Addressing the Competency Crisis Through Local Innovation

Program Innovation Spotlight: Allegheny County Mobile Competency Restoration and Support Team
Across the country, courts and pretrial systems are confronting a growing competency crisis. Individuals with serious mental illness who are found not competent to stand trial can spend weeks or months incarcerated while awaiting admission to a state hospital for competency restoration. The result can be prolonged incarceration, delayed case resolution, disruption of treatment, and significant costs to both local and state systems.
In Allegheny County, Pennsylvania, that challenge had become impossible to ignore.
In 2024 alone, individuals found not competent to stand trial spent more than 13,000 days—more than 35 years collectively—in the Allegheny County Jail while awaiting transfer to a state hospital for competency restoration. Between 2018 and 2024, the median wait for state hospital admission was 82 days. At the time, commitment to a state hospital was the county’s only option for competency restoration.
Rather than accept those delays as inevitable, Allegheny County asked a different question: Could competency restoration be delivered locally, in the least restrictive setting appropriate to each individual, while still meeting the needs of the courts and protecting public safety?
That question led to the creation of the Mobile Competency Restoration and Support Team (MCRST).
Building a Local Solution
MCRST was co-designed by the Allegheny County Department of Human Services and the Behavior Assessment Unit within Allegheny County Pretrial Services. The goal was straightforward but ambitious: provide local competency restoration services that could reduce state hospital wait times and decrease unnecessary incarceration for individuals with serious mental illness who had been found not competent to stand trial but were likely to be restored.
Before developing the model, Allegheny County examined its own data. The findings demonstrated both the scope of the problem and the opportunity for a different approach.
Nearly half—49%—of individuals committed to the state hospital for competency restoration had a misdemeanor as their highest charge. The county also found substantial cycling through the competency system: 30% of individuals committed to the state hospital had multiple commitments during the period reviewed, and 25% experienced multiple state hospital commitments within the same year.
County leaders reviewed research, studied competency restoration models operating elsewhere in the country, and consulted extensively with evaluators, courts, the jail, public defenders, the judiciary, community providers, data analysts, and other subject-matter experts.
Rather than simply replicate an existing program, Allegheny County used those lessons to develop a model specifically designed around its local needs.
Meeting People Where They Are
The resulting MCRST model is a multidisciplinary, mobile approach that combines mental health treatment, competency restoration, psychoeducation, case coordination, peer support, and persistent engagement.
The team includes a program manager, psychiatrist, behavioral health registered nurse, certified peer specialist, dual-diagnosis licensed therapist, competency support specialist, and Justice Related Services forensic support specialist.
Individuals are referred to MCRST by the Behavior Assessment Unit after being assessed as not competent to stand trial but likely to be restored and after the appropriate court order is entered.
One of the program’s defining features is its mobility. Services are not tied to a single facility.
MCRST can work with individuals in jail, treatment facilities, or the community, allowing the team to follow participants as their circumstances change. Treatment and case plans are individualized, and support continues through transitions until the court case is resolved and appropriate community services are established, when applicable.
The program also provides 24/7 on-call crisis support and uses a level-of-care structure to determine the frequency of contact based on an individual’s current mental health needs. Participants requiring the highest level of care may receive four to six contacts each week.
Even when someone is initially resistant to services, the team maintains consistent outreach. That assertive engagement philosophy is central to the model: MCRST meets people where they are rather than requiring people to fit into a predetermined service setting.
From Pilot to Practice
Allegheny County began a soft launch of MCRST in March 2025, initially limiting referrals to individuals in jail who had already been committed and were awaiting transfer to the state hospital, as well as individuals returning from the state hospital.
Twelve people were referred during this initial phase.
The program fully launched on June 1, 2025. Initially, every referred participant was incarcerated. As MCRST established credibility and trust with the courts and community partners, however, the program increasingly demonstrated that competency restoration services could be delivered safely outside of a jail or hospital.
By August 2026, 52% of MCRST’s active caseload was receiving services in the community.
The shift represents more than a change in location. It reflects a fundamentally different approach to competency restoration—one that separates access to treatment from unnecessary incarceration whenever the court determines that community placement is appropriate.
Promising Results in the First Year
The results from MCRST’s first year demonstrate the potential impact of locally designed competency restoration.
The median wait for state hospital admission fell from 82 days to 43 days, meaning individuals who still required hospitalization waited approximately five weeks less than in previous years.
More significantly, 55 individuals were diverted from state hospital admission because of their engagement with MCRST.
