Mark R. Howard
A Better Way
For many Floridians in the 1950s and 1960s, the name Chattahoochee was synonymous with mental illness. The small town, about 45 miles northwest of Tallahassee just this side of the Georgia border, houses the Florida State Hospital, which for decades was the only state-run mental institution in Florida. In that era, children who misbehaved or just acted silly at home were sometimes told to “stop acting crazy, or we’ll send you to Chattahoochee.”
Chattahoochee has other historical significance. After his father had him committed against his will, Kenneth Donaldson spent 15 years there in the 1950s. He sued the state, claiming he’d been confined illegally, and the U.S. Supreme Court agreed. The O’Connor v. Donaldson case changed the standards for confining the mentally ill and contributed to a national policy shift toward deinstitutionalization that saw nearly half a million mentally ill patients discharged from mental hospitals around the country between 1955 and 1994.
Many state mental hospitals were — and are — barbaric places, and many of those discharged didn’t need to be confined to be treated effectively. But the policy of deinstitutionalization means that many seriously mentally ill people who once would have been institutionalized are now on the streets. Their illnesses often go untreated. Many are homeless, lack family support, and when their behavior becomes problematic, they cycle in and out of very expensive institutions — crisis stabilization units, hospitals and jails. Particularly, jails. Between 15% and 20% of all inmates are seriously mentally ill, by some estimates.
Some communities in Florida, to their credit, have looked for better ways to help the mentally ill, starting with alternatives to incarceration. Since 2000, the Criminal Mental Health Project in Miami-Dade County — founded by Judge Steve Leifman of the 11th Judicial Circuit — has worked to keep the mentally ill out of jail. The project includes a program that trains police officers in de-escalating confrontations with the mentally ill and minimizing unnecessary arrests. Another component allows mentally ill people charged with misdemeanors — with the cooperation of victims and defense and prosecuting attorneys — to get treatment while awaiting trial. If a defendant completes the full program satisfactorily, charges are dropped. Meanwhile, the CMH Project has worked to renovate a former mental hospital as a secure facility to target “high utilizers” of public services who haven’t responded to diversion efforts.
Another notable effort: In 2014, Pinellas County, which has been a leader in using data-driven approaches to social services, began developing its own program aimed at people with hardcore behavioral health problems. The county commission funded the creation of an “empowerment team” (PCET) that targeted 31 people — 25 were men, 16 were white — who had been identified as the highest consumers of jail, hospital and crisis-related services in the county. Just those 31 people were costing more than $2 million a year in services.
To say the group was challenging to serve is an understatement. Most had severe psychological problems, including paranoid schizophrenia and bipolar disorder. More than 80% were homeless, alienated from family and other support. Many had extensive substance abuse problems. Most had encounters with the law, with offenses ranging from robbery and assault to prostitution, disorderly conduct, food stamp fraud and trespassing. In the one-year period before the PCET program, they had accounted for 1,816 days in jail, 842 days in shelters, more than $500,000 in Medicaid costs and another $266,000 in rehab and crisis intervention costs. One striking characteristic shared by many was a history of trauma, including physical and sexual abuse they suffered as children.
The members of the empowerment team, which included a uniformed officer from the sheriff’s department, functioned as case managers, building trust with the 31, developing intensive treatment plans, then coordinating mental health counseling, substance abuse counseling and — particularly important — help with housing.
An analysis of the PCET program’s first two years by the Louis de la Parte Florida Mental Health Institute at USF found significant success both in reducing the cost of serving the high utilizers and in improving the quality of their lives.
Total costs for jail and shelter stays, Medicaid and substance abuse treatment fell by more than $600,000, a nearly 60% decline. Jail costs, for example, fell 52% in the PCET program’s first year and 88% in the second year. PCET was able to find housing for 80% of the high utilizers, reducing the cost of shelter stays by more than 90%. Emergency room visits fell from 212 to 146 in the program’s first year, then to 66. The average cost per person for serving the 31 people fell in two years from $33,755 to $15,035.
Daisy Rodriguez, who heads Pinellas County’s Human Services Department, says that while most of those served by PCET will require continuing support, some can be moved to a “lower level of service” that requires fewer resources. The biggest lessons from PCET, she says, will be in improving coordination among the different parts of the mental health system to boost its overall effectiveness.
Connecting the various components of an enterprise — “silos” — is a good goal for any organization, public or private, that’s looking to improve the way it functions. The programs in Miami- Dade and Pinellas show government at its best, using data creatively to develop effective approaches to human problems that can’t be solved, but can be managed — humanely.
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