Mental Health Diversion Travis County

There were many comments and questions that pointed toward a need to better understand and influence how programs or initiatives were strategically situated to have greatest impact and to be evaluated.   

• How will we fund and sustain these initiatives? 
• How do we set accurate expectations? 
• What are the current and future costs? 
• What do we measure and monitor and how? 
• How can we see the system and challenges? 

Participants pointed to many needs and contextual factors that could influence the design of successful programming, as well as various resources that could help support in serving individuals experiencing mental health challenges and intersecting with the criminal legal system. 

• What resources are available in our community and how is the program working with them? 
• How do we build, improve, and retain trust with the community? 
• What kind of care will be provided and to who? 
• How will involuntary be supported? 
• How will we build and support staff? 
• How will we equitably work with and include peers? 

Factors associated with law enforcement involvement and outcomes for individuals in the system was top of mind, based on the number of comments and questions on the topics. There were many questions about who the program can serve, how they will be brought into the programs, how they will be affected, and how different entities will connect in programs and processes. 

• How will intake, assessments, and referral processes work? 
• Who is eligible? 
• How will law enforcement be included and engaged? 
• What is the relationship between pilot and diversion center? 
• How will charges be addressed both with Travis County and other agencies? 

The Crisis Care Diversion Pilot Program is provided by Integral Care. The Diversion Pilot has two program components:

1. Expansion of services at Psychiatric Emergency Services and
2. Establishing a Therapeutic Diversion Program. 

Psychiatric Emergency Services (PES) is a voluntary psychiatric urgent care walk-in resource for anyone in Austin/Travis County seeking treatment for a behavioral health crisis. Integral Care, through the pilot program will: 

• Expand PES’s operating hours to twenty-four hours a day, seven days a week. 
• Add additional peer support services to enhance engagement and retention.
• Expand Integral Care’s clinical team to include additional prescribers to ensure individuals have timely access to a medical professional for medication evaluation.
• Add a 23-hour observation service with three beds and/or lounge chairs. 

Integral Care will also repurpose the 15th Street Crisis Residential program to be an extended stay therapeutic respite program (Therapeutic Diversion Program or TDP) that combines the current bridge housing model used by the City of Austin with a respite level of supportive and therapeutic services. TDP will serve individuals with behavioral health conditions that were deflected to PES or diverted from the criminal legal system. Integral Care will seek to prioritize individuals that are experiencing homelessness and/or are accessing emergency services at greater frequency due to their complex behavioral health needs.  

Travis County, the City of Austin, and Central Health fund the pilot program. Additionally, Integral Care received a grant from the Texas Health and Human Services Commission (HHSC). Integral Care is also contributing financially to this pilot program.  

The Diversion Pilot was designed to leverage and enhance existing behavioral health resources in the community while a larger diversion system for Travis County is developed. The pilot program design was informed by multiple stakeholder meetings and enhanced existing service modalities. 

Under the pilot, PES will serve adults ages 18 and older experiencing a mental health crisis in Travis County who have a history of, or are at risk of, cycling through the criminal legal system, emergency departments, and/or homelessness. Individuals are referred by first responders, emergency departments, the Sobering Center, Travis County jail personnel, and Integral Care’s Jail Liaison(s) who will receive referrals from criminal legal personnel (Travis County Jail Counseling staff, judges, and attorneys).

TDP will serve adults ages 18 and older who require ongoing behavioral health support services in a stable, extended care setting that provides individualized care and treatment. Individuals are deflected to PES and/or currently incarcerated at Travis County Central Booking, Travis County Jail, or Travis County Correctional Complex and plan to reside in Travis County following their release from jail custody. Additionally, Integral Care’s Jail Liaison(s) may receive referrals from criminal legal personnel (Travis County Jail Counseling staff, judges, and attorneys), and referrals from programs managed by Integral Care, such as The Guy Herman Center for Mental Health Crisis Care, The Inn, PES, and mobile teams. TDP shall only serve individuals deflected through law enforcement that avoids initial arrest and/or the filing of criminal charges or who were diverted from the criminal legal system. Individuals served at TDP must be able to perform their own activities of daily living, including self-administering medication, and be at low risk of harm to self or others. The crisis must be successfully stabilized prior to admission to TDP. 