Twenty-three existing state hospital commitments were rescinded because individuals were restored through MCRST services, made significant progress toward restoration, or were diverted to appropriate community-based acute treatment. Another 32 individuals who were found not competent but likely to be restored were referred directly to MCRST without first receiving a state hospital commitment—an option that did not exist before the program.
For 29 individuals, the change was even more significant: they received competency restoration services entirely in the community and never had to be incarcerated to access those services.
MCRST also reported 61 successful discharges during its first year. A successful discharge means the participant’s court case was resolved, the individual was released from jail to the community, outpatient treatment was established, and the person successfully reintegrated into the community.
Early post-program outcomes are equally encouraging. Of 67 individuals discharged from MCRST during the first year, only four—6%—were subsequently incarcerated. Two were ordered to undergo another competency evaluation, and only one—1.5%—was again found not competent.
The program has also demonstrated substantial fiscal impact. Based on the median length and daily cost of Allegheny County state hospital admissions, the 55 state hospital diversions produced an estimated $6.8 million in avoided state hospital bed costs alone—an amount exceeding the program’s operating costs even after staffing was expanded.
That estimate does not include additional potential savings from reduced jail stays, transportation, sheriff staffing, and court processing delays.
Lessons for Other Jurisdictions
MCRST’s first year also produced lessons that may be valuable to jurisdictions considering similar approaches.
One of the most immediate was the importance of planning for demand. Referral volume during the first year was 37% higher than anticipated based on the previous year, requiring Allegheny County to adjust its staffing model as implementation progressed.
The experience also reinforced the value of phased implementation. Beginning with a smaller, targeted referral population gave partners an opportunity to identify problems, refine processes, and establish working relationships before expanding the program.
Judicial engagement proved equally important. Judges need opportunities before implementation to understand the program, ask questions, establish expectations, and develop confidence in community-based alternatives. Collaboration with jail leadership and treatment staff is similarly essential to clarify responsibilities and ensure effective communication when participants remain incarcerated.
Finally, Allegheny County emphasizes the importance of finding the right provider and staff. Building the appropriate team may require additional time and a broader recruitment strategy, but individuals who are genuinely invested in this work can make a significant difference in both implementation and outcomes.
Redesigning Systems Around People
For Allegheny County leaders, MCRST demonstrates what becomes possible when jurisdictions reconsider assumptions about where competency restoration must occur.
“In its first year, our Mobile Competency Restoration and Support Team has shown what is possible when we redesign systems around dignity, treatment needs, and evidence. Individuals served are spending less time in jail, receiving services in the community, and returning to the competency process at dramatically lower rates, all while producing local and state cost savings greater than the program’s operating costs. We’re proud to contribute an approach that can scale and help other jurisdictions solve one of the most pervasive challenges in pretrial justice.”
— Alex Jutca, Director, Allegheny County Department of Human Services
MCRST Program Director Renee Madden also credits the people delivering the services:
“Delivering this program has required significant effort and flexibility; I’m incredibly proud of how seamlessly the team has navigated this, with their consistent, assertive, and empathetic approach to support stability for some of the most complex patients in our county.”
A Model With Lessons Beyond Allegheny County
The competency crisis is not unique to Allegheny County. Jurisdictions across the country continue to struggle with increasing demand for competency services, limited forensic hospital capacity, lengthy waits, and the consequences of keeping people with serious mental illness incarcerated while they await treatment.
MCRST was designed for Allegheny County, but its underlying principles are adaptable.
A smaller jurisdiction might develop a smaller multidisciplinary team, combine staff responsibilities, or partner with a neighboring county. A larger jurisdiction might operate multiple teams serving different facilities or geographic areas. The precise structure can change while preserving the fundamental principle: competency restoration should occur in the least restrictive appropriate setting and should not require incarceration simply to access treatment.
Allegheny County’s first-year results offer an encouraging example of what can happen when pretrial agencies, behavioral health systems, courts, jails, and community providers work together to rethink longstanding practices.
For the broader pretrial field, the lesson may be larger than competency restoration itself. Meaningful system change often begins when jurisdictions examine their own data, question whether existing practices are producing the outcomes they want, bring the right partners to the table, and build alternatives around the needs of the people those systems serve.
MCRST did not simply create another program. It created another pathway—one that demonstrates that improving public systems, supporting court processes, using resources responsibly, and treating people with dignity do not have to be competing goals.









