharged from jail, a hospital, or a treatment facility.

In addition, San Antonio is in the process of building a "homeless campus" to provide medical care for the homeless, as well as food, housing, psychological, and legal services. The campus is scheduled for completion in December 2009, Dr. Hnatow said.

The Bexar County Jail Diversion program received an achievement award from the American Psychiatric Association in 2006, and it has been adopted by the state of Texas as a model for implementing jail diversion programs elsewhere in the state.

"This is a community problem, and it requires a community solution," Dr. Hnatow emphasized.

The team approach brings together law enforcement officers, judges, homeless counselors, and substance-abuse treatment providers. Mentally ill individuals who don't receive proper care cost the system more money, he said.

"It would be cheaper to provide them treatment than to put them in and out of jail," Dr. Hnatow explained.


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