Forensic Mental Health: State Hospitals, Redesign, and the Office of the State Forensic Director

Overview of the Texas State Hospital System

The state’s inpatient psychiatric facilities, also known as state hospitals, remain an area of focus for legislators and mental health stakeholders. The state hospital system is intended to meet the needs of people experiencing the highest level of crisis with limited financial resources and insurance coverage and people with forensic mental health needs, acknowledging that the majority of Texans with mental health conditions can reach recovery in their communities. The purpose of state hospitals is to stabilize people in psychiatric crisis who cannot be treated safely with existing community-based services by providing the following services in a residential care setting: 

  • Inpatient mental health treatment; 
  • Medical services, nursing services, and social services; 
  • Therapeutic activities; and 
  • Psychological services ordered by the treating physician.1 

The goal of the state hospital system is to stabilize people in crisis to return safely to the community to receive treatment and services coordinated through local mental health authorities (LMHAs) and local behavioral health authorities (LBHAs).2 State hospitals serve adults, adolescents, and children. 

The state hospital system received significant state funding in the 88th legislative session through the Texas Health and Human Services Commission (HHSC) and Facilities Commission budgets, detailed below: 

HB 1 (Bonnen/Huffman)
HHSC Rider 52: Additional Mental Health Funding

  • Expansion of Community Inpatient Beds
    • State Hospital Contract Beds: $4,197,500 each fiscal year to contract for 20 competency restoration beds and $4,068,000 each fiscal year for 16 beds; 
    • John S. Dunn Behavioral Health Sciences Center: $4,730,400 each fiscal year to increase funding for 144 beds and $6,132,000 each fiscal year for 24-bed expansion to address forensic waitlist; 
    • Purchased Psychiatric Beds: $99,098,599 each fiscal year to maintain current capacity and for 193 additional state-purchased beds, including 70 in rural communities and 123 in urban communities. Of this funding, $13.7 million is required to be used in Uvalde, and 20 contracted beds for children in DFPS conservatorship; 
    • Inpatient Capacity Expansion: $45,834,616 each fiscal year to contract for 150 competency restoration beds; and 
    • Sunrise Canyon: $2.9 million each fiscal year to increase funding for inpatient beds at Sunrise Canyon Hospital.
  • Step-down Housing and State Hospital Transitions
    • State Hospital Transition Teams: $2.5 million each fiscal year to establish teams to support individuals at-risk of state hospital re-admission through coordinate and needs in the community; and 
    • Step-down Housing Expansion: $8.5 million each fiscal year for step-down housing for individuals transitioning into the community.
  • Administration and Oversight Funds:
    • Contracted Inpatient Beds: $585,121 in FY24 and $546,529 in FY25

HB 1 (Bonnen/Huffman)
HHSC Rider 108: One-time Funding for Facility Inflationary Costs

Appropriates one-time amounts to address increasing costs for SSLCs and mental health state hospitals, including $4,518,050 in GR in each fiscal year for SSLCs, $2,764,946 in GR each fiscal year for state hospitals, and $202,177 in GR each fiscal year for community mental health hospitals.

SB 30 (Huffman/Bonnen)
Section 3.02 – HHSC: New Capacity for Mental Health Services and Inpatient Facilities