All services at PES and TDP are voluntary. Therefore, the Diversion Pilot will not serve individuals who need an involuntary commitment or who do not meet the eligibility criteria noted above.

PES 

First responders may take individuals to PES to deflect individuals from the criminal legal system to a more appropriate behavioral health setting to address the individual’s needs. Law enforcement, including Austin Police Department, Travis County Sheriff’s Office, as well as other law enforcement agencies within Travis County, will be able to drop off the individual and be released from PES within fifteen minutes. Travis County Emergency Medical Services and local emergency departments may directly refer the individual to present to PES for services. Additionally, upon request by Travis County Central Booking and Travis County Correctional Complex, Integral Care’s jail liaison will provide crisis assessments and interventions on site for diversion and linkage to mental health services following release from jail and may refer individuals directly to PES to receive services to assist with successful re-entry and stabilization in the community. 

TDP 

Referrals are received from PES, as deflected by law enforcement agencies, Integral Care jail liaison(s) and Integral Care clinical staff that work collaboratively with criminal legal stakeholders. Referred clients who express desire to enter the TDP program will be assessed by Integral Care staff using a crisis assessment and a standardized assessment of functional, mental, and health status. 

PES is staffed by Integral Care utilizing a variety of positions including psychiatric and nursing staff, practice managers, licensed and professional mental health providers, and peer support specialists (these positions are a combination of Integral Care staff and subcontractor). 

TDP is staffed by both Integral Care and subcontractors, one of which provides 24/7 care and the other providing peer support services. Integral Care staff includes nursing staff, licensed and professional mental health providers and specialized positions for jail liaison, benefits, and housing. 

Yes, peer support will be available at both PES and TDP. Each pilot program component will have 3 peer support specialists.

Human-level goals for the pilot:

• Stabilizing behavioral health conditions and promote long-term community integration through evidence-based mental health and co-occurring treatment interventions. 
• Reduce recidivism by minimizing arrests and incarceration, emphasizing best practice around diversion/deflection strategies and community-based treatment. 
• Support individuals experiencing homelessness with complex behavioral health needs access supportive housing and gain long-term housing stability. 

System-level goals for the pilot: 

• To provide a consistent place for first responders (including law enforcement, EMS, and mental health crisis responders) and other emergency service entities to take individuals experiencing a behavioral health crisis, other than central booking/jail or an emergency department. 
• To identify, build, support, and implement pathways for individuals to move effectively and efficiently between complex systems, including first responders, emergency departments, and the criminal legal system, utilizing the Sequential Intercept Model (SIM) as a framework to guide pathways to care. 
• To allow PES to serve more people needing immediate behavioral health services by expanding access to twenty-four (24) hours a day, seven (7) days a week and ensuring timely access to a medical prescriber. 
• To reduce the number of individuals who continually cycle in and out of the jail, hospitals, and/or homelessness because there is no dedicated pathway for them to concurrently receive extended clinical behavioral health treatment in a residential setting while being connected to housing or other community-based support services. 
• To allow TDP to create a link to housing programs that break the cycle of incarceration and homelessness. 
• Inform and accelerate the effectiveness of a new diversion center. 
• Enhance community collaboration among providers, first responders, jails, and court systems, utilizing the Sequential Intercept Model to improve coordination and facilitate effective diversion strategies.   

The pilot aligns with the goals above in the following ways:

• Help decrease acute symptoms of mental health crisis and engage in person-centered, culturally competent care and safety planning to help restore the individual to pre-crisis functioning. 
• Enhance resiliency by empowering individuals to engage in person-centered safety planning and collaborative treatment planning. 
• Collaborate with individuals to link them to the least restrictive appropriate community resources and supports. 
• Enhance collaborative relationships with stakeholders to support successful implementation of the pilot. 

The contract with Travis County includes a robust set of performance measures: 18 outputs for PES, 19 outputs for TDP, and two outputs for the pilot as a whole. For outcomes, PES has four outcomes and TDP has six outcomes. Further, there will be a Data and Measurables Task Group that will discuss the data management and data sharing agreements and adaptations needed to operationalize the pilot. Integral Care plans quarterly stakeholder updates to share information about the pilot and receive feedback. Travis County is currently negotiating a contract for an independent evaluation of the pilot. 

