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San Antonio, : Addressing Mental Health Crises with a Specialized Mental Health Detail Embedded in the Police Department

San Antonio, Texas: ADDRESSING MENTAL HEALTH CRISES WITH A SPECIALIZED MENTAL HEALTH DETAIL EMBEDDED IN THE POLICE DEPARTMENT

OVERVIEW other considering similar cross-systems approaches. San Antonio, Texas is the second-most in Texas and home to nearly 1.5 million individuals, representing approximately PROGRAM DESCRIPTION five percent of the state’s population.1,2 SAPD Mental Health Detail Nineteen percent of individuals in San Originally a team of two officers who received Antonio live below the federal poverty level.3 training through a crisis intervention team Statewide, Texas’ overdose death rate is 10.5 (CIT) program, the MHD has subsequently per 100,000 population.4 expanded to include ten officers, two In response to an increasing number of detectives, and several social service and emergency behavioral health calls, the health care providers contracted to the city San Antonio Police Department (SAPD) by Baptist Healthcare System. All members of developed the Mental Health Detail (MHD).5 the MHD receive CIT training which teaches Launched in 2008, the SAPD MHD responds members of the detail to effectively respond to calls related to mental health issues, to calls from people experiencing a mental deescalates mental health emergencies, and health crisis, de-escalate mental health connects individuals living with mental illness emergencies, and coordinate treatment with to appropriate care. local behavioral health providers. In addition, local community behavioral health providers San Antonio has developed a number are brought in to educate the detail about of innovative programs that target the serious mental illness. Within the greater challenges of SUD, homelessness, and mental police department, 96 percent of officers are health issues. This case study focuses on CIT trained, and all cadets receive CIT training the MHD and presents key takeaways for in the police academy.

NATIONAL LEAGUE OF CITIES 1 San Antonio, Texas: Addressing Mental Health Crises with a Specialized Mental Health Detail Embedded in the Police Department

The MHD’s work typically begins when 911 untreated or unmanaged mental illness. If the dispatchers send patrol officers to respond to Group confirms an individual making a threat calls. All dispatchers take a 16-hour telephonic is suffering from mental illness, the individual CIT course to help identify and recognize an undergoes threat mitigation where he or individual with a mental health related issue. she is connected to treatment within CCSI When a call comes into 911, patrol officers are and his or her weapons may be confiscated. initially dispatched. If a situation appears to Clinicians lead treatment, however the Group/ involve an individual experiencing a mental CCSI continues to monitor progress of the health crisis, the responding officer will hand individual and follows up with him or her off the case to the MHD. MHD responders consistently for 90 days. Individuals who are arrive in plain clothes and unmarked cars, treatment compliant for 90 days can receive assess the individual, and transport the additional follow-ups quarterly, biannually, or individual to an appropriate facility. Once an annually. individual has been transported to a facility, MHD officers will stay with the individual for Rather than solely part of the justice system, as long as necessary to ensure that they are members of the MHD see themselves as part connected to treatment. of a comprehensive behavioral health care system, partnering with neighboring hospitals, Over the course of the MHD’s work, team psychiatric facilities and other community members recognized a need for enhanced support systems to meet the needs of case management and follow-up for high- individuals in crisis. need individuals. In January 2018, the MHD launched the chronic crisis stabilization initiative (CCSI), which helps remove RESULTS barriers to treatment for individuals who The SAPD found that over the course of have been detained on an emergency one year, the police department had nearly basis three or more times in a month. MHD 700 contacts with 43 individuals with high officers participate in the discharge process, utilization rates of police services (i.e. multiple and escort newly released individuals to 911 calls for police services; three or more pharmacies to ensure that they receive any emergency detentions in a one-month time prescribed medications. The MHD officers period; or use of violence, threats of violence also follow up for 90 days to confirm that the or weapons at the time of police encounter). clinicians are in contact with the individuals Within one year of implementing CCSI, police and are addressing housing, employment, contacts decreased by approximately 68 and other issues that may negatively impact percent. Further, more than half of the 43 mental health. individuals identified as high utilizers had no police contact in the final quarter of 2018, Finally, the MHD runs a Threat Assessment including one individual with substance use Group (the Group). The Group began in March disorder who, in the previous quarter, had 86 2018 and investigates threats of violence police encounters. made by individuals, some of whom may have mental illness. Detectives investigate violent The Group has completed 160 threat threats, assessing whether the individual investigations since its inception in March making them has the means to carry them out 2018. MHD officers have found that and explore whether the individual may have emergency detainment and admission to a

