Dallas County, Texas
Urban/Rural Population: 99.31/0.69ii
In September 2017, the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Association of Counties (NACo) and the Laura and John Arnold Foundation (LJAF) hosted the Data-Driven Justice and Behavioral Health Design Institute (Design Institute) in Rockville, Md. The Design Institute convened 13 teams committed to the Data-Driven Justice (DDJ) initiative. Teams were selected through a competitive process to work directly with expert faculty in facilitated sessions and workshops to create action plans for developing and using integrated data systems that would aid their jurisdictions in identifying high utilizers of jails and crisis services. This case study is part of a series highlighting counties that participated in the Design Institute.
Dallas County leaders are committed to improving the mental health care of individuals involved in the justice system. In 2011, the Dallas County Commissioners Court established the Behavioral Health Leadership Team (BHLT), partly on recommendation from a task force the county formed to assess the design of the local behavioral health delivery system. A main purpose of the BHLT is to identify and engage stakeholders from across the county to plan, develop and deploy effective behavioral health resources. The team includes county and city agencies, the sheriff and other law enforcement agencies, the district attorney, the public defender, courts, advocacy groups, service providers and behavioral health care funders. The BHLT is co-chaired by two elected Dallas County Commissioners. In 2017, the BHLT formed a strategic planning committee that reviewed its charter, membership and operations. One of the recommendations from the committee was increased coordination, including record and data sharing.
The BHLT also aims to help Dallas County be a more effective partner of the North Texas Behavioral Health Authority (NTBHA), which funds and organizes mental health and substance abuse services for Dallas County and five neighboring counties. NTBHA arranges services using the state’s priority service diagnoses, including serious and persistent mental illnesses, to rapidly authorize and facilitate crisis and diversion-oriented services for indigent individuals through 26 approved residential and outpatient service providers. Metrocare Services, one of the largest local mental health providers, contracts with NTBHA and local Medicaid managed care organizations to provide comprehensive mental health services that address a full spectrum of service needs for a wide-ranging and diverse population. The agency also runs a Special Needs Offender Program (SNOP), which offers an array of services that includes assertive community treatment and housing. SNOP co-locates community supervision officers with physicians, nurses and clinical staff.
Through its involvement in the Data-Driven Justice (DDJ) initiative, Dallas County has committed to a using a data-driven approach to expand the care continuum for justice-involved individuals with complex behavioral health needs who are high utilizers of services. At the Design Institute, the county prioritized increasing the means and degree of collaboration between behavioral health stakeholders, which included focusing on how data integration improves identification, assessment and warm hand-offs of the justice-involved population to community-based treatment and supports.
Making Progress by Leveraging Resources and Relationships
The Dallas County Criminal Justice Department (DCCJD) has a primary responsibility to enhance public safety and maximize the effectiveness of Dallas County’s criminal justice resources. To fulfill this mission, the department manages and reduces the jail population through diversion programs, supervised release, pretrial screening and risk-based supervision, as well as close coordination with justice system stakeholders.
In 2013, leveraging a 1115 Medicaid Delivery System Reform Incentive Payment (DSRIP) Waiver from the U.S. Department of Health and Human Services to the State of Texas, Dallas County initiated the Crisis Services Project (CSP). CSP targets individuals in the county jail with unmet or under-met behavioral health needs who are frequent utilizers of emergency rooms and crisis services. The goals of CSP are to reduce readmissions to the jail and utilization of emergency services. The county uses a proprietary software system that matches jail booking data with multiple databases to identify individuals with a history of having serious mental health needs and/or using behavioral health services. That information is used by Adapt Community Solutions (ACS)—a mental health services organization and Dallas County CSP contractor—to recommend review by pretrial staff, which then triggers a court-ordered mental health assessment. The mental health assessment is followed by a pretrial risk assessment. Pretrial staff use the totality of the information to make a pretrial release recommendation to the court. If the judge releases an individual to treatment, then ACS develops a discharge plan and shares the individual’s assessment, treatment history and needs with the community treatment provider. Since 2013, CSP has served over 18,000 unique clients and reduced jail recidivism from a baseline of 31 percent in 2014 to 26 percent in 2017.
