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HomeMy WebLinkAboutmental-health-advisory-board-mhab-annual-report-fy-2022-2023 Contact the Mental Health Advisory Board at: ACBH.MHBCommunications@acgov.org Members: Brian Bloom Chair District 4 Terry Land Vice Chair District 1 Gina Lewis District 2 Thu Quach District 2 Warren Cushman District 3 Ashlee Jemmott District 3 Alison Voss District 3 Juliet Leftwich District 5 Board of Supervisors Representative: Amy Shrago District 5 October 30, 2023 Alameda County Board of Supervisors 1221 Oak St., #536 Oakland, CA 94612 Re: Mental Health Advisory Board Annual Report FY 2022-2023 Dear Alameda County Board of Supervisors, The Alameda County Mental Health Advisory Board (MHAB) is pleased to provide this Annual Report for FY 2022-2023, summarizing our work over the last year and providing our current recommendations regarding ways to improve the local behavioral healthcare system. As discussed below, the MHAB has spent another year considering the very complex and challenging issues associated with the provision of behavioral health services in Alameda County. We appreciate the opportunity to be of service to the community and to the Board of Supervisors and look forward to hearing your response to this report and to the recommendations provided herein. MHAB Composition and Statutory Authority The MHAB, appointed by the Board of Supervisors pursuant to Welfare and Institutions Code Section 5604, is composed of individuals with a wide variety of backgrounds and experience, including providers, consumers, family members and attorneys. The MHAB’s membership also reflects Alameda County’s rich cultural and demographic diversity, with each member bringing a unique perspective to the Board’s important mission. Local mental health boards have a broad statutory mandate in California. In accordance with Welfare and Institutions Code Section 5604.2, they are required, among other things, to: • Review and evaluate the community’s public mental health needs, services, facilities, and special problems in any facility within the county where mental health evaluations or services are provided, including but not limited to, schools, emergency departments, and psychiatric facilities. • Advise the Board of Supervisors and the Alameda County Behavioral Health Care Services Director as to any aspect of the local mental health program. Alameda County Mental Health Advisory Board 2 • Review any county agreements entered pursuant to Welfare and Institutions Code Section 5650 and make recommendations regarding concerns identified within those agreements. • Review and approve the procedures used to ensure citizen and professional involvement at all stages of the planning process. • Submit an annual report to the Board of Supervisors on the needs and performance of the county’s mental health system. • Perform such additional duties as may be assigned to the Board by the Board of Supervisors. The MHAB has had – and continues to have - several vacancies. We urge the Board of Supervisors to fill these vacancies as soon as possible to help facilitate the MHAB’s fulfillment of its important statutory obligations.1 Overview of MHAB Activities in FY 2022-2023 The MHAB spent the last year hearing from a variety of behavioral health experts and stakeholders, including providers, treatment facilities, Alameda County Behavioral Health Care staff, consumers, family members, Behavioral Health Court personnel, organizations advocating for the mentally ill, and other key community leaders. In addition to its regular monthly meetings, the MHAB convened an annual strategy meeting, one special meeting and regular meetings of its Executive Committee, Criminal Justice Committee and Adult Committee. Summaries of the MHAB’s committee work are provided below.2 MHAB members continued to serve on the Care First, Jail Last Taskforce, the Mental Health Services Act (MHSA) Stakeholder Committee, and the MHSA Budget Stakeholder Advisory Committee. In addition, the MHAB provided extensive comments and recommendations regarding the MHSA FY 23-26 Three-Year Plan in a letter to the Board of Supervisors dated June 21, 2023.3 In another letter to the Board of Supervisors of that date, the MHAB expressed its opposition to the County’s expenditure of $26.6 million to expand facilities at Santa Rita Jail.4 Finally, the MHAB conducted two site visits – one of John George Psychiatric Hospital and the other of the Jay Mahler Recovery Center. Both visits were extremely informative. Board members were very impressed by the dedication of staff and appreciative of the hours spent on the tours and subsequent question and answer sessions. 