All the data will be available to the community and those working on developing the future Diversion Center. The pilot will have multiple Task Groups to enhance cross-system collaboration for individuals with behavioral health needs that result in cycling through the criminal legal system. The learnings from the Task Groups and the pilot can help inform the design of the future Diversion Center. 

Quarterly Stakeholder Meetings

Integral Care will convene quarterly, virtual meetings regarding the pilot to foster a shared sense of ownership over the pilot and ensure routine community feedback. These meetings ensure that Pilot updates (successes, challenges, gaps) are communicated, and Integral Care elicits varied perspectives and recommendations on the pilot program. These meetings are open to any interested community member. 

Task Groups

Pilot Task Groups will be small working groups engaged in collaborative, labor-intensive efforts to achieve the charge of each group, as listed below. The management task group will be capped at 20 members and all other task groups will be capped at 15 members. All task groups will include two peers/persons with lived experience. 

Management Task Group for the Pilot

• The Management Task Group will receive and review regular updates from the other task groups which then becomes the basis for action by this Task Group. 
• This group will provide technical assistance and consultation to the other task groups listed below. 
• This group will provide ongoing assessment of the implementation of the pilot with a specific focus on operational process, pathway development, service provision, and data management. 
• Representatives from the following entities will be invited to participate: first responders, District/County attorneys offices, jail personnel, peer/person with lived experience, and County, City, hospital, Central Health, and other partnering agencies.

Pathway Task Group for the Pilot 

• The Pathway Task Group will establish the pathways for referrals to be deflected or diverted in the pilot. This Task Group will identify and develop Memorandums of Understanding (MOUs) for each referral pathway, update respective policy and procedures, and develop a training plan for their respective departments. 
• Two sub-task groups will be established: (1) Deflection; and (2) Diversion. 
• Representatives from the following entities will be invited to participate in the Sub-Task Group Deflection: first responders, Sobering Center, emergency department, jail personnel (Counseling staff, corrections staff, transport staff), and peer.  
• Representatives from the following entities will be invited to participate in the Sub-Task Group Diversion: jail personnel (counseling staff, corrections staff), attorneys, judges, and peer.  

Data and Measurables Task Group for the Pilot 

• The Data and Measurable Task Group will address the data management and data sharing agreements and adaptations needed to operationalize the pilot. 
• This Task Group will monitor the pilot’s performance data, identify gaps in that data, make needed adjustments to the performance measures, and consider and integrate community input regarding data collection on the pilot.  
• Representatives from the following entities will be invited to participate: Integral Care’s analyst, One Data, and Population Health Director; Travis County, City of Austin, Central Health, law enforcement, and jail data analysts; legal counsel representative (ad hoc); and peer.  

Clinical Interventions and Community Resource Task Group for the Pilot 

• The Clinical Interventions and Community Resource Task Group will review the clinical interventions, services and support services provided in the pilot. It will also evaluate community resources to appropriately refer individuals for service to, ensuring exit pathways are established and MOUs are executed, as appropriate.  
• Representatives from the following entities will be invited to participate: mental health service providers; Diversion, Equity, Inclusion, and Belonging representatives; peers; other identified community agencies such as substance use disorder providers, housing and homeless services (i.e. The Other Ones Foundation, Ending Community Homelessness Coalition, Marshalling Yard). 

Travis County leadership believes it is important to learn from diversion-related experiences, programs, facilities, policies, and practices of other cities and counties. Travis County leaders, and community partners from the Sheriff’s Office, Integral Care, Central Health, and others, have visited locations with diversion centers including Nashville, TN, Tucson, AZ, Yavapai County, AZ, Miami, FL, Houston, TX, and Lubbock, TX. Travis County leaders are also consistently reviewing reports published by organizations like the Texas Judicial Commission on Mental Health or the Council of State Governments – Justice Center that provide information on best practices in developing diversion-related programming and supporting desired outcomes for the target population. As Travis County continues to support development of our system of programs, facilities, and other capabilities that support diversion for individuals with behavioral health challenges, we intend to pursue inclusive processes that incorporate a broad range of community voices to adapt best practices developed by other communities into solutions that work for our community.

