Q & A with The Equitas Project Executive Director Vincent Atchity
Vincent Atchity is the Executive Director of The Equitas Project, whose goal is: disentangling mental health and criminal justice, and has worked in public health for many years focusing on managed care, cost control, outcome improvements. He has served on the Governor’s Mental Health Task Force, among others.
In this Q & A, he talks about the recent success of a homelessness project in Texas, the goal of bringing a similar project to Colorado, health care work he is dedicated to today, and some of the mental health highlights from this legislative session.
EV: Tell me a bit about yourself, I know that you came to The Equitas Project a couple of years ago, but what were you doing before that?
I have a public health background, and immediately before The Equitas Project I was working with an organization in Northern Colorado called the North Colorado Health Alliance. We were part of the implementation of the Affordable Care Act when the state expanded Medicaid access and we created care management teams to try and work with Medicaid enrollees to improve their health outcomes and reduce overuse of high cost aspects of a safety net system, like visits to emergency departments and unnecessary hospital readmissions, that were avoidable by means of intervention into their lives, by helping them keep up with treatment plans, overcome transportation hurdles, et cetera.
EV: Is this public health background what led you to begin working on this new project in Colorado centered around mental health and criminal justice? I know you are working closely with Rep. Lois Landgraf on implementing a similar program in Southern Colorado. What does that look like, and can you tell me a bit about this new program?
Sure, Rep. Landgraf and I went on a trip to Texas, to Bexar County and have been in conversation about starting a similar type of project in her district for a couple of years now. I have not yet been involved heavily in this process yet, but I am interested in the work, and hope to get involved in the future. This specific project is something that she has been able to pursue through local partners in El Paso County.
The pathway to this project is partially from my interest and previous work with Medicaid enrollees and in population health and thinking about how so many different factors in a person’s life contribute to their health outcomes. I think it has become commonplace in public health to describe one’s health as a product of a number of different factors, genetics, behavioral choices, and environment, and access to care. These are credited with forming your overall health. The behavioral and environmental aspects are something that are of most interest to people like me who are interested in population health because those are the ones that we may have control over to some degree.
One of the things that we learned when working with Medicaid enrollees …is that there are a number of different things contributing to their overuse of things like the emergency department. When you look at the Medicaid claims to look at what is driving that, there was not some diagnosis that leapt out…. instead what they have is a series of co-existing diagnoses that are often things associated with environmental conditions, behavioral health, chronic poverty, and mental health that make it difficult to make it to PCP appointments. They have transportation issues, family issues, and they are often drawing on a number of different community resources to try and cobble their lives together.
We were doing care management to try and identify the factors contributing to the lack of continuity of care. We found that different aspects of our systems are just not well coordinated with one another…providers were not communicating with one another, and we would go in and do simple things, like getting all these providers on the phone with one another to provide care to that patient. This kind of coordinated system work contributes to what we are doing now by convening these different stakeholders at the intersection of mental health and criminal justice.
The different agencies did not know much about one another, or about the bureaucratic hiccups that got in the way of delivering a positive outcome for the client. Just by getting the different entities to communicate with one another we were able to close some of the gaps in the safety net system.
EV: This seems like an effort to create a coordinated care system. Is this the type of approach that Bexar county took when developing their homelessness program?
Yes….this gets us to the trip to Bexar County. Instead of expanding the jail to deal with overcrowding, the mental health department proposed an alternative which was to design this site that would allow access to care for folks whose health needs were of a greater magnitude than their criminality or their threat to public safety. So, law enforcement had some place other than jail to to take somebody who really needed health care help. Bexar County has a bunch of different aspects to the campus. It’s something like a 30 acre campus, right outside of downtown San Antonio and it has different tiers, and levels of access.
At the entry level, there is a fenced in courtyard, with a carport-like shelter and people can go in there and have safe shelter without any stipulation regarding their sobriety, things that are often a deterrent for shelter for people. You cannot bring contraband and drugs or alcohol inside, but you can get rid of such things in the “amnesty” boxes they have at the entrance. There is a kennel facility for people with companion animals. They provide you with bedding and meals. They help you sort out your medication. Once you are inside the courtyard, caseworkers who work in the facility will start doing outreach with you, perform a needs assessment, and and try to persuade you to consider a detox program if needed. When you are ready, then there are these additional tiers of housing available on site, and the campus has this building that have 30 community resource agencies so that the residents can cover all of their needs in a one-stop-shop…food stamps, Medicaid, find employment counseling. A lot of what is challenging about resources in communities is that they are scattered about the community and people without private transportation have a hard time getting from one place to another and keeping appointments.
To make a long story short, 15 years later the county never had to expand their jail and they have served over 60,000 people, successfully integrating people back into the community.
This new project that Rep. Landgraf is specifically focused on the needs of veterans. That is a particularly focus group with a need for mental healths and improved access to other community resources.
EV: Do you think that there is anything specific to Rep. Landgraf’s district that makes this an area of Colorado a potential success for program like the one in Bexar County?
Rep. Landgraf’s district is home to a great many military families and veterans. The is a great deal of shared concern that communities can and should be doing better by those who have served the country in this way, and who face a series of challenges associated with unmet mental health needs when it comes to successfully reintegrating into the domestic economy.
EV: Beyond this project, what else are you working on, what are you spending your mental energy on?
The Equitas Project, an initiative of the David and Laura Merage Foundation, is a non-profit with the goal of disentangling mental health and criminal justice. We are dedicated to activating leadership to be on the same page in regard to adopting policy and practice reforms that will improve health outcomes and reduce overreliance on the justice system. We have helped different coalitions of leaders and stakeholders co-author sets of recommendations…which have led to legislation over the past couple of sessions. Lately, we have been starting to work with a committee of legal, forensic psychiatry experts on revisiting outdated civil commitment laws, so that people with severe mental illness are able to get access to the care they need. I think that the main work that we carved out for ourselves, for Equitas, is to shine a spotlight on the problem—that jails and prisons are the largest psychiatric facilities in every state, and that calls for help in mental health crises too often lead to law enforcement response and arrest–and to focus the attention of leaders on solving this problem…keep asking the right questions of the right people, and not let this public health crisis fade from their consciousness as a major policy focus.
EV: Following the legislative session, are there any standout bills that you were watching, or bills that you think will have a pretty big impact on mental health policies?
Well, we are structured as a private operating foundation, and we do not lobby for or against bills, but we do educate leading up to a session and during session, without taking a position. But now that the bills have passed we can talk about them and there are some key ones. There was a bill, the PAD, the psychiatric advance directive, similar to medical advance directive. This does the same type of thing where you can designate someone as your health advocate, and designate some health treatments that are preferred for you. This is expected to be helpful for folks living with mental health vulnerabilities…clinical responders can otherwise end up doing things that are counterproductive. There was another key bill that decriminalized controlled substances, taking possession from a felony to a misdemeanor, which is important as we evolve into a community that understands that substance abuse is a health issue and not a criminal issue. The problem with that is that the bill may not have created a fund to properly supply the community with the health care resources required for successfully managing addiction.
A key bill from the previous session that is just being implemented now is the Bridges Program in the court system in Colorado. And what that does, is put a staff person in every judicial district whose sole role is to be a bridge builder connecting the judges and decision-makers within a judicial district to all the mental health resources in that community. The goal is to provide the judges with easy access to reliable alternatives to incarceration.
This Q & A was edited for length and clarity.