The Road to an Effective RTC Program

By Wendelyn Pekich, MBA, CCHP

As they headed south on Interstate 17 through the Arizona desert, the three officials knew something had to change. For several years the State of Arizona, trying to cope with the recession, had been shifting more and more funding burdens to the state’s 15 counties. Now, on that summer day in 2009, the trio— each involved in a different aspect of Yavapai County’s corrections system—was determined to find a new approach.
The result of that trip was a bold, innovative program that enables Arizona’s less populous counties to efficiently fulfill their constitutional obligation to ensure that every criminal defendant be competent before standing trial. Thanks to the Restoration to Competency (RTC) mental health program now in its fourth year at the Yavapai County Detention Center, most of Arizona’s rural counties are able to satisfy that requirement in a timely fashion and without breaking the bank.
The program, which was recently honored with the American Correctional Associ-ation’s 2014 Innovation in Corrections Award, pools the resources of 10 counties and a Native American nation to provide jail-based RTC services for just one-fourth the cost of what similar treatment would cost at the state hospital. The program is conducted by Wexford Health Sources, the Pittsburgh-based health care provider that also contracts to provide health services at the county jail. The program enjoys success rates that mirror national averages, including the average time it takes to restore defendants to legal competency.
On top of that, Yavapai officials say defendants in the program are generally more compliant and less likely to malinger, because of the Restoration to Competency program’s location on the jail premises.
The Challenge
Until about a decade ago, the State of Arizona paid for restoration to competency services, which were provided by the full-time professional staff at Arizona State Hospital in Phoenix. Though the counties were responsible for transporting and securing their defendants, the high cost of restorative mental health treatment was borne by all taxpayers across the state.
That changed when the national economy went sour. Like their counterparts across the country, Arizona lawmakers searched for ways to reduce costs. The state shifted the fiscal burden of restoration to competency services to the counties whose defendants were being treated.
The state’s two largest counties, Maricopa (Phoenix) and Pima (Tucson), began their own jail-based Restoration to Competency programs. But most Arizona counties are vast expanses of rural acreage with small tax bases; these entities were hit especially hard by the recession. The $671-per-day cost of treating incompetent detainees for months at Arizona State Hospital, even for just a handful of defendants per year, could create a significant gap in these counties’ budgets. 
The Road Trip
That’s why Jack Fields, John Russell and Becky Payne found themselves on the road to Tucson, where they met with Pima County Jail officials to discuss RTC options. On the 220-mile trip back home, the Yavapai officials tossed around every idea they could think of. “It's not rocket science,” Payne recalls them saying, “it doesn't seem that difficult."
Payne, a registered nurse and Health Care Unit administrator for Wexford Health at the Yavapai County Detention Center, knew their small county couldn’t afford year-round clinical professionals who might only be needed at peak times. The key, she realized, was dynamic staffing that could accommodate routine fluctuations in the jail census.
Chief Civil Deputy County Attorney Fields crunched the numbers, while Russell, soon to become Chief Deputy for the county Sheriff’s Office, added the law enforcement perspective. It quickly became apparent that if Yavapai were to create a program and open it to neighboring communities, multiple counties could share in the cost savings. This model would also provide a more consistent number and flow of program participants, making it far more practical and financially feasible to hire and retain the necessary mental health professionals.
Finally, they struck upon a workable solution: If Yavapai also welcomed defendants from neighboring counties, the program could support a basic staffing level while saving each of the counties money. By supplementing a small full-time staff with contracted professionals, the Yavapai RTC program could supply a full complement of clinicians when necessary, while cutting back to smaller staffing levels as the needs of the jail population dictated.
They eventually took their idea to then-Sheriff Steve Waugh. He quickly embraced the plan to extend the county’s successful partnership with Wexford Health by adding an RTC program.
“From a law enforcement perspective, and from a jail management perspective, it makes so much more sense to provide restoration services within a secure jail setting,” Chief Russell says. “We knew that once it got up and running, a jail-based program would be better for us, better for the detainees and better for the taxpayers who fund it all.”  
On April 1, 2010, the Yavapai Restoration to Competency program opened its doors. About two-thirds of the defendants it treats come from the Yavapai County judicial system, but through inter-governmental agreements it also accommodates detainees from nine other counties (Mohave, Coconino, Navajo, Apache, LaPaz, Gila, Graham, Yuma and Pinal) and the Fort McDowell Yavapai Nation.
Proven Outcomes, Proven Savings
As of August 2013, the program had admitted 129 defendants, with a restoration rate of 79 percent—virtually the same as national averages. The American Academy of Psychiatry and the Law (AAPL) reported in October 2009 that of the estimated 60,000 competency evaluations ordered nationally each year, 20 percent conclude the defendant is incompetent to stand trial. The same AAPL study found that the national average length of stay in a restoration to competency program is 120 days, an outcome matched by the Yavapai program.
