Public Behavioral Health Services for Individuals with Serious Mental Illnesses: A Position of The League of Women Voters of San Diego County

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1 Public Behavioral Health Services for Individuals with Serious Mental Illnesses: A Position of The League of Women Voters of San Diego County February

2 LWVSD MENTAL HEALTH UPDATE COMMITTEE MEMBERS Bettie Reinhardt, B.S. Nursing, M.P.H./Health Services Administration. Committee Chair. Over 50 years in mental health field as psychiatric nurse in hospitals, specialist in mental health care quality, peer review and care coordination, and in National Alliance on Mental Illness (NAMI) leadership. Consults on NAMI Affiliate Development, primarily for NAMI California. Vicki Beck, M.S. Health communications specialist. Worked at the Centers for Disease Control and Prevention, the USC Annenberg School for Communication, and the UCLA Center for Health Sciences, including the UCLA Neuropsychiatric Institute and Hospital. Worked with administration, faculty, journalists, and TV writers on a broad range of medical topics, including mental health issues, research, and crises. Writing the story of a family member with serious mental illness. Deanne George, J.D. NAMI San Diego member. Yale Law School grad, worked on the school s Mental Health Law Project, representing mental health consumers at commitment hearings and in class action/impact litigation. Private law practice in Los Angeles and San Diego, now retired. Family member and caregiver for someone with a serious mental illness. Sylvia Hampton Health Director for League of Women Voters (LWV) of San Diego County. Management Training Advisor for LWV of California. Past president of LWV of San Diego County. Health Rights Advocate for single payer system. Elizabeth Kruidenier, B.A. Director of Behavioral Health, LWV of San Diego County. Former Co- Chair of NAMI North Coastal and current Director of Outreach and Community Engagement. Member of the Behavioral Health ( BH ) Advisory Housing and BH Advisory Adult Councils, Work Well Employment Committee, and the Suicide Prevention Committee. Serves on Alliance For Regional Solutions, coalition for north San Diego County. Co- Chair of the North Coastal Community BH Forum as well as a family member of someone with mental illness. Rachel Perlmutter, B.A. Advocate for mental health since Stanford University grad, teacher. Served on the board of the Cape Ann, Massachusetts NAMI for three years. Family member and caregiver for someone with a serious mental illness. Katherine Smith- Brooks, M.S. Advocate for mental health since 1991, serving on numerous boards and commissions in San Diego County. Master s in Education from San Diego State University, additional Certificates in Teaching, Alcohol Studies, and Early Childhood Intervention. Member of NAMI, serving in leadership and training positions including President and Vice President. Appointed as a Fifth District representative to the San Diego County Mental Health Board for 12 years, serving as Chair from Family member of someone with a serious mental illness. 2

3 Changes in the Mental Health Environment Since the 1997 Position was Adopted In 1997, the League of Women Voters of San Diego County (LWVSD) adopted a position on mental health care. Many things have changed in the intervening years. Although the 1990s were known as the Decade of the Brain because of the dedication of research to brain disorders, the Human Genome Project was not completed until The subsequent understanding of the genetic influence on mental illnesses has led to new approaches to treatment but no silver bullet. Evidence- based practices for both treatment and support services have become the community standard. California s method of funding public mental health services has also changed significantly. LWVSD s current position not only remains basically sound but can now be seen as ahead of the system changes. We emphasized integration of services integration is now the buzz word in this County and across the country. We urged outreach into the community, a range of housing options, criminal justice system diversion, and collaborative input to the public mental health planning and policy- making processes. These remain important objectives. Thanks to the original study committee for their work! Our position continues to work with all of the changes listed below: Medi- Cal moved from paying for a limited range of medical services to the Rehab Option in 1993, which included a broader range of treatment services and some support services, then to the Recovery Model in 1998, which attempts to provide even more comprehensive client- centered services and supports. The emphasis moved from stabilization, often in a Board and Care or Independent Living Facility, to recovery to the best of an individual s capacity and desire, living as independently as possible and desired. Terminology changed from the mentally ill to individuals with mental illness, and from suffering from to living with mental illness. Programs and services moved to a focus on the individual client as a person, rather than a focus on just the person s illness. Proposition 63 was passed in 2004, the California 1% surcharge on taxable income over $1 million (millionaire's tax), as the Mental Health Services Act (MHSA). o MHSA requirements pushed the mental health community to think about evidence- based methods to prevent or provide early intervention in serious mental illness (SMI) and to try new approaches. o MHSA Innovations developed teams including clinicians, family members, and consumers in County facilities and in homes to facilitate access to services and supports. o Full Service Partnerships (FSP) developed and then expanded to take services to people who cannot for whatever reason come to a clinic. The use of local and nationwide data resulted in the expectation that a majority of individuals living with serious mental illness will also have substance use issues and further led to combining the Mental Health Department with the Alcohol and Drug Services Department into the Behavioral Health Department (BHD) at the San Diego County Health & Human Services Agency (HHSA), also referred to as the County in this document. The Psychiatric Emergency Response Teams (PERT), consisting of trained law enforcement personnel teamed with psychiatric clinicians, expanded to all regions of the County; working relationships between the BHD and law enforcement jurisdictions improved; and PERT evolved to become the 3