  • $33,600,000 in GR for construction of a behavioral health campus in Uvalde, TX; 
  • $21,400,000 in GR for a grants management system; 
  • $101,890,000 in GR for constructing a 200-bed adult unit at the new state hospital in Dallas, Texas, with at least 75% of the beds to be used for forensic purposes; 
  • 138,773,054 in GR for an electronic health record system upgrade for state hospitals; 
  • $50,000,000 in GR for deferred maintenance for state facilities; 
  • $14,000,000 in GR for state facilities emergency repairs; 
  • $121,000,000 in GR to construct a 50-bed maximum security unit (MSU) on the existing SSLC campus in Lubbock; 
  • $15,000,000 in GR to renovate a unit at the State Antonio state hospital into a 40-bed MSU; 
  • $159,000,000 in GR to construct a 75-bed state hospital, with at least 50 forensic beds; 
  • $120,000,000 in GR to construct a 50-bed MSU in the Rio Grande Valley; 
  • $573,000,000 in GR to construct a 250-bed replacement at the Terrell State Hospital, including 50-bed MSU, 140 forensic beds, 35 adolescent beds, and 25 civil beds; 
  • $452,000,000 in GR to construct a 200-bed replacement for North Texas State Hospital – Wichita Falls, including a 24-bed MSU, 136 forensic beds, 24 adolescent beds, and 16 civil beds; 
  • $50,000,000 in GR for pre-planning, planning, land acquisition, and initial construction of a new 50-bed El Paso State Hospital, with 50% of the beds to be forensic; 
  • $45,000,000 in GR to construct 30 additional beds at the Sunrise Canyon facility in Lubbock, Texas, with at least 50 forensic beds; 
  • $100,000,000 in GR for a one-time community mental health program for county-based collaboratives that must:
    • Construct jail diversion facilities, step-down facilities, permanent supportive housing, crisis stabilization units, and crisis respite units, not including office space; and 
    • Provide a local match of 25% if the collaborative includes a county with a population of less than 100,000, 50% if the collaborative includes a county with a population of at least 100,000 but less than 250,000, or 100% of the grant amount if the collaborative includes a county with a population of 250,000 more;
  • $175,000,000 in GR for a one-time grant program to construct or expand a mental health inpatient facility to have at least 50% forensic capacity, using only donated land, to increase inpatient bed availability for forensic patients ordered to a state hospital for competency restoration. Of these funds:
    • $85,000,000 for construction of up to 100 inpatient beds by a hospital located in the Rio Grande Valley region that, as of June 1, 2023, is: 
      • A licensed as a general hospital; 
      • Has a Level 1 trauma designation; 
      • Is located in a county with a population of more than 300,000; and 
      • Has fewer than 100 licensed psychiatric beds. 
    • $50,000,000 for construction of no more than 100 inpatient beds by Montgomery County to expand the existing Montgomery County Mental Health Facility; and 
    • $40,000,000 for construction of up to 60 inpatient beds by Victoria County;
  • $4,712,356 in GR to make Child Care Licensing Automated; 
  • $64,000,000 in GR to construct 72 beds, with 36 forensic beds and 36 civil beds, at the Baptist Hospital in Beaumont, Texas; and 
  • $15,852,990 in GR to establish a one-time children’s hospitals construction grant program that may only be used to construct inpatient mental health beds for children and the grantee must provide a local match at least equal to:
    • 25% of the grant amount for construction in a county with a population of less than 100,000; 
    • 50% of the grant amount for construction in a county with a population of at least 100,000 but less than 250,000; or 
    • 100% of the grant amount for construction in a county with a population of 250,000 or more.

SB 30 (Huffman/Bonnen)
Section 3.03 – Facilities Commission: Permian Basin Behavioral Health Center

$86,700,000 in GR to the Texas Facilities Commission to construct a 100-bed comprehensive behavioral health center, with 40 forensic beds, to serve the Permian Basin region.

State Hospitals: Civil and Forensic Commitments

Inpatient mental health services are provided by state, community, and private hospitals to children, adolescents, and adults experiencing a psychiatric crisis due to mental illness. Inpatient hospitalization may be necessary for a period of time so that individuals can be closely monitored in order to: 

  • Provide accurate diagnosis and review of past diagnoses and treatment history; 
  • Adjust, stabilize, discontinue, or begin new medications;
  • Provide intensive treatment during acute episodes during which a person’s mental health worsens; and/or,
  • Assess or restore a person’s mental competency to stand trial.3

As of June 2024, the state hospitals had 2,354 beds for mental health services.4 HHSC designates local mental health authorities (LMHAs)/local behavioral health authorities (LBHAs) as responsible for achieving continuity of care in meeting a person’s need for mental health services. Within this continuum of care, the state hospitals’ primary purpose is to stabilize people by providing inpatient mental health treatment. Each state hospital has a utilization management agreement with a partnering LMHA/LBHA that requires the LMHA/LBHA to screen all individuals seeking mental health services to determine if inpatient psychiatric services are required. If the screening and assessment determine that there is a need for inpatient psychiatric services, the LMHA/LBHA decides on the least restrictive treatment setting available, with the most restrictive setting of a state hospital considered the provider of last resort. When the LMHA has not screened and referred the individual for inpatient services, a hospital physician can determine if the person has an emergency psychiatric condition appropriate for admission to the state hospital. 