The Dell Medical Mental Health Forensics report, released in March 2023, recommended building a Diversion Center that would support individuals with behavioral health challenges who are at risk involved in the criminal legal system “to avoid jail whenever possible and receive mental health disorder care, while also supporting community safety”. The Travis County Commissioner’s Court also passed a resolution in March 2023 that provides general guidance, such as some of the services that will be provided in a local Diversion Center.  

Travis County staff will be hiring a team of experienced design consultants, that will be led by architects and engineers, to support local stakeholders in developing answers for questions like, “under what circumstances will individuals be able to receive services in the center?,” “how many people are estimated to be served?,” and “what services and supports will they receive?” to create recommendations for physical design options for the center that will be reviewed by the Commissioner’s Court, who will determine whether to move forward with any of the options. At the start of this process, Travis County leaders, the design consultants, and community stakeholders will establish a process for soliciting input from the public and reviewing workgroup recommendations for center design.

The Diversion Center will be an important source of support for individuals at the intersection of behavioral health and criminal legal systems. The resolution passed by the Commissioner’s Court states among other things that the Diversion Center will provide pre- and post-arrest services, services for individuals with substance abuse issues, and connections to supportive services to aid their transitions back into the community. We anticipate that there will be options where individuals involved in the criminal legal system will be able to access services voluntarily at the Center as a part of their legal processes. However, there is also reportedly a shortage of treatment facilities for individuals with the most serious mental health issues, at a higher risk of negative interactions with law enforcement, and who may be ordered by the courts to be held involuntarily to stabilize their conditions and help to facilitate resolution of their legal issues.  

The Diversion Center is also intended to be a resource to provide services to help these individuals stabilize during a crisis and transition to the next appropriate place for help. This short-term stabilization and transition support will likely also apply for specialized populations, including Individuals with Developmental Disabilities (IDD), Traumatic Brain Injuries, and individuals experiencing homelessness when law enforcement deems them a risk of harm to themselves or a danger to public safety.  

During the Diversion Center design effort described in the response to Question #2, the design consultant team will develop estimates for the construction and operating costs for each set of recommendations developed by the workgroups. These estimates will also be reviewed as a part of the selection process by the Commissioner’s Court.   

Travis County staff have also developed budgeting processes and use various risk management and monitoring practices to ensure appropriate use of public funds. We are also researching a diverse set of funding sources at the local, state, and federal levels to fund the Diversion Center. We will also continue to build on existing community partnerships with funders for County programs and facilities and are developing new relationships with others. 

As the Diversion Center project moves from the design phase into the site preparation and construction phases, Travis County will bring together stakeholders, including mental health and recovery peers and representatives from peer-led organizations, to confirm our understanding of the needs for wrap-around support and to determine how those supports will be provided through the diversion center and other county programs and partnerships.  

Measuring progress and outcomes will be a central element of the work Travis County supports to advance diversion efforts, and we will be using many tools to measure progress both across the system of interventions/programs to deflect and divert individuals with mental health challenges, and for specific programs. The Crisis Care Diversion Pilot contract with Integral Care includes performance measures across several program areas. Travis County is also in the process of working with the Dell Medical school to design an independent program evaluation to expand our understanding of how the Pilot is driving outcomes for the intended population. As the Steering Committee begins work to develop recommendations for system goals and direction and highest impact priorities, the group will be discussing approaches for establishing a baseline for system performance to effectively track progress over time. Finally, Travis County is also planning to host a series of workshops to educate the public on data and measurement practices and soliciting impact on what “success” looks like for diversion efforts and how it could be measured. 

There are several ways to stay informed about the development of our local diversion system of supports. These include: 

• Press conferences held by members of the Commissioners Court 
• Presentations at Commissioners Court hearings 
• Community Engagement sessions hosted by Travis County 
• The Travis County Diversion webpage with email address

All the data will be available to the community and those working on developing the future Diversion Center. The pilot will have multiple task groups to enhance cross-system collaboration for individuals with behavioral health needs that result in cycling through the criminal legal system. The learnings from the task groups and the pilot can help inform the design of the future Diversion Center.