4 most- used method for people with serious mental illness to enter into behavioral health services in the County, helping when possible to divert people from the criminal justice system. Over 1000 supportive housing beds were developed, ranging from shelters to predominantly permanent housing, through creative partnerships between the BHD and other governmental agencies and community based organizations. Funding changes: MHSA funds became a significant portion of the County s mental health budget while the economic downturn reduced the portion of sales tax and motor vehicle licensing fees dedicated to mental health. California s repeal of the mandate for counties to supplement federal funds for Individuals with the Disabilities Education Act (IDEA) eliminated the requirement for California Department of Health Care Services (DHCS) to reimburse counties and sent school districts back to providing only the federally required services. The 2011 realignment of funds for mental health services from the State General Fund to counties gave counties more control over the way they spend funds, but also allowed the State legislature to set a designated amount of funding in advance, rather than reimbursing counties for required services. Realignment of public safety services from the State Department of Corrections and Rehabilitation to counties for non- violent, non- serious, non- sex offenders again allowed County flexibility but within constrained revenue. The funds for mental health still come from the federal government as its portion of the Medi- Cal programs and from the State DHCS. However, the legislature has named sources for the realignment funds and virtually no mental health funds now come from the State General Fund. The Affordable Care Act brought expansion of Medi- Cal to all eligible childless adults a population that was previously served by programs for the indigent. Changes and Trends on the Horizon The Board of Supervisors authorized the formation of a 90- day task force on January 27, 2015 to plan the implementation of California s Assertive Outpatient Treatment law, known as Laura s Law. More details should be known by the 2015 LWVSD ILO Annual Meeting. A court ruling in Washington state has banned psychiatric boarding, the practice of holding but not treating individuals in mental health crisis in the emergency department for more than 24 hours until a bed opens up. Such a ban is widely expected to follow in other states. The practice is not good policy, but neither is discharging someone to home or the streets without treatment. Having services available at the time and place they are needed seems to be the only long- term answer. Integration of behavioral and physical health has been embraced by the healthcare industry nationwide and is bound to continue, although the legislature s funding mechanism (the Coordinated Care Initiative (CCI)), may not meet statutory requirements. This would send the State administration and legislature scrambling. 4