There are two types of inpatient commitments in which individuals are provided comprehensive inpatient mental health services: civil and forensic.

Civil Inpatient Commitments

Civil commitments to a state hospital can happen through a variety of entry points. Although voluntary admission is possible, the majority of civil patients are committed involuntarily. Generally, LMHAs screen referrals (from individuals and others in the community such as family members or law enforcement officials) to determine the best and least restrictive placement for services. If the LMHA does not screen the referral, the state hospital conducts an emergency psychiatric screening to determine whether admission is appropriate.5

Forensic Inpatient Commitments

Justice-involved individuals needing forensic inpatient services are admitted to all the state hospitals. Individuals who require maximum security beds are admitted to either Rusk State Hospital or the Vernon Campus of North Texas State Hospital. Forensic commitments happen for two reasons: 

  • Individuals have been admitted to a hospital by judicial order because they have been determined incompetent to stand trial and are in need of competency restoration services so that they can better consult with legal counsel and understand the charges against them; or 
  • Individuals have been determined to be not guilty by reason of insanity and were ordered to a state hospital for a period of time not exceeding the maximum sentence length of the crime they committed.6

The current state hospital system has seen an increasing percentage of admissions for forensic commitments. The 88th legislature included budget Rider 109 which states “it is the intent of the Legislature that HHSC prioritize admissions to mental health state hospitals for forensic patients to address the state hospital forensic waitlist”.7 The Rider requires HHSC to prepare and submit a report on the census at each state hospital with a breakdown of civil, forensic, and maximum-security patients by October 1 of each fiscal year for the previous fiscal year.8

The figure below reflects this shift, showing a change of forensic admissions climb from 30 percent in FY 07 to 64 percent during FY 23. In August 2024, it was reported that about 73 percent of the state hospital population were court-ordered by criminal courts for treatment and the waitlist for forensic state hospital services was approximately 1,790 people.9,10 This shift leads to individuals’ longer lengths of stay, which compounds already long waitlists, and causes individuals to remain in the county judicial system as they wait to receive competency services if they are found incompetent.11

Average Census of State Hospitals12

State Hospital Redesign

Since legislation passed in the 2013 legislative session, Texas has been in the process of redesigning and improving the state hospital system to “consider the needs of existing state psychiatric hospital facilities, as well as the future demand”.13 In response, the 85th Texas Legislature directed HHSC to develop a plan to address these needs, and appropriated funds for the planning and development phases. The original Comprehensive Plan for State-Funded Inpatient Mental Health services was released in August 2017.14 An update to the original plan was released in 2021 and is available online.15 

Since the 85th legislative session, Texas has been planning, developing, renovating, and constructing the state hospital system in the state. It was recognized that Texas’s psychiatric state hospital services were, in many instances, being provided in outdated facilities that needed significant repair, renovation, or replacement. The legislature invested over $2.5 billion for replacement and renovation of the hospitals across the state, including new hospitals in Houston, Dallas, Lubbock, and Amarillo.16

The state hospital projects are part of HHSC’s Health and Specialty Care System (HSCS), which is founded on three principles: systems-based continuum of care, unparalleled treatment, and easy access. 

As of May 2024, the current status of the projects includes:

In Planning 

  • New: 75-Bed Non-MSU Bed Hospital in Amarillo 
  • New: 50-Bed Maximum Security Hospital in Lubbock 
  • Terrell State Hospital – 250-Bed Replacement Hospital 
  • North Texas State Hospital – Wichita Falls Campus 200- Bed Replacement Hospital 
  • El Paso Psychiatric Center Expansion 
  • Rio Grande State Center Expansion 
  • San Antonio State Hospital – Conversion of 40 forensic beds to 40 MSU beds

Under Construction

  • New: 292-Bed Hospital in Dallas 

Completed

  • Rusk State Hospital – Replacement 
  • Kerrville – Renovation and Expansion 
  • New: 264-Bed Hospital in Houston 
  • Austin State Hospital – Replacement Hospital17

