1. Health

How the 'no wrong door' approach to mental health treatment is playing out in Hillsborough County

TAMPA — Cops faced a tough call when they encountered someone acting oddly.

Was it mental illness or substance abuse or, as is so often the case, both? Did the person need medical attention? Then, in Hillsborough County's myriad hospitals and behavioral health care facilities, where should they take the person?

"Basically we had to triage the problem," said Officer Daniel McDonald, the homeless liaison for the Tampa Police Department. "And out of multiple different facilities we had to figure out where the folks would go."

That changed in March, when an intake center known as a central receiving facility opened at Gracepoint, a Tampa-based nonprofit organization that offers help for people with mental health and substance abuse issues. The facility, the only one of its kind in the Tampa Bay area, serves as a behavioral health emergency room with a coordinated web of services to ensure the person in crisis is getting the right level of care, said Gracepoint CEO Joe Rutherford.

The concept has existed for years but gained steam statewide last year with the passage of a law that overhauled mental health and substance abuse treatment and mandated a "no wrong door" approach for people entering the system. Even so, this year the state Legislature cut the budget for such programs by more than 40 percent.

Because of the first waves of funding from the state, Gracepoint's capacity increased, admitting about 1,100 people a month, 400 more than before. The organization expanded what Rutherford called "wrap-around" services to divert people from a crisis or ensure they get follow-up care. Police officers and sheriff's deputies now get in and out in an average of 90 seconds and no longer have to diagnose problems on the street and figure out where to take people.

"The adage of 'no wrong door' is absolutely correct," McDonald said. "We bring them there, and they sort out the rest."

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The facility works like this:

A person experiencing a behavioral health crisis can be taken to Gracepoint by law enforcement, emergency medical services, family or themselves.

Inside, a staff member assesses the person's physical condition to ensure they don't need medical attention. They're evaluated to see if they meet criteria to be taken into custody under the Baker Act, a law allowing for the involuntary commitment of people believed to be a harm to themselves or others, or the Marchman Act, which is similar but for people abusing drugs or alcohol.

They are then taken to either the Baker Act unit, which has 60 beds, or the Marchman Act unit, with 30 beds run by ACTS, a substance abuse treatment organization. Both are on the same campus.

"Once you're in, you're in and you're secure," said Roaya Tyson, chief operating officer of Gracepoint.

If they don't meet either law's criteria, staff members set them up with case management and outpatient care services.

Beyond the brick-and-mortar facility, Gracepoint expanded its services to target high utilizers in a county that logged about 15,000 Baker Acts last year — a 34 percent increase from 2011, according to data from the University of South Florida. A care coordination team was created with housing and health specialists plus two people who have experienced some type of behavioral health issue to get the person set up in the community.

The organization also expanded its mobile crisis team, which intervenes before a mental health issue reaches the level of a Baker Act, and impact team, which engages with people in the month after they're discharged to get them set up with a doctor and medication.

Those teams are useful for law enforcement, said Stephanie Krager, a Hillsborough County sheriff's homeless initiative deputy who has been pushing for a central receiving system since the first one in the state opened almost 15 years ago in Orlando.

Krager, who also runs crisis intervention training for the Sheriff's Office and surrounding agencies, said deputies see the same people who fall through the cracks without follow-ups once they're discharged. They also run into people who don't meet Baker Act criteria but clearly need help, pointing to an example of a man who was digging a hole in his yard at 3 a.m.

"With mobile crisis," she said, "they can see a lot more than law enforcement has been trained for."

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That type of intervention and case management is playing out across the bay in Pinellas County, which has also seen a steady rise in Baker Acts. The Sheriff's Office formed a unit made up of two deputies and two social workers who respond to and follow up on mental health-related calls.

When it comes to substance abuse, the county has no state-funded, secure facility to take people under the Marchman Act. Instead, about 1,200 people a year who could benefit from treatment end up in jail, said Jerry Wennlund, CEO of Personal Enrichment through Mental Health Services, a behavioral health nonprofit.

Sheriff Bob Gualtieri added case workers from PEMHS in the jail to work with Marchman Act patients, and potentially send them to Operation PAR, an addiction and mental health treatment center.

The county doesn't have a central receiving facility, although Wennlund and Gualtieri both said it could use one. In the absence of one, Gualtieri is working on securing funding for intensive case management to coordinate discharge planning and follow-up.

"You're trying to get them all the services they need as opposed to them hopscotching from one provider to another with nobody being responsible for their overall care," he said.

The lack of a facility comes down to what it so often does in a state that's consistently ranked near the bottom for mental health funding: money.

That's a problem for Hillsborough's system as well.

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The state Legislature first budgeted for central receiving facilities two years ago with a $10 million allocation. The goal was to "provide a single point of entry for multiple behavioral health providers, conduct initial assessments and triage, and provide case management and related services, including jail diversion programs for individuals with mental health or substance abuse disorders," according to that year's budget. Last year, that budget allocation doubled to $20 million.

Five projects received funding in 2016 including Gracepoint, which got a total of about $1.8 million from both years, Rutherford said. The organization put about $3 million of its own budget toward facility changes.

Four more received funding this year, bringing the total to nine across the state serving 22 counties, according to the Florida Department of Children and Families.

But in the most recent legislative session, the third year, the allocation for all the facilities was cut by 41 percent to about $11.9 million. Sen. Jack Latvala, R-Clearwater, the Senate's appropriations chairman, said his chamber tried to maintain the full amount and pointed to the House of Representatives. The House's health care appropriations subcommittee chairman, Rep. Jason Brodeur, R-Sanford, said his chamber proposed a $5 million cut based on a DCF recommendation. At some point during negotiations, it was whittled down to the final amount.

The funding was never guaranteed from year to year, but the cut still baffled Rutherford. Gracepoint's internal data shows the programs are diverting people from crisis, reducing repeat admissions and saving money. And the mental health bill passed last year reinforced the importance of programs like this, he said.

"We have to take something we finally have determined can demonstrate effectiveness and dismantle it," he said.

Gracepoint officials are scrambling to find money within their own coffers to make up for the cut. Rutherford has spoken with legislators, including state Sen. Dana Young, R-Tampa, who pledged to help restore the funding in the next session.

Until then, they're bracing themselves for service reductions that Rutherford said will reverberate through the whole system. That includes law enforcement, Krager said.

"Anything we can do to put funding toward these folks, avoid them getting arrested" would help, she said. "We need places to put these folks so they're safe."

Contact Kathryn Varn at (727) 893-8913 or Follow @kathrynvarn.