Lower utilization by 'frequent flyers' to reduce pressure on jail

In my essay on my recent Harris County Jail tour, I described how a relatively small number of "frequent flyers" account for a huge proportion of jail utilization. In reaction, Lillian Aguirre Ortiz from Mental Health America of Greater Houston forwarded me a couple of documents assessing outcomes of a pilot program at the Houston Police Department. (See here and here.) Called the Chronic Consumer Stabilization Initiative, the pilot focuses on community-based efforts to reduce jail, hospital and police utilization for the 30 Houstonians suffering from severe mental illness who are responsible for the most police calls. (She sent the same materials to Charles Kuffner, who beat me to the punch posting about it. See also coverage of the program from the Houston Press and a column in the Houston Chronicle from attorney George Parnham.) According HPD's analysis of the six-month pilot:

It was determined that 30 consumers alone were responsible for 194 calls for service resulting in 194 offense reports and 165 EDOs [Emergency Detention Orders] from six of their most active months recorded in the HPD database. This is a total of 553 time consuming events which averages close to one hour of work per officer per event. After intense intervention by the two case managers, the same 30 individuals were only reported to have been involuntarily committed for a total of 39 times, a significant decrease by 76.4% while only 65 offense reports and 65 known calls for service were generated resulting in a 67.3% decrease. The end result revealed a total of 169 reported events with a 70% overall decrease observed within six months of the pilot. These numbers indicate that the CCSI pilot program significantly decreased the number of interactions between individuals diagnosed with serious and persistent mental illness and the Houston Police Department. This decrease in interactions with law enforcement may be due to families and care givers appropriately seeking assistance through the mental health system rather than through law enforcement as a result of education received from the CCSI staff.

Think about that: The thirty most prolific mentally ill "consumers" of law enforcement services in Houston were responsible for 194 police offense reports in six months, so reducing that to 65 all of a sudden looks like a positive development. Said the report, "Many of these clients would benefit from a structured residential setting, staffed with mental health professionals 24 hours/365 days a year. These facilities are not currently available within Harris County."

Investing in case workers and community-based support to reduce arrests and overincarceration of such individuals - who inevitably are turned back out on the streets anyway, eventually, when they're sent to jail or a psych hospital - would go a lot further toward reducing jail overcrowding than building more jail space to hold the same folks over and over again. Another notable element is the attribution of the reduction in police calls to changing responses by family members and caregivers, not always direct intervention CCSI staff. If that observation is accurate, educating and supporting direct caregivers - who often find themselves feeling helpless and unprepared in the face of chronic, severe mental illness - can make a huge difference.

Who are Houston's 30 most prolific mentally ill "consumers" of police services?

Thirteen of the thirty clients (43%) have a diagnosis of Schizophrenia. Eight (27%) have a diagnosis of Schizoaffective Disorder. Seven (23%) have a diagnosis of Bipolar Disorder with Psychotic Features. Eleven of the thirty clients (37%) have substance abuse dependence. Surprisingly, six (20%) have a diagnosis of Mental Retardation. Additionally, fifteen (50%) have significant medical issues (i.e. diabetes, HTN, seizure disorder, and injuries resulting from trauma). Twelve (40%) are in need of dental treatment.

The lack of consistent treatment generally cannot be attributed to a lack of benefits. Twenty four of the thirty clients (80%) receive SSI benefits. Six (20%) have a guardian and eight (27%) receive case management. Eighteen (60%) have family involvement that does not appear to benefit the client. This family involvement at times is for unknown secondary gain. The family does not maintain care for the client but is unwilling to relinquish care to a guardian or other entity.

Only six of the thirty clients (20%) are homeless. Eleven (37%) reside on their own or a family home and thirteen (43%) reside in personal care homes. The clients who reside in personal care homes are frequently placed in different homes based on their own behavior or an unwillingness of the personal care home to provide adequate care for the client.

The program undoubtedly saves money. According to this addendum, based on results from the pilot, if the program were expanded to 60 individuals, it would save $867,793 in the first year while costing $282,364 to implement. What's more, those savings appear to exclude jail costs! Listed costs were only calculated for participants in the pilot - the Houston PD and the Harris County MHMR authority.

If Harris County wants to reduce jail overcrowding, first things first should be to ramp up CCSI-style community supervision for those responsible for the highest rates of jail utilization. Pick the 500 or 1,000 most frequent jail visitors and make their effective community supervision a priority. Supply case-management type support in addition to law enforcement supervision, where necessary. And if the county wants to build "mental health beds," as Sheriff Garcia has proposed, they should be medical, not correctional facilities - the kind of "structured residential settings" the CCSI report laments aren't available in Houston.

Consider the relative cost-benefit analysis: Sheriff Garcia wants to spend a quarter-billion dollars to expand the jail to create a mental health wing and to expand the overcrowded booking area. At 3% over 20 years, that comes out to around $16.8 million per year, PLUS another $5+ million or so in annual staffing costs - enough to require a tax increase. If it would cost $282,364 to provide such extensive supervision to the sixty highest utilizers of police and jail services among the mentally ill, as declared in the addendum to the HPD report, then for the $21.8 million annually taxpayers would spend on an expanded jail, CCSI-type case management support could be provided for more than 4,600 "frequent flyers" - probably more since once you get down the list their utilization levels won't be nearly so high as those in the pilot. (Likely the risk factors dealt with among the non-mentally ill in that group will differ significantly, but problems with substance abuse will be a recurring theme.)

A few years back Malcolm Gladwell at The New Yorker wrote a piece titled "Million Dollar Murray" that told the story of one such high-utilization "consumer" of police services and healthcare services, describing a homeless man whose medical bills alone cost the city of Reno, NV $1 million over a single decade. Heaven knows what the costs would be if you tacked on police, court, and jail expenses. But there are Million Dollar Murrays in every US city of any size, and certainly passing through every urban jail.

Clearly investing in community-based supervision and support like the CCSI program gets a lot more more bang for the buck than the current "catch and release" approach: Maximizing evidence-based supervision of the most frequent offenders outside of jail makes much more sense than expanding the jail to hold the same people over and over without ever addressing the core problem. HPD and its partners deserve a lot of credit for piloting CCSI, but the program deserves to be scaled up considerably, and doing so should be a much greater priority than jail building.