Photos, summaries, and more detailed information of each state hospital project can be found on the HHSC Changes to the State Hospital System webpage.18 

During the planning phases of these initiatives, stakeholders recognized that building new hospitals and adding additional beds would be ineffective if not considered in conjunction with the continuum of housing needs. Investments in permanent supportive housing, step-down housing, and community housing is vital to ensure appropriate use of inpatient beds. Without a continuum of housing available, state hospital beds will continue to be occupied by individuals that do not need that level of care. Further, without the appropriate supports and services in the community, there will continue to be individuals cycling in and out of the state hospital because of no appropriate alternatives.

Office of the State Forensic Director

To address the challenge of a changing population within the state hospital system, HHSC has an Office of the State Forensic Director (OSFD). This position was created through SB 1507 (Garcia/Naishtat) in the 84th legislative session to work at the intersection of behavioral health and justice systems.19 Dr. Jennie Smith serves as the current director and works to improve the statewide coordination and oversight of forensic services and prevent justice-involvement for people with mental illness, substance use disorders, and/or intellectual and developmental disabilities.  

The OSFD provides policy leadership, subject matter expertise, and technical assistance to shape policies and recommendations for behavioral health and criminal justice programs.20 Additionally, the OSFD liaises with the Joint Committee on Access & Forensic Services (JCAFS), which provides customer/consumer and stakeholder input and recommendations to HHSC regarding access to forensic services in Texas.21

The OSFD oversees several initiatives, including the collaboration on the forensic sub-plan of the Statewide Behavioral Health Strategic Plan: Texas Strategic Plan for Diversion, Community Integration, and Forensic Services; Eliminate the Wait campaign, and the creation and operation of the Texas Behavioral Health & Justice Technical Assistance (TA) Center.

Strategic Plan

Recommended by the JCAFS, a forensic sub-plan of the Texas Statewide Behavioral Health Strategic Plan was released in September 2022, identifying strategies to enhance services in the continuity of care for people involved with the criminal justice system. The plan, featuring the “Texas Strategic Plan for Diversion, Community Integration and Forensic Services: Fiscal Years 2022-2026” is on the HHSC website.22

Eliminate the Wait Campaign

According to HHSC, Eliminate the Wait is a “a statewide campaign to increase competency restoration services for Texans by taking a comprehensive and integrated approach to this challenge.”23 HHSC, in partnership with the Judicial Commission on Mental Health, judges, law enforcement, local jails and sheriffs, prosecutors and defense attorneys, and behavioral health providers, has been working on identifying strategies to address the intersection of mental health and criminal justice through these efforts. “The Eliminate the Wait: The Texas Toolkit for Rightsizing Competency Restoration Services” can be found on the HHSC website.24

Texas Behavioral Health & Justice Technical Assistance Center

The Texas Behavioral Health & Justice Technical Assistance (TA) Center publicly launched in May 2023 as a partnership with HHSC’s OSFD and the Texas Institute for Excellence in Mental Health. The Center “provides free specialized technical assistance for those who work in Texas behavioral health and justice systems to reduce and prevent justice involvement for people with mental illness, substance use disorders, and IDD”.25

The TA Center “connects Texans with resources related to behavioral health and justice services. The TA Center aims to support people working in Texas’ behavioral health and justice systems, as well as people with lived experience in these systems. The TA Center supports local agencies and communities to work collectively across systems to improve outcomes for people with behavioral health conditions.”26 

Community Focus vs. Institutionalization

In the ongoing discourse surrounding the treatment of people with mental health disorders within the criminal justice system, lie deeply ingrained myths regarding these individuals and the subsequent necessity to confine them in jails or institutions. One common myth is the belief that individuals deemed unfit for trial due to mental health disorders are inherently dangerous and must be confined to jails or institutions for the safety of society. However, research indicates that the risk of violence among this population is often linked to factors such as substance abuse and a history of violence, rather than solely to their mental health status.27