NATIONAL LEAGUE OF CITIES 2 San Antonio, Texas: Addressing Mental Health Crises with a Specialized Mental Health Detail Embedded in the Police Department

hospital for individuals experiencing mental Integrated Mobile Partners Action illness who may pose a danger to themselves Care Team (IMPACT) is preferable to admission to jail. Individuals IMPACT is a cross-systems partnership may be in and out of jail in a matter of between the SAPD MHD, the San Antonio Fire weeks and lost to follow-up but connecting Department/Mobile Integrated Healthcare individuals to treatment enables the Group to Team, and local behavioral health and monitor treatment for 90 days or longer. social service providers. The program uses multi-agency teams to offer individuals FINANCING AND experiencing homelessness medical treatment SUSTAINABILITY or navigation through the city’s social services network. This initiative removes barriers to The MHD is funded through local taxes that treatment by ensuring that case management are allocated by the San Antonio City Council. is available from emergency response to The size of the unit is determined by the chief crisis stabilization to treatment. Upon coming of police and is based on the city’s population into contact with the team, individuals and overall police force size. Additionally, San experiencing homelessness who are willing to Antonio’s Department of Human Services accept help are transported and connected awarded a contract to cover the costs to social services and health care treatment.6 associated with three clinicians from Baptist Of the 3,030 contacts the IMPACT program Healthcare System to staff the MHD. Funding made from October 2015 through February is provided every one to two years based on 2018, over half were referred to behavioral the city council’s legislative calendar. At its health or social services providers. inception, the police chief requested that the unit be funded as a budget line item separate The South Alamo Regional Alliance and apart from general police funding – this for the Homeless (SARAH) has allowed the unit flexibility in hiring non- SAPD (or MHD) works closely with the South police counseling staff and contributes to its Alamo Regional Alliance for the Homeless sustainability. (SARAH) across San Antonio and Bexar The SAPD MHD also receives indirect research Counties to support individuals experiencing support from the Meadows Mental Health homelessness. As the local Continuum of Care Policy Institute, which provides independent, Lead Agency, SARAH is charged with creating data-driven and policy and program guidance an improved social services system that to improve mental health services in Texas. effectively provides support, coordination, and housing to homeless populations in this area. COLLABORATION ACROSS SYSTEMS Center for Health Care Services The city of San Antonio has invested (CHCS) significantly in initiatives and organizations CHCS provides integrated care to children that assist people experiencing homelessness, and adults with mental health conditions, SUD, and/or mental illness. The SAPD substance use challenges and intellectual or MHD collaborates with a number of public developmental disabilities in and around the and private agencies, ensuring integrated, 19 offices it operates throughout San Antonio. responsive care. Examples include: CHCS is a key referral site for the MHD. The

NATIONAL LEAGUE OF CITIES 3 San Antonio, Texas: Addressing Mental Health Crises with a Specialized Mental Health Detail Embedded in the Police Department