5 The Housing First model of providing stable and affordable housing to people with serious mental illness versus short term or transitional housing is proving successful where ever used, and will continue to be a funding challenge, in large part because of the question of whether it is treatment or a social service. Affordable permanent housing for people who do not need wrap around supportive services but who are trying to survive on Supplemental Security Income (SSI) will continue to be a major need in a high- rent area such as this county. Prevention and early intervention services are likely to grow and improve as outcomes are measured and funds are directed toward the most effective services. New proposals such as the legalization of marijuana will require LWV to look carefully at how a non- mental health proposal impacts people affected by serious mental illness. In this case, multiple studies have shown that youngsters genetically at risk for mental illness are at significantly increased risk for developing psychoses if they use marijuana between the ages of 12 and 15. Will legalization of marijuana provide more or less control over availability to youth? San Diego County Board of Supervisors: Dave Roberts, District 3 Experts Interviewed San Diego County Officials: Nick Macchione, MS, MPH, Director, Health and Human Services Agency; Alfredo Aguirre, LCSW, Deputy Director, Behavioral Health Services Department; Piedad Garcia, LCSW, EdD, Director of Adult Programs, Behavioral Health Services System of Care; and Henry Tarke, LCSW, former Director of Children s Programs, Behavioral Health Services System of Care. Community Leaders: Jim Fix, PhD, Executive Director, Psychiatric Emergency Response Team (PERT); Judi Holder, AA, CPRP, Executive Director, Recovery Innovations; Gregory Knoll, Esq., CEO, Legal Aid Society and Consumer Center for Health, Education, and Advocacy; Judith Yates, RN, MSN, First VP, San Diego/Imperial Counties Hospital Association. Current Position Adopted in 1997 Regarding the San Diego County HHSA Behavioral Health System, LWV of San Diego County supports: 1. The establishment of a coordinated system of 24- hour regional centers, each providing a full spectrum of health services, including a case manager for each patient where indicated. 2. Treatment programs for the dually- diagnosed (mental illness plus substance abuse / addiction) 3. The maintenance of a full- time, adequately staffed and funded community outreach program for the seriously mentally ill. 4. The provision of coordinated, integrated services by its various agencies for mentally ill clients of all ages. 5

6 5. Planning and providing for adequate, steady funding streams for programs for County mentally ill clients. 6. Increased funding for shelter beds, supportive services and housing for the mentally ill. 7. Holding persons with psychiatric disabilities who are accused or convicted of a crime be held in appropriate psychiatric facilities rather than jails. 8. Increasing and updating the training of special response teams of law enforcement officers who respond to emergencies involving persons who are mentally ill. 9. The establishment through the County Mental Health Services of an adequately funded, independent coalition of providers made up of clients, family members and interested citizens empowered to recommend necessary changes. What the Committee Learned About the Objectives of the Current Position The League s vision of regional health centers has played out differently than we imagined. The funds initiated by the Affordable Care Act are flowing to Federally Qualified Health Centers (FQHCs) that we usually call Community Clinics to serve as "medical homes." Around- the- clock service availability is limited but the medical homes are available in all regions of the county. Not every client has a case manager, and requiring this could be more intrusive than most people need or want, but managed care does mean care coordination and quality management. State DHCS changes to Medi- Cal now require all but certain exempt individuals to receive Medi- Cal- funded services via managed care organizations that contract with medical homes, mental health clinics, and other providers in settings with coordinated approaches moving toward full integration. There is still work to be done to reach the desired level of integration. In the fall of 2014, the County, in collaboration with the Council of Community Clinics, held the County s fifth annual Integration Summit and reported on some successes. The County s, nonprofit organizations and managed care leaders began meeting a number of years ago to develop a coordinated or integrated services plan. Quality of care versus quantity of care (fee- for- service) is likely to become the payment model for nearly all of healthcare before the next update of this position. Quality of care reimbursement usually means bundled care delivered by a managed care system. Using evidence- based practices or, in some cases, emerging practices with outcomes evaluation is important, but more so in public systems where there are never enough dollars. San Diego s BHD reports outcomes to the Behavioral Health Board (a State- mandated Board appointed by the Board of Supervisors) in dashboard reports (graphical presentation of key performance indicators). The Quality Improvement department examines the reports for potential problems. 6