Another prevalent myth is that institutionalization is the only means of ensuring public safety. Contrary to this belief, community-based restoration programs have shown efficacy in reducing recidivism rates among individuals with mental health disorders.28 These programs provide tailored support, treatment, and rehabilitation services within the community, addressing the root causes of behavior while promoting integration and connection to support networks. Additionally, community-based approaches have been found to be more cost-effective than institutionalization, offering a pragmatic solution that benefits both individuals and society.29

Many states have competency restoration programs within communities — 16 states have formal community-based competency restoration programs and 35 state mental health agencies report that they pay for these services.30 Texas has adopted pretrial risk assessments and outpatient competency restoration programs to serve as alternatives to traditional inpatient competency restoration services.3132 These initiatives seek to alleviate the strain on state forensic waitlists by reducing the number of individuals awaiting inpatient admission due to incompetence to stand trial with mental illness or co-occurring disorders. By offering prompt access to clinically appropriate services, these programs ensure timely treatment while minimizing the need for prolonged hospital stays. Moreover, community-based interventions for individuals who do not require the restrictive environment of a hospital setting promotes autonomy and social integration. By diverting individuals to community-based programs, strain on state hospitals is reduced and resource allocation is optimized.33 Recovery should always be the focus, regardless of if someone is in an institution or the community.

