TCOOMMI is not an acronym that easily rolls off the tongue,
but since 1987 this awkwardly named agency has
helped eliminate awkward barriers for inmates needing post-release medical
or mental health services in Texas.
Texas Correctional Office on Offenders with Medical or Mental Impairment,
the full name of the office, was
established by the state’s legislature to supervise treatment for “special
offender populations” such as the elderly,
those with serious medical or physical disabilities and or
mental/developmental impairments. TCOOMMI staff
are charged with responsibility to coordinate services to offenders through
not only the Texas Department of
Criminal Justice (TDCJ), but other health and human service agencies in all
254 Texas counties. The word
“offenders” is used because “the majority of our work involves people on
parole and probation, not just those who
are incarcerated”, said Ms Dee Wilson, Director of the program. TCOOMMI
Director, Ms Dee Wilson, noted that
while it may be hard to believe, “given the size of the inmate population,
we have about three times as many
people on parole or probation in Texas.” Of the 25,000 to 30,000
offenders served in a year, “most of these will
be from adult and juvenile parole and probation,” Ms Wilson noted.
Now receiving funding of $35 million TCOOMMI has been able to expand from
only supporting discharged inmate
services to “emphasize the front end of the juvenile justice and adult
criminal justice systems. In addition,
legislation impacting pre-trial stages of the criminal justice system was
enacted”, according to the agency’s
biennial report. The vast bulk of TCOOMMI’s funds are spent in directly
purchasing medications and services for
offenders after release. Relatively small sums are spent on administration
and pre-release planning.
As of the end of 2004 Texas was the only state to mandate
continuity of care (COC) for all persons under its
jurisdiction. “Our legislature mandates that anyone in the correctional
system with significant medical,
mental or developmental problems will have continuity of care,” the director
commented. Additionally her st
aff can assist in fi ling applications for Medicaid and Social Security
Administration programs such as
Supplemental Security Income and Social Security Disability Insurance.
TDCJ had an inmate population of 168,105 at the end of 2004,
second in size only to the Federal Bureau of
Prison total of over 180,000. Texas incarcerates at a rate of almost 700
individuals per 100,000 in population,
surpassed by Louisiana’s rate of slightly over 800 per 100,000. In planning
for post-release care TCOOMMI
contends with the full range of medical and mental health problems
afflicting offenders, including approximately
2,500 inmates with HIV infection (2001 statistics from Bureau of Justice
Statistics, January 2004).
Data-sharing between the correctional department and other
social and behavioral agencies are part of the
state post-release program. One goal of this data exchange is to determine
which incoming inmates have
been clients of mental and public health service agencies to help determine
the need for continued services
while incarcerated and to aid in accessing records of inmates.
A cross-match of the more than 628,000 persons under some
form of state sanction (incarceration, parole or
probation, and community corrections programs) noted that 17% of these names
resulted in “hits” on the lists
from mental health/mental retardation service providers. That percentage is
in line with estimates from several
sources that around 16% of inmates nationally have some diagnosable mental
illness. However, since Texas’
human services department notes only about one-third of those who require
assistance can be served at current
funding levels, it seems likely that substantially more than 17% of that
628,000 plus individuals have some
pre-existing mental impairment.
Innovative Use of Data
T
COOMMI has been able to
coordinate data from several departments in the state government, allowing
for
better planning and service delivery. One recent effort was to determine the
adequacy of mental health screening
programs at county level jails. Three different state intake facilities were
chosen for a study focusing on
information counties are required to provide when inmates are sent to a
state facility. Based on that data
TCOOMMI found that large numbers of current inmates who did not have a
mental illness diagnosis noted on
these forms, in fact have been clients, or were at the time of intake,
clients of mental health services in the state.
Of 100 inmate records reviewed, 15% had a mental health diagnosis while
incarcerated, most of which
matched the outside service provider diagnoses. Of the remaining 85
offenders re-evaluated at the state facility,
fully 34% were found on the CARE system (CARE is the statewide Mental Health
and Mental Retardation
database).
Efforts are now being undertaken to improve
jail-based screening programs. Another data analysis that shows
promise is matching released offenders with the statewide data to determine
the effectiveness of the state’s
prison system to properly diagnose and treat offenders while they are
incarcerated. At the state’s “intermediate
sanction facilities” it seems many inmates with prior mental health service
histories are not being identified at
TDCJ institutions. Over seventy percent of inmates at these facilities with
previous connections to the MH
service programs are released without being identified or offered
post-release treatment plans.
As these examples show, even with the efforts of TCOOMMI,
many offenders who could benefit from programs
are being missed. More importantly, however, these also show the agencies
how to improve these efforts and
what steps they need to implement to assure inmates do not slip between the
cracks. TCOOMMI has
statewide contacts for mental health services as well as probation and
parole officers with advanced training in
mental health issues. Recently the agency initiated mental health diversion
programs that offer treatment
alternatives for offenders. Still another effort has started in Harris
County (Houston) to reduce the number of
defendants who would otherwise require stays in state mental hospitals for a
determination of, or restoration of,
competency.
As part of its mandate from the Texas legislature the Office
has developed Memoranda of Understanding
(MoUs) with other state departments as well as community based mental health
and mental retardation service
providers. All the participating agencies are required to be involved in
cross-training or educational events so all
are aware of new developments in the various fields.
In addition the agencies are to advise one another on any
policy or procedural changes that could affect
continuity of care at least 30 days before these changes take effect and to
permit input on them. TCOOMMI
on its part ensures offenders being released from institutional facilities
have access to a ten day supply of
medications upon their release. “Our release planning begins six months
before the expected date of release,
so we can let our service providers know when to expect someone”, Ms Wilson
said.
