Improving Outcomes through Coordinated Health and Justice Systems

Bexar County is a Familiar Faces Initiative (FFI) Peer-Learning Site that models effective cross-sector data sharing and familiar faces programming to divert residents with behavioral health conditions such as mental illness and/or substance use disorders from jail to treatment. In the early 2000s, Bexar County was facing a severe jail overcrowding problem and the possibility of having to build new jail beds. To best serve community members, the county  transformed its approach to develop an integrated behavioral health continuum of care and criminal legal system. 

Bexar County strategically addresses emergency department and jail bookings system-wide through cross-system data sharing and care coordination, as well as supportive housing and community-based treatment. In FY21-22, county-operated behavioral health systems assessed 18,596 people and provided access to services to meet all their social determinants of health, improving long-term outcomes. This case study highlights the Bexar County departments and programs supporting familiar faces and enhancing public safety. 

Behavioral Health and Justice Strategy

The Bexar County Office of Criminal Justice (OCJ) leads the local diversion, behavioral health and public safety programs’ strategies and investments. OCJ partners with other county departments and providers including the Center for Health Care Services (CHCS), the Bexar County Sheriff’s Office, the Bexar County District Attorney’s Office, Haven for Hope, the Southwest Texas Regional Advisory Council (STRAC), the City of San Antonio and local stakeholders and community-based organizations.

DEPARTMENT OF BEHAVIORAL HEALTH

In 2015, OCJ created the Department of Behavioral Health (DBH) to work with local partners, including CHCS, STRAC and the National Alliance for Mental Illness, City of San Antonio, to develop and monitor behavioral health programs in the community. DBH is now a branch of the Bexar County Department of Preventative Health and Environmental Services.

SOUTHWEST TEXAS REGIONAL ADVISORY COUNCIL

Texas is divided into 22 Regional Advisory Councils (RAC), designated to develop, implement and maintain a regional trauma and emergency health care system that is available to every person in the designated region. RAC members include health care systems, EMS agencies and air medical providers. STRAC oversees the trauma and emergency health care system in Bexar and 21 additional counties. STRAC is a 501 (c)(3), non-profit, tax-exempt organization consisting of 65 general and specialty hospitals, air medical providers and over 70 EMS agencies. In 2015, STRAC began collaborating with Methodist Healthcare Ministries (MHM), a local hospital system,  to address increases in crisis mental health patients stranded in emergency departments and challenges in EMS. At the same time, Bexar County OCJ approached STRAC to collaborate on solutions to address the overuse and  misuse of jails for individuals with behavioral health conditions. STRAC, through startup funds from MHM, commissioned a study exploring the costs associated with the safety net population, specifically familiar faces. The study  found disproportionately high utilization of specific hospital services within local systems as compared to similar-sized jurisdictions. The high costs of providing crisis mental health services persuaded local hospitals and philanthropy to join a coordinated care system to address the needs of familiar faces. STRAC created the Southwest Texas Crisis Collaborative (STCC) to focus on ending ineffective utilization of services for the safety net population at the intersection of chronic illness, mental illness and homelessness in San Antonio and Bexar County. STCC is a comprehensive, integrated system of care representing Bexar County, the City of San Antonio, all
major health care systems, philanthropy, public safety and behavioral health providers. Participating members of STCC fund and operate:

• Data collection, integration and analysis to identify and monitor familiar faces
• Care teams and care management interventions, and
• Integration and sustainability of programs in the health care delivery system. 

With numerous entities involved and significant funding supporting the behavioral health continuum of care, STCC utilizes a data-integrated referral system, Signify Community, to track case management, provide real time system load (e.g., available beds at each provider) and collect data to demonstrate the value of existing programs and diversions. Signify automatically pulls data through secure HL7 data feeds from hospital electronic medical records, behavioral health providers and clinics. Signify relies on Universal Release Forms to share individual-level data across systems.