organization offers a wide range of programs This is not only because these individuals to assist people who are experiencing may be resistant to such treatment, but homelessness, including outreach, residential also because the system creates a number shelter, mental health and SUD treatment, of barriers to accessing care. For example, skills training, rental assistance, and case clinicians may need orders of protective management. Additional services include custody to treat an individual, but these a 24-hour crisis and substance use hotline, orders cost approximately $450 for each a crisis stabilization unit, a mobile crisis individual. Clinicians must also go, in person, outreach team, mental health services, SUD to court to ask for orders of protective treatment, HIV services, primary care, and custody; they cannot request these orders community reintegration/therapeutic justice remotely. Transportation costs from hospitals services.7 CHCS is funded through municipal or emergency rooms to long-term treatment tax revenue; Medicaid reimbursement; facilities may not be covered. These logistical and grants from hospitals, pharmaceutical and monetary barriers make access to companies, and faith-based organizations.8,9 long-term treatment difficult. SAPD MHD representatives believe there is more the state of Texas can do to facilitate long-term ROLE OF CITY treatment by removing or mitigating some of LEADERSHIP these barriers. The city council is publicly supportive of the Mitigate continuing threats. The Threat program and has provided funding for the Assessment Group may take away the MHD since its inception in 2008. As part of weapons of the individuals it investigates the city’s budget proposal for fiscal year 2019, or prevent individuals from purchasing the mayor and city council identified filling new weapons. However, these threat police department vacancies and expanding mitigation techniques are often temporary. the MHD as priorities. Members of the city If an individual has not been committed to council have also participated in “ride alongs” a psychiatric treatment facility, they may with officers of the Mental Health Detail. Of retrieve their weapons once an investigation particular importance, the Police Chief has is complete as well as purchase new weapons. been a strong champion of the unit since its In San Antonio, of the more than 150 cases inception. where the SAPD removed weapons from the home of an individual, there were only five LESSONS LEARNED cases where this intervention was permanent. Representatives from SAPD are hopeful that Responding to Challenges state and federal policy makers can pass SAPD MHD identified several challenges that legislation to make the Threat Assessment they are working to overcome to provide Group’s activities more effective and more effective and comprehensive emergency permanent. response and crisis stabilization services. Create a policing culture that prioritizes Facilitate long-term treatment. It is often treatment over arrest. In September 2019, a difficult to get individuals experiencing 7-year-old boy with autism and behavioral mental illness, substance use disorder, and/ health issues was removed in handcuffs or homelessness into long-term treatment. from his school by the San Antonio

NATIONAL LEAGUE OF CITIES 4 San Antonio, Texas: Addressing Mental Health Crises with a Specialized Mental Health Detail Embedded in the Police Department

Independent School District (SAISD) police addressing an individual’s healthcare and social during a behavioral health crisis. In contrast, needs upwards of six months after a behavioral representatives from the SAPD MHD note health emergency will not meaningfully impact that MHD officers receive training to avoid the rates of recidivism. In San Antonio, once use of force or handcuffs whenever possible. the MHD addressed barriers that individuals Combined with their lack of police uniforms, experienced in seeking and continuing care, MHD attempts to encourage a policing culture they were able to interrupt cycles of repeat where individuals experiencing mental illness, interactions with police. substance use disorder, and/or homelessness are connected to treatment instead of Integrate clinicians with law enforcement arrest. While SAPD does not control policing in crisis response teams. Having non-police protocols for SAISD police, the state of Texas social workers, therapists, and/or counselors has contributed to a policing culture that on the team improves communication with is more responsive to individuals in need community-based clinicians and can help with its passage of the Sandra Bland Act. overcome information sharing barriers. Further, The Act requires police officers across the a trained clinician may be able to establish state to complete a “40-hour…education trust with an individual in need when a police and training program on de-escalation and officer cannot. crisis intervention techniques to facilitate Finance initiatives through a dedicated interaction with persons with mental budget to promote sustainability. The MHD 12 impairments.” is able to hire non-police staff, including clinicians, to support their work because they Key Takeaways for Cities have a unit level budget within the larger police For other cities considering similar cross- budget. This can also insulate the unit from systems approaches to supporting individuals organizational changes in the police and fire with substance use disorder, those experiencing departments. homelessness, and those with mental health issues, there are several key lessons that can be Use data to demonstrate value to learned from the SAPD MHD. stakeholders. Delivery of case management or medical services provided after release Emphasize connections to care and follow- from jail has been associated with a reduced up. Programs that aim to help vulnerable risk of re-arrest.13 For cross-systems initiatives, populations, such as people experiencing demonstrating this connection is paramount. homelessness, SUD or mental illness, must Program evaluations, such as the pilot study do more than simply drop off individuals at conducted by the SAPD, can help tell the story clinics or hospitals for treatment. Consistent of overall program results to stakeholders, and meaningful follow up with individuals including details impacting public safety costs can ensure that they are receiving needed such as police response frequency, number of services and can result in reduced recidivism. calls to dispatch, personnel time saved, etc. Further, this follow-up should occur promptly;

Unless otherwise noted, all information is based on an interview with the San Antonio Police Department.