1 The MHAB’s “Recruitment Flyer” is appended herein as Attachment A. 2 The meetings of both the MHAB’s Adult and Criminal Justice Committees are open to the public and are recorded. Recordings of these meetings and the materials and visual presentations from the committee meetings referenced herein can be found at the MHAB’s website: https://www.acbhcs.org/mental-health-advisory-board 3 This letter is appended herein as Attachment B. 4 This letter is appended herein as Attachment C. Alameda County Mental Health Advisory Board 3 MHAB Recommendations After in-depth discussions with numerous providers and other experts, input from community members and advocates, and visits to mental health facilities, the MHAB makes the following recommendations regarding ways to improve local mental health services: 1. Create a Clear, Publicly-Accessible System Map that Provides an Overview of the System of Care for the Seriously Mentally Ill (SMI) and those with Substance Abuse Disorders (SUD) Alameda County’s behavioral health system is incredibly complicated. Because it is decentralized and utilizes a variety of outside contractors and facilities, it is very difficult for consumers and their families, as well as for providers and policymakers, to decipher.5 The situation is even more complex when it comes to the seriously mentally ill and those who have substance abuse disorders, since that particularly vulnerable population can enter and exit the system at many different points and receive various levels of care. To address this significant challenge, the MHAB recommends that ACBH create a system map illustrating the various ways people with SMI and/or SUD can receive care in Alameda County – from acute, subacute, crisis residential to outpatient services – and how they might move from one level of care to another. This visual representation of the continuum of care should be accompanied by a supporting document that describes each facility/program, its capacity, the type of patient follow-up provided, and any gaps in service availability or other unmet needs. The MHAB already regularly requests and receives very useful information about various components of the system of care, e.g., through presentations, site visits and public comment. However, the Board is only able to see pieces of the puzzle and not the big picture, hindering our ability to effectively exercise our oversight duties. In addition to the system of care map, understanding any capacity issues, gaps in service availability or other unmet needs is essential to understanding where additional resources need to be focused. The MHAB has made several inquiries and understands that nothing like what we are proposing currently exists. The system of care map and supporting document should be publicly available and easily accessible so that it can serve as an important resource for a wide variety of groups. It would help consumers and their families to navigate the system of care. It would also support providers as they seek to coordinate services, and advocacy groups as they champion the needs of the seriously mentally ill. ill. This resource would be a concrete way to improve communication and education for families to support the individual in navigating the complex mental health system. It would also provide an invaluable tool for the Board of Supervisors because it would help inform the Board’s crucial decision-making process around resource allocation and program prioritization. The target audience of the system map and supporting document should be the general public, inclusive of consumers, families, providers, and policy-makers, and should thus be easy to access and understand. 5 See 2021-2022 Alameda County Civil Grand Jury Final Report, “Alameda County Mental Health System Too Complex to Navigate.” (available at: https://grandjury.acgov.org/reports) Alameda County Mental Health Advisory Board 4 2. Improve Ongoing Continuity of Care for the SMI and SUD Population From the work the MHAB has done this past year, the Board has learned that Alameda County faces inordinate challenges serving the treatment needs of those who have serious mental illness, a severe substance use disorder, and/or a co-occurring mental health disorder and a severe substance use disorder. Far too often this population receives minimal services and cycles in and out of acute psychiatric facilities, jail, and homelessness. One way to improve outcomes for those living with SMI and SUD and to reduce the chance of relapse and cycling in and out of facilities is to have a single point of contact (care coordinator) who actively reaches out to ensure the individual has ongoing access to psychiatric services, medical care, social services and housing. Individuals living with SMI and/or SUD have many challenges and it is very difficult to navigate the system of care, insurance, housing, transportation, a job or volunteering, and social services. When individuals run into barriers in accessing these services, they are more likely to relapse and cycle in the system. Having a case worker actively engaged with each person and proactively ensuring ease of access could significantly improve outcomes and prevent cycling. It would also help Alameda County better understand the issues and make targeted improvements. Along those lines, we encourage building capacity at existing support organizations, including at federally qualified health centers (FQHCs), to be ready for future CalAIM mandates, and other ways that promote whole person care in order to pave the way for supporting SUD and SMI, to allow for addressing mental health and substance use as well as social determinants of health (e.g., housing) in a one-stop shop. 3. Increase the Number of and Length of Stay at Crisis Residential Treatment