Program for Intensive Care Coordination (PICC)

One of the programs STCC operates to address the underlying needs of familiar faces in Bexar County is the Program for Intensive Care Coordination (PICC). PICC aims to reduce the utilization and impact on 911 and hospital systems by addressing psychiatric and social needs through intensive case management and collaboration. PICC identifies the highest-need familiar faces, defined as those with six or more Emergency Detention Orders in a 12-month period, and coordinates case management through Signify. Case managers build rapport with clients and refer or provide services including:

• Access to a psychiatrist
• Medication assistance and management
• Transportation to service providers
• Assistance with obtaining benefits
• Purchase essentials (e.g., food, clothing)
• Connection to housing options
• Employment assistance
• Connection to medical care and behavioral health services, and
• Advocacy in the justice system, when possible.

Justice System Diversion and Community Care

Over the last decade and in partnership with STRAC, the Bexar County Commissioners Court through OCJ has leveraged county partnerships to implement:

• Pretrial diversion programs, including the District Attorney’s Pretrial Diversion Program and a Jail Intake Mental Health Diversion Program
• Case management software for pretrial services and specialty courts that feeds into Signify
• The District Attorney’s Cite and Release Diversion Program, which resulted in avoidance of 6,235 bookings and an estimated savings of $4.7 million in booking costs between 2019 and 2022
• The Specialized Multidisciplinary Alternate Response Team (SMART), a mental health co-responder and follow-up program, and
• A civil court-ordered outpatient mental health program for individuals booked on low-level, nonviolent offenses who have severe and persistent mental illness, and have been non-compliant with past psychiatric treatment.

Bexar County has also supported the development of brick-and-mortar facilities to provide community-based care to individuals with behavioral health conditions. CHCS opened the Restoration Center in 2008 as a one-stop diversion center, offering 24-hour crisis care, a minor medical clinic and a sobering unit. Since its creation, CHCS has diverted over 100,000 residents from emergency rooms and jail into treatment programs, saving taxpayers over $96 million. Haven for Hope is a 962-bed facility that brings multiple service providers to a 22-acre campus for people who are experiencing homelessness. Since 2010, Haven for Hope has reduced the annual point-in-time  count of homeless individuals in downtown San Antonio by 77 percent.1 In 2018, the Bexar County Sheriff’s Office opened the Justice Intake & Assessment Annex, a 24-hour facility that screens people for potential diversion at booking. The Bexar County Reentry Center also opened in 2018 and is located at the exit of the jail where four reentry technicians connect people to services. In 2020 and in partnership with a local hospital system, the New Opportunities for Wellness (NOW) urgent mental health clinic opened to provide behavioral health services to individuals not in crisis, regardless of insurance status, within eight hours of request.

Next Steps

The Bexar County Commissioners Court is investing America Rescue Plan Act Recovery Funds in pre-crisis strategies and programs. These investments include a stigma reduction campaign, a warm line for non-emergency/crisis calls and increased behavioral health services in schools. They are also using these funds to support additional treatment bed capacity in the criminal legal system, local psychiatric facilities, wellness centers, the NOW Clinic and hospitals.

NACo would like to thank Mike Lozito, Director of the Office of Criminal Justice, Gilbert Gonzales, Director of the Department of Behavioral Health, Leticia Dominguez, Manager of the Department of Behavioral Health and Kellie Burnam, Assistant Division Director of STRAC for sharing information on Bexar County. Mr. Lozito can be reached at Mike.Lozito@bexar.org, Mr. Gonzales at GrGonzales@bexar.org, Ms. Dominguez at Leticia.Dominguez@bexar.org and Ms. Burnam at Kellie.Burnam@strac.org.

This case study was created with support from Arnold Ventures as part of the Familiar Faces Initiative, seeking better outcomes and lower incarceration rates for individuals who frequently cycle through jails, homeless shelters, emergency departments and other local crisis services.

SOURCES
1 Haven for Hope: Organizational Overview. 2022. https://www.havenforhope.org/wp-content/uploads/2022/07/Organizational-Overview-with-UW-Logo-1.pdf