NATIONAL LEAGUE OF CITIES 5 ENDNOTES

1 Census Bureau. “2013-2017 American 6 Beltran J. “SAPD team takes new approach in Community Survey 5-Year Estimates. ACS targeting chronic homelessness” San Antonio Express- Demographic and Housing Estimates: Sonoma , News. (July 24, 2016). https://www.expressnews.com/ CA; Fort Collins, CO; Huntington, WV; Indianapolis, news/local/article/SAPD-team-takes-new-approach- IN; Manchester, NH; , PA; Raleigh, NC; in-targeting-chronic-8406227.php Rapid City, SD; San Antonio, TX; Wichita, KS.” https:// 7 The Center for Health Care Services. https://chcsbc.org/. factfinder.census.gov/bkmk/table/1.0/en/ACS/17_5YR/ DP05/0500000US06097|312M300US22660082742 8 Id. 5|312M300US265805439460|312M300US26900183 9 Helman S. “The San Antonio Way: How One Texas 6003|312M300US317003345140|312M300US37980 City Took on Mental Health as a Community – and 4260000|312M300US395803755000|312M300US3 Became a National Model.” The Globe. (2016). 96604652980|312M300US417004865000|312M300 https://www.bostonglobe.com/metro/2016/12/10/ US486202079000. the-san-antonio-way-how-one-texas-city-took- 2 https://www.census.gov/quickfacts/fact/table/ mental-health-community-and-became-national- sanantoniocitytexas/POP060210 model/08HLKSq1JdXSTZppaECk2K/story.html. 3 Bureau. “2013-2017 American 10 City of San Antonio. “FY2019 Adopted Operating and Community Survey 5-Year Estimates. Selected Capital Budget.” (2018). https://www.sanantonio.gov/ Economic Characteristics: California, , Portals/0/Files/budget/FY2019/Adopted-Budget- Indiana, Kansas, New Hampshire, , Document-Web-Version.pdf Pennsylvania, South Dakota, Texas, West .” 11 Seedorff, M. (Sept 17, 2019). 7-year-old student with https://factfinder.census.gov/bkmk/table/1.0/en/ Autism taken from school in handcuffs. Fox San ACS/17_5YR/DP03/0500000US06097|312M300US22 Antonio. https://foxsanantonio.com/news/local/7- 6600827425|312M300US265805439460|312M300US2 year-old-student-with-autism-taken-from-school-in- 69001836003|312M300US317003345140|312M300US3 handcuffs-09-18-2019. 79804260000|312M300US395803755000|312M300U S396604652980|312M300US417004865000|312M300 12 Sandra Bland Act. (2017). SB1849. https://capitol.texas. US486202079000. gov/tlodocs/85R/billtext/html/SB01849F.htm 4 National Center for Health Statistics. “Drug Overdose 13 Falconer, Erin, Tal El-Hay, Dimitris Alevras, John Mortality by State.” (2019). https://www.cdc.gov/nchs/ P. Docherty, Chen Yanover, Alan Kalton, Yaara pressroom/sosmap/drug_poisoning_mortality/drug_ Goldschmidt, and Michal Rosen-Zvi. “Integrated poisoning.htm. multisystem analysis in a mental health and criminal justice ecosystem.” Health & justice 5, no. 1 (2017): 4. 5 Rambaldi C. “SAPD: Mental health calls are up, citywide programs making a difference” Fox San Antonio. (February 27, 2018). https://foxsanantonio. com/news/local/sapd-mental-health-calls-are-up- citywide-programs-making-a-difference