The DCCJD is also working with Meadows Mental Health Policy Institute (MMHPI), a local nonprofit, to develop and implement the Smart Justice Jail Diversion Project (SJJDP). The goal of SJJDP is to improve public safety by diverting individuals with serious psychiatric conditions to treatment and housing. The first phase of the project launched in July 2015 and focused on understanding the landscape of mental health services for justice-involved individuals and determining the rates of mental illness and treatment connections in the jail population. Through that research, Dallas County found that it needed to 1) improve screening and early identification of mental illness at booking, 2) conduct mental health assessments to determine clinical needs and recommend treatment plans to the court and 3) develop release plans that include warm hand-offs to treatment providers and resource brokering. The county used the Sequential Intercept Model to map and identify the points in the system where practices could be changed to improve decision-making and support diversion.
In January 2017, the county started on the implementation phase of SJJDP. During this phase, the jail and courts began using new policies and processes to improve responses to mental illnesses. For example, the public defender and district attorney signed a memorandum of understanding on the handling of cases involving defendants with serious mental illnesses, and a mental health personal recognizance docket was created that delegated release decisions to designated magistrates. The county also developed new pretrial protocols. The new processes mean that individuals with serious psychiatric conditions and manageable risks who are eligible for diversion are released from jail on personal recognizance bond in six days, on average—and with a connection to treatment—compared to 38 days, on average, for all individuals with serious mental health conditions.
Moving Forward and Advancing New Ideas
Dallas County wants to take its data-sharing capabilities to the next level, and there are many initiatives already underway that provide the opportunity for continued innovation. For example, MMPHI created and recently launched a real-time patient registry and notification system that allows data sharing between hospitals, psychiatric facilities, treatment and emergency service providers to facilitate rapid and more informed decision-making and connections to care and services. The system is governed by the Dallas-Fort Worth Hospital Council, which maintains admission, discharge, diagnostic and payor information for 90 local hospitals. Additionally, the system integrates community-based service encounter data from NTBHA. Dallas County is near finalizing an agreement to soon add jail admission and discharge data to the registry.
Recognizing the relationship between health and housing, Dallas County has a strong interest in addressing housing and related supportive services through the behavioral health housing workgroup (BHHWG) of the BHLT and related providers and system stakeholders. A new Homeless Management Information System was launched in late 2017 that is beginning to help with collecting information about the housing and service needs of individuals who enter homeless shelters and access housing services. Additionally, the new information system was designed to prioritize clients according to need and integrate with other social service providers that operate at the county and city level, including job training and food assistance services.
Through the BHLT and its BHHWG, Dallas County is in the process of expanding its respite care infrastructure to include crisis respite and medical respite. Also, a new Texas state law provides matched grant funding to counties and their local mental health authorities to support respite beds, among other things. Currently, NTBHA is leading efforts to create a “crisis hub” that will include crisis respite and an observation center. The crisis respite center would give police who encounter people in crisis an alternative to taking those individuals to jail. The county is also in the process of creating an extended observation unit in partnership with county-supported Parkland Hospital. To help plan for these expanded respite programs, Dallas County is learning from neighboring Tarrant County, where a hospital built a clinic specializing in health care delivery for homeless individuals. That clinic provides primary care and dental services, as well as a pharmacy, lab and imaging services. A case management provider and financial assistance navigators are also on site.
Dallas County is at the leading edge of major advances in leveraging data to make significant improvements to its continuum of care for justice-involved individuals. As the county continues to develop a system of diversion and expand the operations of its mental health services delivery system, it continuously looks at the role information technology and data can play to make better policy decisions and identify new practices. Through its participation in the Design Institute, Dallas County reaffirmed and advanced its commitment to enhancing alternatives to jail for individuals with mental illnesses and complex health conditions by prioritizing partnerships that innovate promising solutions.
NACo would like to thank Dallas County Commissioner Theresa Daniel, Dallas County Smart Justice Jail Diversion Program Manager Michael Laughlin and Senior Director of Systems Management at the Meadows Mental Health Policy Institute Ron Stretcher for sharing information on their efforts.
iU.S. Census Bureau. QuickFacts: Dallas County, Texas. https://www.census.gov/quickfacts/fact/table/dallascountytexas/PST045216 (accessed March 19, 2018).
iiU.S. Census Bureau. Urban and Rural Population by State Data, 2010. https://www.census.gov/geo/reference/ua/urban-rural-2010.html (accessed March 19, 2018).Standard