What makes Sammy run?

Huge and helpless, schizophrenic and hypertensive, Sammy Allen has fallen between the administrative cracks of a local mental health system that can't seem to get its ACT together (continued)

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Oak Cliff's Jefferson House offers few amenities. For $340 a month, Sammy Allen got three meals a day and one of eight beds in a single room.

In each felony case, he was found incompetent to stand trial and was sent to a psychiatric hospital until it was determined he had regained competency. Afterward, either his case would be dismissed and he would be released, or he would be sent for a short time to a correctional facility.

He's been repeatedly evaluated as homicidal, violent, and dangerous--an Yberpsychotic. "He's required so much medication that if we were to give it to one of us, it probably would kill us," one psychiatrist testified at a long-ago Allen competency hearing. "But to him it's just enough to sort of calm him down a little bit."

According to Dr. W. Miller Logan, the ACT team psychiatrist, there are no more than two or three places in the entire state that would be appropriate for someone such as Allen--facilities that offer long-term supportive housing for a mentally ill person who has never worked and therefore isn't eligible for disability benefits, and who has no private medical insurance. (Allen says he currently receives $485 a month in Social Security benefits. He has been on Medicaid in the past, but he is not drawing it currently.)

Hospitality House, a 65-bed licensed nursing and residential care facility located in Mount Pleasant, about 135 miles east of Dallas, is one such place. When contacted, Kristi Graves, a social worker at the facility, said that Hospitality House is now, for the most part, focused on rehabilitating people to reenter mainstream society rather than providing a place for a person to live out his life while being cared for. Graves added that Dallas County MHMR has to refer an individual to Hospitality House and must pick up a significant portion of the bill, which she estimated to be about $200 a day.

Allen has been under court-ordered outpatient treatment countless times, but the tool to enforce compliance is the threat of being sent to a state hospital--in reality more of an economic problem for the state than a disincentive to someone such as Allen. According to a 1996 report by the Performance Review Division of the state Comptroller's office, which analyzes cost-cutting measures in government agencies, the average daily cost to provide what is loosely called "supported housing" (housing in the community with an attending case manager) for a Texas consumer is $22, compared to $185 a day at a state hospital.

The report goes on to state that the mentally ill "historically have been served in state institutions. Such views, however, have changed significantly in the last several decades. Services that integrate consumers into their communities have proven to be not only effective, but also cost-efficient."

Of Allen's 46 stays in state mental hospitals since 1971, most were for only two to three months. Some lasted only two weeks. Consumers like Allen now spend most of their time living in low-cost motels, in boarding homes, in shelters, and in apartment complexes, where case managers visit periodically to check up on the consumer's status.

According to Sharon Killen, systems manager for DMHMR Adult Mental Health, people are discharged into Dallas County from state hospitals approximately 1,000 times a year; DMHMR's Liaison Services coordinates the outpatient care for these persons. From September 1, 1996, through March 31, 1997, the time period for which the most recent data is available, DMHMR served 12,009 consumers on an outpatient basis. Of that number, 1,367 received intensive case management, meaning that rather than the consumer just coming into a local clinic for medication, a case manager regularly monitored the person in the community.

"Every day I get asked or get a phone call saying, 'Hey, can you provide services for this consumer?' And I have to say, 'I'm sorry, I can't, I don't have the manpower,'" says Jesse Valdez, coordinator of DMHMR's ACT team.

In essence, ACT teams serve as mental health clinics on wheels, offering intensive outpatient services to what DMHMR terms "level III consumers": people who haven't cooperated in taking their medication; people who have moved through the mental health system's revolving doors (psychiatric emergency rooms, psychiatric intensive care units, jails, state hospitals, shelters, and boarding homes); people like Sammy Allen.

Originally conceived in Wisconsin in the late 1960s, ACT teams were developed as a way to monitor patients discharged from psychiatric hospitals, intervening before a patient got to the point where he or she had to be readmitted. The local ACT team has been a part of Dallas County MHMR since 1994, but wasn't officially mandated by Texas MHMR until 1995. Its purpose is to deal with people who weren't being helped by standard case management. The team consists of a registered nurse, a master clinician, five case managers, two community integration specialists (all full-time), and a half-time psychiatrist.

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