7 Each age group - - children and youth, adults, and older adults - - is served by a System of Care Council (SOCC) that provides counsel to the Behavioral Health Director. The Children s SOCC was one of the first to be formed in 2000 and does the best job of bringing everyone to the table that serves or represents this age group: mental health, child welfare and foster care, probation, juvenile courts, education, intellectual disabilities, families, and youth. In addition, this council has its own evaluation committee. The Housing Council was established at this same time in 2000 and also does a good job of bringing everyone to the table to plan for affordable, additional, and better housing for those with a mental illness. Another part of integration is the provision of services and supports for people with the dual diagnosis of serious mental illness and substance use disorder. The County of San Diego convened the Dual Diagnosis Workgroup and developed a Dual Diagnosis Strategic Plan ( ). Dr. Ken Minkoff and Dr. Christie Cline designed a "Train the Trainer" implementation program and trained the first 30 CADRE (cross- trained providers to serve people with co- occurring disorders) members in Comprehensive, Continuous, Integrated System of Care (CCISC) in January 2003 over an 18 month period. The program has evolved over the years and now includes over 300 CADRE- trained members. The ultimate goal of San Diego County CADRE is to develop an entire system of care that is welcoming, recovery- oriented, integrated, trauma- informed, and culturally competent. There is some historical confusion over terms dual diagnosis first referred to individuals with a diagnosis of both mental illness and intellectual disability. Currently, dual diagnosis is usually stated more specifically as mental illness with co- occurring substance use disorder. The County's Department of Mental Health and the Department of Alcohol and Drug Services have formally combined under one director and are served by one Behavioral Health Services Advisory Board. The County s integration of these services is better than Medi- Cal s integration of funding streams and program requirements, but the State DHCS is working on waivers to improve top to bottom behavioral health care integration. In 1997, LWVSD supported an Outreach Program that would assist with case finding and bring people living with serious mental illness into public mental health services. The County contracts behavioral health services by holding a managed competition for County- run services, resulting in several new contracts and contract- like requirements for remaining County- run services and contracting out all MHSA services and supports. All of the County s contracts now require the contractor to implement program- appropriate outreach, which includes, for example, finding unserved, multi- need individuals who are homeless or recently incarcerated, or enrolling families who are good candidates in NAMI s Family- to- Family Education Program. Often the outreach and need seems to outstrip the program services available. For instance, the new In Home Outreach Team (IHOT) appears underfunded and has difficulty keeping appointments or supplying enough peer specialists to meet the need for IHOT services. Outreach also includes communication by the BHD with stakeholders to bring everyone into the program planning process, especially MHSA planning. (NOTE: Several committee members attended a recent round of MHSA planning meetings held in different areas of the County, and each reported that she was the only attendee without a financially vested interest in being there. There are ways, both low tech and high tech, of communicating with the public that the BHD is not utilizing 7

8 that could increase participation.) Mental health funding is addressed in more detail earlier in this report and even more so in the funding attachment to the report. In summary, no one in the public system has enough money. The federal government does not provide adequate funds for entitlement programs such as Medicaid (Medi- Cal in California) or IDEA. The State legislature does not provide adequate funds for the programs it has realigned to the counties. Since mental health is a State DHCS responsibility, San Diego County puts little additional funding into mental health beyond that required to draw down State tax revenue and federal funds. That said, however, our County still manages to provide a broader array of effective services and supports for both children and adults/older adults than does most of the private sector. The term services and supports is used throughout this report to indicate the necessity for more than psychiatric intervention with hospitalization and medication. Housing is at the top of that list. It is very difficult for a person living with a serious mental illness to maintain adherence to a treatment plan if he/she has no place to put her meds or his stuff. The BHD s current supported housing is serving 1,196 individuals with serious mental illness and ranges from shelter beds to permanent housing (92%). Housing First programs have proved themselves. Such programs provide the people at the greatest peril with homes up front, and then deliver the support they need to help them stay there. This can save a great deal of money when these folks would otherwise be ricocheting between expensive services, such as jails and emergency rooms. A range of housing options gives individuals the amount of structure that they individually need. Supported employment is also important. Employment opportunities are developed in different ways, giving people choices. Some clubhouses provide work- ordered days and jobs for people who are ready to try them. Programs of community based organizations such as NAMI, Recovery Innovations, and Family & Youth Roundtable provide information about clients mental health challenges and ways to manage them as well as ways to turn their lived experience into support for their peers. Other programs teach the basics of getting into the workplace and help with employment issues. Supported education is a more recent phenomena and it has had its ups and down in San Diego County. Most of the support now comes from the disabilities services departments of local community colleges. Having a representative of the BHD to assist with students mental health challenges has been an on and off thing. The State Department of Rehabilitation works with BHD to provide employment and education resources including tuition, books and supplies for curricula the department deems reasonable. Listed last, but equally important as any other support services, are those for families. The County provided soft money support for NAMI s Family- to- Family Education Program from the outset and funded the program in four major languages in the very first round of MHSA funding. The County has also funded other family programs such as NAMI Basics for caregivers of children, Schizophrenia Education for Families and Caregivers, and training for NAMI support group facilitators. 8