Facilities Crisis residential treatment (CRT) facilities provide crucial therapeutic services in a structured residential program as an alternative to hospitalization for individuals experiencing an acute psychiatric episode or crisis. According to the Crisis Residential Program Study 2020 Report of the Adult System of Care Subcommittee of the California Mental Health Planning Council: Crisis residential programs reduce unnecessary stays in psychiatric hospitals, reduce the number and expense of emergency room visits, and divert inappropriate incarcerations while producing the same, or superior outcomes to those of institutionalized care. As the costs for inpatient treatment continue to rise, the need to expand an appropriate array of acute treatment settings becomes more urgent. State and county mental health systems should encourage and support alternatives to costly institutionalization and improve the continuum of care to better serve individuals experiencing an acute psychiatric episode. That report stated further that: Recovery, resilience, wellness, and community have always been the cornerstones of the Crisis Residential Program model, and they are entirely congruent with federal and state mandates for community-based mental health services. The Alameda County Mental Health Advisory Board 5 economy and effectiveness they represent makes the need to “mainstream” them into the community an essential priority for every county mental health department straddling the two worlds of human needs and fiscal constraints. Crisis Residential Programs are a time-tested yet long-underutilized model whose time has come. CRTs are clearly underutilized by Alameda County, which currently only has contracts with three such facilities: Jay Mahler, Woodroe Place and Amber House. Jay Mahler is operated by Telecare and has 16 beds; Woodroe Place and Amber House are operated by Bay Area Community Services (BACS) and have 17 and 12 beds, respectively. Accordingly, only 45 CRT beds are currently available in Alameda County, which has a population of more than 1.6 million. The MHAB has repeatedly heard – from a variety of providers, from the facilities we toured and from family members of the SMI - that more CRT beds are desperately needed to serve those suffering from acute psychiatric episodes. In addition, the length of stay at CRTs – which is typically only 14 days - should be increased to 30 days. For many individuals, a 14-day stay is not long enough to receive meaningful care. In 14 days, many clients are barely stable and are often not well prepared to be successful in next steps. It often takes a week or more for a person to begin to recover from crisis and for staff to be able to engage the client in therapeutic options. Moreover, stabilizing an individual and adjusting medication generally takes longer than 14 days. Arranging for next steps psychiatric care and housing takes time, too. Longer stays would significantly improve outcomes by providing staff increased opportunity to treat the client and prepare a sound discharge plan. This would also allow time for the client to stabilize, adjust to medication and be prepared for next steps.6 4. Continue to Assess the Need for Sub-Acute Treatment Beds In last fiscal year’s Annual Report, the MHAB recommended that the county expand capacity at the Villa Fairmont Mental Health Rehabilitation Center (MHRC). Since 2017, ACBH has purchased 70 of the 96 beds at Villa Fairmont, allowing the remaining 26 beds to be sold to other service funders. The MHAB is pleased to acknowledge that ACBH announced this year that to increase utilization of Villa Fairmont, the county will purchase an additional 18 beds at Villa Fairmont at a cost of 3.2 million for a total of 88 beds. The MHAB also understands that ACBH is committed to identifying an additional 1.4 million in funding to purchase the remaining 8 beds. Increasing MRHC bed capacity in the county by almost 40% is significant and will help the county support new initiatives, divert mentally ill defendants from jail, and implement ACBH’s Forensic Plan. However, there is no public-facing data nor a comprehensive analysis of unmet need in the county to establish that even this increased MHRC capacity will satisfy the county’s need for sub- acute treatment. Accordingly, the MHAB recommends that ACBH continually assess the availability of and need for inpatient treatment beds in the county so that it can be accurately determined how many beds are necessary to meet sub-acute treatment need. 6 The MHAB applauds ACBH’s recent efforts in securing two Behavioral Health Community Innovation Project (BHCIP) grants which will create two additional Crisis Residential Treatment (CRT) facilities which will add as many as 32 beds to the Crisis Residential Program model in Alameda County. Alameda County Mental Health Advisory Board 6 5. Expand the Capacity of and Publish Data Regarding Behavioral Health Court The Alameda County Behavioral Health Court (BHC) is a very effective resource that has reduced recidivism and improved mental health outcomes for those who have participated in the program. Yet it is significantly underutilized. The 2021-2022 Alameda County Civil Grand Jury Final Report described BHC as