References

  1. Texas Legislative Budget Board. (2022). State hospitals: Mental health facilities in Texas, legislative primer. https://www.lbb.texas.gov/Documents/Publications/Primer/6279_State_Hospitals_Primer.pdf ↩︎
  2. Ibid. ↩︎
  3. Texas Admin Code, Title 25, Part 1, Chapter 411, Subchapter J https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=25&pt=1&ch=411&sch=J  ↩︎
  4. Texas Legislative Budget Board. (2022). State hospitals: Mental health facilities in Texas, legislative primer. https://www.lbb.texas.gov/Documents/Publications/Primer/6279_State_Hospitals_Primer.pdf ↩︎
  5. Ibid.  ↩︎
  6. Ibid. ↩︎
  7. Legislative Budget Board. (2023). HB 1 General Appropriations Bill – Conference Committee Report 3rd Printing. https://www.lbb.texas.gov/Documents/Appropriations_Bills/88/Conference_Bills/Conf_CCR_GAB_88R.pdf ↩︎
  8. Ibid. ↩︎
  9. Texas Health and Human Services. (2024). July 2024 JCAFS Agenda Item (Version 4). [Data set]. https://www.hhs.texas.gov/sites/default/files/documents/july-2024-jcafs-agenda-item-4.xlsx ↩︎
  10. Ibid. ↩︎
  11. Texas Health and Human Services. (n.d.). Office of Forensic Coordination. Retrieved December 7, 2022, from https://www.hhs.texas.gov/about/process-improvement/improving-services-texans/behavioral-health-services/office-state-forensic-director ↩︎
  12. Carr, K. (2024). State Hospital Update: A Presentation for the Joint Committee on Access and Forensic Services. Texas Health and Human Services. https://www.hhs.texas.gov/sites/default/files/documents/jan-2024-jcaf-agenda-item-8a.pdf ↩︎
  13. Department of State Health Services. (2014). Analysis for the ten-year plan for the provision of services to persons served by the state psychiatric hospitals. https://static1.squarespace.com/static/5bec7c0a1137a6f21d74e0ee/t/604ce0813a2cb004c0352b85/1615650992047/Appendix+1+-+DSHS+Report+2014+-+Cannon+Report.pdf ↩︎
  14. Health and Human Services Commission. (2021). Addendum: A comprehensive plan for state-funded inpatient mental health services. https://www.hhs.texas.gov/sites/default/files/documents/about-hhs/process-improvement/addendum-comprehensive-plan-state-hospitals-jan-2021.pdf ↩︎
  15. Ibid. ↩︎
  16. Texas Health and Human Services. (n.d.). Changes to Texas State Hospitals. Retrieved December 28, 2023, from https://www.hhs.texas.gov/about/process-improvement/improving-services-texans/changes-texas-state-hospitals#:~:text=Bed%20Replacement%20Hospital-,Summary%3A%20HHSC%20is%20planning%20to%20build%20a%20replacement%20hospital%20for,approved%20by%20the%202023%20Legislature. ↩︎
  17. Texas Health and Human Services. (n.d.). Changes to Texas state hospitals. Retrieved December 28, 2023 from https://www.hhs.texas.gov/about/process-improvement/improving-services-texans/changes-texas-state-hospitals#:~:text=Bed%20Replacement%20Hospital-,Summary%3A%20HHSC%20is%20planning%20to%20build%20a%20replacement%20hospital%20for,approved%20by%20the%202023%20Legislature. ↩︎
  18. Ibid. ↩︎
  19. Texas Legislature Online. (n.d.). SB 1507, 84 (R). Retrieved May 16, 2024 from https://capitol.texas.gov/BillLookup/History.aspx?LegSess=84R&Bill=SB1507  ↩︎
  20. Texas Health and Human Services. (n.d.). Office of Forensic Coordination. Retrieved December 28, 2023 from https://www.hhs.texas.gov/about/process-improvement/improving-services-texans/behavioral-health-services/office-state-forensic-director ↩︎
  21. Texas Health and Human Services. (n.d.). Joint committee on access and forensic services. Retrieved December 12, 2022, from https://www.hhs.texas.gov/about/leadership/advisory-committees/joint-committee-access-forensic-services ↩︎
  22. Texas Health and Human Services Commission. (2022). Texas statewide behavioral health strategic plan featuring the Texas strategic plan for diversion, community integration and forensic services. https://www.hhs.texas.gov/sites/default/files/documents/hb1-statewide-behavioral-health-idd-plan.pdf ↩︎
  23. Texas Health and Human Services. (n.d.). Office of the State Forensic Director. Retrieved December 7, 2022, from https://www.hhs.texas.gov/about/process-improvement/improving-services-texans/behavioral-health-services/office-state-forensic-director ↩︎
  24. Texas Judicial Commission on Mental Health & Texas Health and Human Services. (2021). Eliminate the wait: The Texas toolkit for rightsizing competency restoration services. https://www.hhs.texas.gov/sites/default/files/documents/eliminate-the-wait-toolkit.pdf ↩︎
  25. Texas Behavioral Health and Justice TA Center. (n.d.) Who we are. Retrieved December 28, 2023, from https://txbhjustice.org/about/who-we-are ↩︎
  26. Ibid. ↩︎
  27. Elbogen, E. B., & Johnson, S. C. (2009). The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of general psychiatry, 66(2), 152–161. https://doi.org/10.1001/archgenpsychiatry.2008.537 ↩︎
  28. Lamberti, J. S., Weisman, R. L., Cerulli, C., Williams, G. C., Jacobowitz, D. B., Mueser, K. T., Marks, P. D., Strawderman, R. L., Harrington, D., Lamberti, T. A., & Caine, E. D. (2017). A randomized controlled trial of the Rochester forensic assertive community treatment model. Psychiatric services (Washington, D.C.), 68(10), 1016–1024. https://doi.org/10.1176/appi.ps.201600329 ↩︎
  29. Kennedy, H. G., Simpson, A., & Haque, Q. (2019). Perspective On Excellence in Forensic Mental Health Services: What We Can Learn From Oncology and Other Medical Services. Frontiers in psychiatry, 10, 733. https://doi.org/10.3389/fpsyt.2019.00733 ↩︎
  30. National Alliance on Mental Illness. (n.d.). Community-based competency restoration. Retrieved May 8, 2024, from https://www.nami.org/Advocacy/Policy-Priorities/Supporting-Community-Inclusion-and-Non-Discrimination/Community-Based-Competency-Restoration/ ↩︎
  31. Texas Department of Criminal Justice. (2018). Presentation to the house select committee on opioids and substance abuse planning. https://capitol.texas.gov/tlodocs/85R/handouts/C3942018032710001/3afe8965-22c4-46d7-891c-5becc466923e.PDF ↩︎
  32. Texas Health and Human Services. (n.d.). Competency Restoration. Retrieved May 8, 2024, from https://www.hhs.texas.gov/providers/behavioral-health-services-providers/competency-restoration ↩︎
  33. Ibid. ↩︎

Updated on December 13th, 2024



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