9 In Western countries, the movement from treatment in large mental hospitals to treatment in community mental health systems has resulted in a heavy burden of care for the families of people with mental illness. Families are frequently excluded from treatment and care plans for a variety of reasons. The County s BHD has not funded NAMI s Provider Education Program that models partnership among providers, families, and clients, but the California Mental Health Services Authority has supported it throughout the State, including in San Diego County. The likelihood that consumers with complex support needs are involved in some form or fashion in the criminal justice system is high. In fact, 2.2% of the U.S. adult population (seven million people), is in prison or jail, on probation, or on parole, and 16% of that population has a mental illness, or an addictive disorder (35%), or both (45%). Statements that County jails such as that in Chicago or Los Angeles are America s largest psychiatric hospitals are really misnomers. Jails and prisons do house more people living with serious mental illness than do hospitals but they are not treatment facilities. People with mental illnesses serve longer sentences than other offenders convicted of equivalent crimes. Many offenders with mental illnesses have committed an offense that is often a manifestation of their illness rather than the result of criminal intent. For each individual who receives treatment for a psychiatric illness in a hospital, about five others with mental health conditions are treated, or confined without treatment, in penal facilities. While families are sometimes relieved when a loved one is jailed because they are relatively safer than on the streets or in a previous situation, people with mental illnesses just as often have their treatment interrupted. San Diego jails have two psychiatric hospital areas, one in the downtown men s jail and one in Los Colinas, which is the women s jail. That does not ensure that people who need to be admitted to these types of treatment areas get there, although local NAMIs can provide helpful resources. In San Diego County, the sheriff furnishes or contracts for all personnel, and psychiatric services are provided by contractors. Beginning with Sheriff Kolender, the sheriff s office has actively worked to reduce the number of people with serious mental illnesses in the jails by finding ways to expand PERT, develop a mental health court calendar, and by advocating for a continuum of criminal justice system diversion programs similar to that developed for Bexar County, Texas. The sheriff and the chief probation officer have worked with the BHD to identify and fund treatment services for people released from the prison/parole system after implementation of public safety realignment. See this report s earlier description in the Changes section. The Psychiatric Emergency Response Team (PERT) is the major player in diversion from the criminal justice system at the time of this update. Because a licensed clinician rides with the officer or deputy, assessment can take place at the time of the call versus unnecessarily transporting someone in a mental health crisis to an emergency room or to a booking facility. Linkage to mental health services can take place right then and family members can be assisted with immediate coping mechanisms as well as support services and resources such as NAMI programs. Most PERT calls are a response to 911 calls, although it is possible for referrals to go 9

10 through the PERT administration or come from local law enforcement s requests for welfare checks. Crisis Intervention Teams (CIT) were developed in Memphis in about 1990 by collaboration between NAMI and the Memphis police department; they are now up and running in nearly every State of the union. This training for law enforcement involves awareness of behavioral health issues, the ways that traditional policing may make matters worse, and development of skills to respond appropriately to a person in a mental health crisis. San Diego s PERT is an unusual version of CIT because it pairs the CIT- trained officer/deputy with a clinician and is considered CIT on steroids. No other Behavioral Health Department in California has made such a large investment in this form of response to people in behavioral health crisis. The San Diego County PERT Program came out of a collaborative effort of the BHD, NAMI, local court officials, and the San Diego Police Department. Many other such task forces have come and gone. Other groups have taken root and can be counted on year after year to bring together community stakeholders. The San Diego Coalition for Mental Health (SDCMH) is one. Formed in 1990 to advocate for mental health funding when it all still came out of the state s general fund, it became part of the larger California Coalition for Mental Health (CCMH). SDCMH provides information for and communication with a wide variety of members and, via CCMH, a voice in state advocacy. Other groups are mandated, such as the Mental Health Advisory Board, whose membership was recently broadened to become the Behavioral Health Advisory Board, and the Community Corrections Partnership that determines the structure of and allocations to the AB 109 public safety realignment programs. At the least, every issue touched on in this report seems to have at least one council, committee, association, or workgroup dedicated to sharing successes and failures. More than one group is working on homelessness, more than one on housing issues, one on employment, several on treatment methods. Live Well San Diego, the HHSA Director s ambitious effort to improve the total health and wellbeing of all county residents, requires ongoing collaboration among community leaders as well as stakeholders. Proposed Position The update committee recommends a simple restatement of the original position objectives, combining several where it makes sense. Regarding the County Behavioral Health System, LWV of San Diego County supports the following objectives to benefit those affected by serious mental illness: 1. Provide an integrated behavioral and physical health care system that includes a full array of integrated, coordinated, effective services and supports for all individuals who experience serious mental illness, including children, transitional age youth (emerging adults), adults and older adults. Services should be reasonably accessible to residents in all regions of the County. They should include services for early identification and intervention, treatment and crisis management, wrapping services and supports for individuals who are not candidates for clinic- 10