follows: BHC is a collaboration between the Alameda County Superior Court, the District Attorney’s Office, the Public Defender’s Office, and ACBH. Its mission is to promote public safety and assist SMI persons who commit non-violent crimes by diverting them away from the criminal justice system. Judges, lawyers, and mental health professionals work in partnership with the court’s client, aka “partner,” to develop a treatment plan for the “partner,” who has been charged with a non-violent crime. The program diverts those who qualify for the program out of Santa Rita Jail and into a one to two-year treatment program with an Alameda County-based mental health provider. The “partner” is closely monitored by the court, and upon successful completion of their treatment plan, the “partner’s” pending criminal case and associated arrest record are sealed. The MHSA funds many of the treatment providers and the clinical team that staffs the BHC program. The lawyers and judges are funded by their respective departments. The report found that while “witnesses universally spoke highly of BHC,” there was no data available to the public to support the perception that BHC is “a major asset” to Alameda County: However, limited data from 2015-2016 indicates that BHC improves public safety, improves psychiatric outcomes for the participant, and lowers public costs. San Francisco BHC, which has similar rigorous criteria for enrollment, provides public data that indicates BHC reduces incarceration and violent behavior. The Grand Jury could find no available data that assesses why people drop out of BHC or don’t follow through. There is also no available data that looks at whether the program provides racial and geographic equity. Alameda County allows 30 people in BHC at one time and a maximum of 100 people. There is only one BHC site in Alameda County—in Oakland. Witnesses stated that there are waiting lists for referral to BHC. By comparison, San Francisco has a BHC cap of 300 people annually for a population less than half of Alameda County’s. Witnesses stated that expansion of BHC necessitates expansion of ACBH staff involvement, but more importantly, there is insufficient community- based treatment infrastructure. The MHAB agrees that BHC is a major asset to Alameda County and recommends that more data be gathered and available to the public regarding its effectiveness. Based on meetings with personnel from the Superior Court, the District Attorney’s Office, the Public Defender’s Office, and ACBH, as well as on MHAB members’ direct observations of BHC proceedings, the MHAB Alameda County Mental Health Advisory Board 7 also agrees that additional ACBH staff are needed to assess prospective participants in the program. There are currently only two clinicians to staff BHC. As a result, individuals who would qualify for the program aren’t getting the services they need in a timely manner. We recommend that BHC be staffed by four fulltime ACBH clinicians to enable more timely and efficient assessments. Also, increasing the number of and length of stay at CRTs will significantly increase the ability of BHC to successfully divert qualifying individuals away from the criminal justice system. Currently, most BHC clients simply have no place to go. Another helpful addition to the BHC would be a Family Advocate who would be in court and could connect with and help families support their loved ones who are participating in the BHC. 6. Increase Cultural and Linguistic Responsiveness in Mental Health Services The MHAB recommends that Alameda County address the low utilization/penetration rate for underserved communities (i.e., AANHPI, limited English proficient speakers, smaller communities) by increasing culturally and linguistic responsive services (e.g., language access, ethnic healing practices, and bilingual/bicultural providers). Specifically, we recommend that the County: • Incentivize bilingual and culturally responsive providers who are culturally aligned with community to work in safety net settings (e.g., higher pay, recruitment/ retention bonuses, loan forgiveness, targeted academic training pipeline programs placed within community- based settings). • Invest in a culturally and linguistically competent workforce, beyond just language interpretation. • Provide payment and reimbursement structures that recognizes the culturally and linguistically competent services (i.e., reimburse at higher rate or separately for interpretation and bilingualism/ multi-lingualism). • Protect funding for CBOs that provide culturally-based prevention programs that demonstrate effectiveness in breaking down barriers and/or promote increased awareness and acceptance of mental health services. 