A significant difference for the jail-based program is how rapidly medical personnel can begin treatment. “Time is of the essence, and having a jail-based RTC program allows us to begin the restoration process virtually immediately. We get a better assessment, we get better treatment,” says Dr. Ron Smith, director of Behavioral Health Services for Wexford Health. “The sooner they get into treatment, the sooner they get out of it—and the fewer resources we need to restore competency.”
On average, detainees in Yavapai County begin treatment in the RTC program 4.6 calendar days from the date a commitment order is signed. This includes the time program administrators wait to receive the commitment order. Defendants from other counties begin treatment within 10 days, after transportation to Yavapai can be arranged. In contrast, although jail officials do not have verified statistics from Arizona State Hospital, nurses and transportation supervisors around the state recall defendants languishing for 30 to 60 days waiting for an RTC bed to become available at the state hospital.
The overriding objective of any restoration to competency program, wherever it is housed and whoever operates it, is to improve the mental state of legally incompetent criminal defendants. These individuals must be able to assist in their defense and understand the legal proceedings that will affect their lives and, potentially, their liberty. While the U.S. Constitution requires this for the defendants, it also benefits society as a whole. The maxim that “justice delayed is justice denied” applies here. Crime victims, the judicial system—and the taxpayers—deserve to have cases resolved as promptly as possible.
Restoration to competency programs play a vital role in allowing a judicial system to move forward toward an ultimate determination of guilt or innocence. But a well-managed, efficient RTC program like the one administered in Yavapai County can produce additional substantial benefits to the taxpayers.
Since it opened in 2010, the Yavapai RTC program has saved taxpayers in participating counties more than $6.75 million compared to what they would have been forced to pay for the same services at Arizona State Hospital. The cost of successfully treating incompetent inmates has saved Yavapai County $4.71 million; the partnering rural counties have realized an additional $2.04 million in savings. For cash-strapped counties, these savings—averaging $511,000 to $1.17 million per year—can help local governments provide countless other programs and services to their citizens.
The National Association of Counties recognized the value of the program, selecting it for one of only three national “Courthouse Awards” in 2011. A panel of experts honored then-Yavapai Sheriff Steve Waugh for spearheading the creation and implementation of the RTC program.
Why Jail-Based?
The fiscal benefits to counties in having an RTC option beyond the Arizona State Hospital are clear. Then the question becomes: Why does it have to be housed in the restrictive environment of a jail?
“They [detainees] have a tendency to do better in the restoration program when they’re in a county jail. There can be a kind of incentive for them to go to the more relaxed state hospital because it’s not a jail environment. When they’re being treated at a jail, they tend to regain competency sooner,” says Fields, the county attorney who helped launch the RTC program after that fateful road trip.
Court-related restoration to competency programs are different than more traditional treatment programs at a state hospital. The Yavapai program, notes Dr. Mark Collins, the RTC program psychiatrist, must address the patient’s cognitive abilities—not only must any psychosis be eased, but the defendant has to be able to understand what is happening to him.
Among the benefits of housing an RTC program within the jail:
• Transportation—Defendants are already secured there, and don’t have to be moved to another facility.
• Security—Detention officers are trained to handle unruly detainees, and their very presence minimizes the chances of detainees acting out.
• Facilities—Many jails already have health care facilities on the premises, with trained medical personnel and pharmacy operations. In fact, these facilities generally enjoy greater flexibility than hospitals in the selection of therapeutic medications available to treat patients.
• Proximity—Two-thirds of the Yavapai County RTC participants come from Yavapai County, and many of the partnering counties are in the northern half of Arizona. The jail-based RTC program treats the defendants closer to home and greatly improves the opportunity for family and friends to visit, which can have substantial therapeutic benefits. They’re kept in their own community and their friends and family have a greater ability to visit. Having supportive contact can be very therapeutic, Dr. Stewart says.
Can It Work Elsewhere?
This RTC experience can be replicated in other jurisdictions and other states, but only if the circumstances are just right, according to Dr. Smith. When others consider it, he warns, corrections officials must always recognize the fiscal challenges of starting such a program. In Arizona, he notes, officials had little choice because the state was imposing the cost burden on counties and the only option was to find a way to operate a program more affordablely.
Meanwhile, the few Arizona counties that are not part of the Yavapai partnership have recognized the benefits of the innovative approach. One county near Tucson has partnered with that jail’s RTC program, and another launched its own program after consulting with Yavapai officials.
Clearly, the idea of jail-based Restoration to Competency is an idea whose time has come, for the criminal justice/corrections system, for detainees, and for the taxpaying public.
“We want to be able to hold people responsible for their actions if they engaged in criminal conduct. At the same time, we want to make sure people’s rights are respected,” Fields says. “Overall, regarding the idea of controlling our own destiny, I think we’ve very much succeeded.” 
Wendelyn Pekich has 30 years of marketing and communications experience, specializing in health care. She has spent the last eight years promoting correctional health care as a director for Wexford Health Sources in Pittsburgh, Pa.