11 run care, and long term services and supports. Integrated services and supports should include timely and affordable access to all necessary health care providers and medications that fully address physical, mental health, and substance use disorders. This combines current objectives 1. and 4. which both address integration. The update committee agrees with the 1997 position that integrated services and supports are crucial to the health and wellbeing of individuals as well as being money and time savers. The term effective is very important since brain research and treatment evaluation moves very quickly. LWVSD can convene a task force to review effectiveness of any specific approach it wants to support or, more likely, insist that the Behavioral Health Department show why it considers a new service effective. 2. Ensure that integrated mental health and substance use disorder services are part of a behavioral health system throughout the County, with full services available regardless of point of entry into the system (no wrong door). The current position is re- framed by updating dual diagnosis to behavioral health terminology, and by describing behavioral health care as a delivery system and not just a program or group of programs. 3. Ensure outreach services in all regions of the County for all residents who might need or benefit from the behavioral health system, using partnerships with the faith community, businesses, and other gateways into the community as well as traditional mental health community members. Rather than one super outreach program, the County has built outreach requirements into every service and support contract, aimed at each contract s target population. Outreach should also include appropriate non- contracting community organizations such as faith communities and local businesses. 4. Exercise careful management, and leverage when possible, funds received from all sources in order to maintain continuity of services and supports during all economic conditions. The original position seemed to suggest that the County has control over program design and funding. That has not been even partially true since Proposition 13 was passed. Mental health is a State government responsibility and much of the programming is mandated by the State legislature. The County can seek additional sources of funding including its own general fund and must manage what it receives from the State very carefully. Strategic collaboration with other agencies can take the place of hard cash as it did when developing supported housing with Redevelopment Agencies. 5. Provide an array of supports: a full range of housing that includes Housing First and other supported housing options, including shelter beds and permanent affordable housing; supported employment; supported education; opportunities for spiritual development; exercise 11

12 and diet; training and support for family members; and inclusion of families in service and support development. This County had no experience with County- developed housing when this position was developed. Since then, six programs have provided supported housing to more than 1,100 clients. A slight change in wording reflects what has been learned in the process and adds other supports that have since proven useful. 6. Divert individuals from the criminal justice system to behavioral health services and supports when possible, and to secure treatment- oriented settings when incarceration is required. Diversion has been shown to be possible when all of the pieces are in place. When public safety and/or the law require incarceration, the facility must make appropriate treatment fully accessible. 7. Provide specialized law enforcement/clinical teams in all areas of the County, available when needed to respond to possible behavioral health crises on a 24/7 basis. In 1997, the County had one pilot PERT team in San Diego Police Department s Western Division. The teams now operate in all law enforcement jurisdictions in the County and are the envy of the rest of the State, if not the country. The sheriff has said that all deputies will be PERT- trained. The training classes are full every time they are offered. Still, there are not enough teams to ensure availability when needed. 8. Collect and use meaningful input from a broad range of community stakeholders via innovative outreach, transparency, and participation in useful collaborative groups. The committee s interviews revealed a significant number of stakeholder groups already working but not necessarily welcoming the community or getting meaningful input to the Behavioral Health Department. A final note about Assisted Outpatient Treatment (AOT) The committee did not study the effect of voluntary versus involuntary services or the black robe effect of court- ordered treatment programs. It did carefully study needed services and supports. Coincidentally, these are the services and supports required by California s AOT law, also known as Laura s Law. 12