7. Double-Down on Strategies that Invest in Workforce, Including Recruitment and Retention, and Expand Providers to Include Lay Counselors Recruitment and retention remain extremely challenging for the mental health workforce, particularly for the CBO providers providing the vast majority of the outpatient behavioral health services to county residents. Bilingual staff are exceptionally difficult to recruit. In addition, collective bargaining at CBOs and the uncertainties around how CalAIM may impact reimbursement structures have slowed CBOs’ ability to increase pay for their staff, further impacting recruitment and retention, and creating access issues for the increasing number of people Alameda County Mental Health Advisory Board 8 who need such services. Given that compensation is a critical part of recruitment and retention, the MHAB recommends that the County invest more resources to support CBO providers who provide these services to county residents. This would include increased funding and flexibility during the transition periods of CalAIM, and some assurance that the changes to come will not significantly decrease the reimbursement rate for these providers. We also recommend that the County continue to invest and develop behavioral health training program and pipelines, including residence programs for psychiatrists and psychiatric nurse practitioners. Moreover, given that the workforce crisis does not have any quick solutions, the County should expand the workforce to include team members beyond the licensed and licensed- track professionals, and invest in training programs directed at peers and lay counselors (non- licensed professionals) who can fill in the gaps to serve clients in need. Investing in these peers and lay counselors, both in training programs and adequate reimbursement structures for CBOs to provide them with competitive pay, would increase the likelihood of culturally- and linguistically- concordant staff and clients. 8. Continue to Support Prevention and Early Intervention (PEI) Programs that are Focused on Reducing Negative Outcomes and Effective At Connecting People with Mental Health Services Proposition One on the March ballot in California proposes a “modernization” of the Mental Health Services Act (MHSA). Among other things, it would mandate that MHSA money be focused more on the treatment and housing needs of the SMI and SUD population (which many argue was the original intent of the legislation). Current spending on programs that focus on prevention and early intervention may be decreased. Accordingly, the County’s MHSA funding decisions may be shifting dramatically in the years ahead. When it comes to funding for prevention and early intervention, it’s important to note that The Mental Health Services Oversight & Accountability Commission (MHSOAC) established priorities for the use of County’s prevention and early intervention programs, concluding that they should play a role in connecting individuals in need to mental health services and have a well- defined strategy on how they will be effective in “reducing seven negative outcomes that may result from untreated mental illness: suicide, incarceration, school failure or dropout, unemployment, prolonged suffering, homelessness, and removal of children from their homes.” As the County grapples with the new MHSA funding priorities mandated by Proposition One (assuming it passes), the MHAB recommends that the County compare the outcomes of PEI programs and continue to support those programs that can demonstrate their effectiveness in meeting the goals set forth above by the MHSOAC. As discussed in the MHAB’s June 21, 2023 letter to the Board of Supervisors regarding the draft 3-Year MHSA Plan: The Plan provides funding for a very large number of programs countywide. Although each of the programs may be worthwhile, many are not focused on providing mental health services or treating mental illness. Many of the programs Alameda County Mental Health Advisory Board 9 cite community engagement, social events and general wellness activities as their goal and accomplishment, but it is not clear the extent to which mentally ill individuals are actually connected to mental health services. Nor is it clear whether these programs use evidence-based treatment methods to help people who are suffering from the most severe, disabling and persistent forms of mental illness. We recommend that the County develop and implement more purposeful metrics and accountability for delivering on mental illness/health aspects of the program goals. MHAB Committee Work Adult Committee Behavioral Health Adult Committee meetings over the last year covered a variety of important topics, including, but not limited to, the following: • 988 State and Alameda County Overview Guest speakers: Dr. Anh Thu Bui, Medical Consultant, MediCal Behavioral Health Division, California State Department of Health Care Services Stephanie Lewis, Interim Crisis of Care Director, ACBH Narges Zohoury Dillon, LMFT • The Workforce Crisis in Behavioral Health Guest Speaker: Matthew Madaus, Executive Director, Behavioral Health Collaborative, Alameda County • Collaborative Compensation Analysis and CalAIM Payment Reform Guest Speaker: Mathew Madaus, Executive Director, Behavioral Health Collaborative, Alameda County • Cultural and Linguistic Responsive in Mental Health Services Guest Speakers: Kao Saechao, LCSW, Specialty Mental Health Director, Asian Health Services Joseph Perales, DrPH, LCSW, Clinical Director, La Clinica - Casa del Sol • ACBH and Older Adult System of Care Overview, Update and Challenges Guest Speaker: Kate Jones, ACBH Adult and Older Adult System of Care Another Adult Committee meeting focused on tackling community barriers