One particularly interesting requirement is that service
providers and the Community Supervision (parole/
probation) and Community Detention offices provide joint staffing to review
compliance to both treatment
and supervision for those with mental health diagnoses to assure options are
explored before an offender is
re-incarcerated should there be difficulties.
TCOOMMI serves as the dispute resolution center if there are
jurisdictional or other conflicts involving an
offender. This mechanism replaces the older method of relying on
parole/probation and courts. The courts
often lacked options other than re-incarceration for those not in
compliance. Texas, as most states, has
encountered severe budget problems in the past several years. This makes
another provision of the MoUs
a priority, the call to, “actively seek federal funds to operate or expand
the service capability.”
In particular they want to maximize Medicaid or other
entitlements. That effort is in part thwarted by recent
changes to Medicaid eligibility standards introduced by Texas. Federal
Medicaid revenues to various
agencies involved in the TCOOMMI projects increased from somewhat over
$397,000 in fiscal year 2002 to
more than $1 million in FY 2004. However, a major change in policy at the
Department of Health and Human
Services in Texas has meant that perhaps 15% of released offenders who
previously were able to access public
Medicaid funded mental health services can no longer do so, according to
TCOOMMI’s report. This appears
to account for a 22% drop in revenue the partner agencies experienced in the
fi rst quarter of FY 2005. That
decrease seems to be lessening as time goes on and more recent information
shows that perhaps 10%
of adult offenders and 5% of juvenile offenders may not be eligible for the
Medicaid services. “The legislature
has been very, very supportive of services for offenders with mental and
medical issues and has provided
TCOOMMI with its own funds to purchase services for those who cannot access
them otherwise”, Ms Wilson
noted. “We can pay for medications and other care when there are problems
with funding.”
“Some people might complain that we are treating offenders
better, putting them ahead of others in the
community for services. This is really a public safety issue, you don’t want
offenders on a long waiting list;
that is asking for more trouble”, she continued. Texas’ Department of Health
and Human Services has
implemented a program called Resiliency and Disease Management, a
comprehensive mental illness
disease-management effort using evidence-based approaches to mental health
care. RDM, as it is called,
offers more focused and supportive care to those eligible for the program.
Due to less than optimal funds, the legislature limited this disease
management service to patients
with diagnoses of schizophrenia, bipolar disorder, or severe clinical
depression. Those who do not qualify for
RDM are to access non-public mental health services. Particularly in rural,
poorer counties of Texas there
are few if any mental health professionals.
Texas is not alone in lacking adequate community based
services for the mentally ill. Most states have
lagged in creating and supporting centers for treatment and care of these
illnesses. The Health Resources
and Services Administration, part of the Federal Department of Health and
Human Services, notes there are
more than 1100 areas formally designated as having a shortage of mental
health professionals across the
country.
Ms Wilson sees no great problem for outpatient care for
inmates who can find places to live. “If they can return
to their families, we can get outpatient services even in some really out of
the way places. Our biggest need,
not just in the rural parts of Texas but across the state, is for
residential programs. We have people who really
need supervision and mental health treatment, and there are not enough of
these.”
New Directions
Ms Wilson noted, “Our advisory board and others are looking
at ways we can improve on services prior to
incarceration. We want to see how we can offer better care for offenders and
provide better, safer communities.
If we can expand services at the local level this will be big help.”
In the past TCOOMMI has concentrated on the mentally ill
under state sanction. With new legislation the
agency expanded coverage for other offenders with special needs, including
health care issues. One
impediment the agency found was in its program for medical release of
seriously ill inmates. Legislation
that has recently been repealed limited such release to inmates with less
severe criminal records and to
only one state operated nursing care institution. In fact, TCOOMMI found
large numbers of inmates who were
eligible for such release, refusing to go to the skilled nursing facility.
One reason for this seemed to be the
isolation of the facility from major population centers, thus keeping
offenders from seeing their families.
One new strategy involves an alphabet of agencies that would offer release
from the prison system’s major
medical facility (operated by University of Texas Medical Branch in
Galveston) to a free world facility within 24
hours of an inmate being declared eligible for release for medically
recommended intense supervision.
This will involve not only having accommodations available
for inmates, but rapid work to determine if the offender
will be able to access Medicare or other public payment programs. If this
effort proves successful, other facilities
will be added. “Early medical release is only a very small part of what we
do for offenders who are incarcerated
and have physical impairments”, Director Wilson said. As part of its
services TCOOMMI completes discharge
plans for inmates with chronic illnesses that are not immediately
life-threatening, such as HIV, cardio-vascular
disease and diabetes.
These plans include setting up appointments for releases
with health care providers and in some cases
providing medication at release. “We don’t do all the care providing by any
means. We contract with
state and other agencies because they are the experts”, commented Ms Wilson.
For example she said, “For
our older inmates we have people from Aging who go into the facilities and
assess the offenders then work with
us on a continuity of care plan for post release. That’s the case for anyone
with medical problems.”
When asked if there are “success stories” about offenders
served, Ms Wilson said that with 30,000 or so
people each year served by the agency, “there are just too many to recall.”
The agency operates with a
headquarters staff of 12 at the state capital in Austin with an additional 6
located in Huntsville. “We have an
advisory board of 31 members, more than our staff, but each of these members
brings something valuable
to the table.” Nine members of the advisory panel are appointed by the
governor with the rest representing the
various partnering agencies. “We have people from local corrections, from
other sate agencies and from our
service providers across the state. Every once in a while someone on the
advisory board will ask if we want to ‘
get a more focused group’. We really don’t want that, we need their guidance
and input on what is working and
how to improve things,” Ms Wilson commented.
