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Patient Care

Tex. Agencies Collaborate to Resolve Mental Health Care Crisis

San Antonio Express-News

Aug. 21—Roughly 1,400 people a day use Haven for Hope as an overnight homeless shelter, the largest in San Antonio. The bustling 37-acre facility, just a mile west of downtown, is considered state of the art, with an outdoor sleeping courtyard, dormitories, a detox center, a psychiatric observation unit, a medical and dental clinic and a chapel.

Since opening in April 2010, Haven has been heralded for its array of services, but it also is a source of frustration for first responders.

According to the San Antonio Fire Department, the dispatch center received more 911 calls from Haven for Hope than any other address. In July 2017, the Fire Department alone responded to Haven 124 times and transported 81 people to medical facilities. Some were for trivial problems, like a toothache, Fire Chief Charles Hood said Monday.

"That ties us up," Hood said. "That keeps us from going to critically ill patients, such as your family members, house fires, car wrecks, drownings, all of those things."

Around 2 1/2 years ago, a handful of health professionals and emergency responders organized what came to be known as "Haven meetings" to discuss the high volume of calls.

In time, the group recognized that the issue was much broader. In Bexar County, there were a number of programs for people experiencing mental health issues or homelessness, but there was little coordination among them. Often, the agencies failed to follow up with clients.

The group decided a larger collaboration was needed.

On Monday, after a year of preparations, the Southwest Texas Crisis Collaborative formally launched in an effort to provide a comprehensive system of care for anyone experiencing a mental health crisis. The "unprecedented" collaboration involves 23 public and private health care providers and emergency responders.

"This is a pivotal and transformative moment for our health care system," said Marc Raney, interim CEO of Methodist Healthcare Ministries, which is helping fund the collaborative. "This will have a tremendous benefit for our community."

Initially, the collaborative will focus on five initiatives. Some have been in existence for nearly a year while others are still developing. They include:

  • The addition of a paramedic to the Fire Department's Mobile Integrated Health Team. The paramedic will be stationed at Haven for Hope from 8 p.m. to 7 a.m., when health care resources at the campus are limited.
  • A technology platform that allows all participating organizations to develop and access a treatment plan for a patient. This helps combine social, financial and local resources for patients who frequently call 911 or use crisis services.
  • Continued funding of inpatient beds at Nix Health. The Psychiatric Emergency Service, operated by Nix Health, was in jeopardy of closure earlier this year due to changes with a federal incentive program. The new collaborative allocated money to ensure 16 beds would remain available there, along with funding for 16 more beds.
  • A computer system that allows police officers to see in real time which facilities have open beds for patients experiencing a mental health crisis.
  • The launch of a transitional housing program for people with mental health diagnoses who are getting out of jail.

Officials estimate that the collaborative will save taxpayer money and boost mental health services for patients.

"The goal is straightforward," Bexar County Judge Nelson Wolff said, "to improve access to mental health services and to get the person in the right place at the right time in the most efficient way."

In 1989, the state of Texas faced a similar lack of coordination, but among trauma facilities, especially in rural areas. Patients were not receiving the care they needed.

That year, the Legislature passed a bill that aimed to fix the problem. Texas would develop a statewide trauma system to improve communication, enhance planning and expedite response times. Hospitals, first responders and ambulance services would all be involved.

The state was divided into 22 regions, or Trauma Service Areas. Each region was overseen by an advisory council. The Southwest Texas Regional Advisory Council covered 22 counties, including Bexar County.

The initiative was a huge success. Over the years, each council grew to encompass emergency systems planning for strokes, cardiac, neonatal and maternal injuries.

Today, the Southwest Texas Regional Advisory Council oversees coordination of 71 ambulance services, 63 hospitals, 16 cardiac centers, 17 stroke centers, four medical air providers and two level-one trauma centers.

That coordination means, for example, that a trauma patient gets to a trauma center, said Eric Epley, executive director of the Southwest Texas Regional Advisory Council. "If we have uncomplicated, nonmedical patient who is psychiatric, we should take them to a psychiatric center."

Now, the council also will oversee the Southwest Texas Crisis Collaborative.

Before Monday's announcement, officials have tried to address various long-standing issues in Bexar County's mental health system.

In the early 2000s, city and county officials, concerned over the criminalization of the mentally ill and the inefficient use of law enforcement to address mental health crises, developed a series of steps to mend the system.

Among the problems officials identified: Emergency rooms were clogged with nonviolent detainees in need of psychiatric help. Police officers who brought detainees to an emergency room had to wait, at times for up to 15 hours, for them to be seen.

At the time, the San Antonio Police Department estimated it spent about $600,000 annually on overtime and additional shifts for the officers.

In 2005, the Crisis Care Center opened at the University Health Center downtown to help address the problem. The new drop-off center, a collaboration of several local agencies, was designed to get officers back on the street within 15 minutes. With the Crisis Care Center in place, medical, psychiatric and jail-diversion programs were all under one roof.

Officials heralded the results. In the last 10 years, the Center for Health Care Services, the agency that oversees the Crisis Care Center, estimates that over 100,000 people have been diverted from emergency rooms and jail cells because of their services, saving Bexar County and the city of San Antonio an estimated $96 million.

Other studies, though, showed more improvement was needed.

In 2015, a study of Bexar County's mental health system found that police officers detained and transported more than 9,000 people to local hospitals. A police officer is allowed to detain an individual without a warrant if they are exhibiting symptoms of a mental illness and appear to be a threat to themselves or others.

Only half of them needed emergency medical services, the study found. The rest simply needed psychiatric care. That clogged emergency rooms and increased wait times.

It also failed to provide the best care possible.

"Someone who is in a mental health crisis is in a very vulnerable condition," said Rose Rodriguez, a psychiatrist who oversees behavioral health services at Nix Health. "I would much rather have them be in our care than in law enforcement custody ... or in an emergency room, where they don't have psychiatric services."

In response to the study—and the issues identified at Haven for Hope—officials informally launched the Southwest Texas Crisis Collaborative.

Staff is calling the last year an "incubator year," as officials worked to recruit participating agencies, secure funding and formalize contracts. Many agreements weren't finalized until June, the collaborative said.

Some projects were launched during that time, including a change to Bexar County's medical communication system that allows police officers to know in real time the number of psychiatric beds available at emergency departments and mental health facilities.

"This saves a lot of time," Police Chief William McManus said. "Police officers don't have to go searching for a hospital."

In the coming months, the collaborative will continue to develop the five programs detailed Monday. It will unveil additional initiatives next year.

"(This) is a really exciting time in our community and in behavioral health. We're bringing all the systems together in an organized way," said Dr. Sally Taylor, chief of behavioral medicine at University Health System. "It was no small feat."

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