to deaf community counseling services. Alameda County Mental Health Advisory Board 10 Criminal Justice Committee The Criminal Justice Committee invited a wide range of speakers to present at its meetings over the last year and was appreciative of the meaningful discussions that ensued. Presenters included, but were not limited to, the following: • Gavin O’Neill and Danielle Guerry, from the Office of the Collaborative Courts in Alameda County, who discussed how the Courts have proven successful in reducing recidivism and improving health outcomes among those with mental health challenges and addiction who’ve entered our criminal justice system. • Roberta Chambers and Kira Gunther, from the Indigo Project, who discussed two multi- year proposals to use MHSA funds to prevent incarceration and divert individuals into mental health services, and to support mental health consumers who are justice involved to transition back into the community through peer-led and family-focused programs. • Juan Taizan, Director of ACBH Forensic, Diversion and Re-Entry Services, and his team, who spoke at meetings focused on the Incompetent to Stand Trial (IST) Diversion Program, and on behavioral health services and corresponding challenges at Santa Rita Jail. • Representatives from the Behavioral Health Court (judicial officers, District Attorneys, Public Defenders, and ACBH staff) who discussed ways to extend the reach of the Behavioral Health Court so that more mentally ill defendants can be diverted from jail into appropriated treatment in the community. The Criminal Justice Committee also dedicated one meeting to a discussion of important mental health-related state legislation, and another to the Board of Supervisor’s proposed expenditure of $81 million ($26.6 million of county money and 55 million of state funding) to create a Mental Health Program Services Unit (MHPSU) at Santa Rita Jail. As discussed in our June 21, 2023 letter, the MHAB strongly opposed the Jail expenditure because it would: 1) be antithetical to the principles and goals established by the Board of Supervisor’s Care First, Jail Last Task Force; 2) make no sense, since the experts involved in the Babu Consent Decree found that as much as 70% of the positions at the jail are still vacant, three years later; and 3) be a waste of precious resources because Santa Rita Jail is currently half full, holding less than 1,800 individuals, and the Babu settlement assumed a jail population of as many as 3,000 people. For those reasons, the MHAB urged the Board of Supervisors to put the Jail Expansion Project on hold and invest instead in community-based services to reduce the population of individuals in Santa Rita with mental illness, substance abuse and co-occurring disorders. We reiterate that request here. Alameda County Mental Health Advisory Board 11 Conclusion The MHAB has worked diligently over the last year to exercise its statutory duties of oversight and asks that the Board of Supervisors give our recommendations your careful consideration. We and look forward to hearing your response. Please let us know if you have any questions. Sincerely, Brian Bloom MHAB Chair Terry Land MHAB Vice Chair Contact the Mental Health Advisory Board at: ACBH.MHBCommunications@acgov.org BOARD APPLICANTS WANTED What is the Mental Health Advisory Board (MHAB)? Every California county is required by state law to have a mental health advisory body. In Alameda County, members of the board are appointed by the Alameda County Board of Supervisors (BOS) for a three-year term. The MHAB’s charge is to review and evaluate Alameda County’s mental health needs, facilities, services and special problems; advise the BOS and the Alameda County Mental Health Director on any aspect of the local mental health programs; review and comment on the county's performance outcome data and communicate its findings to the California Mental Health Planning Council; provide input into the development of the county’s Mental Health Services Act (MHSA) plan; and submit an annual report to the BOS on the needs and performance of the county’s mental health system. Looking for passionate and dedicated team players to join the board! Alameda County is seeking Alameda County residents who are passionate about ensuring and advocating for responsive, equitable mental health prevention, intervention and treatment services, who want to use their voice and expertise towards this end. Qualifying board members include consumers of mental health services and their family members, as well as community members and individuals who have experience with and knowledge of mental health systems. In order to ensure diverse perspectives and round out current MHAB membership, individuals representing the following groups are particularly desired: ●Have expertise and/or a strong interest in children and youth-related issues ●Identify as Latinx ●Have worked in the field or have special knowledge of the field ●Are interested in and/or have expertise in local or state legislation ●Have experience working in county or city services or government What does serving on the MHAB involve? As a board member, you will be required to: ●Work in collaboration with other board members to fulfill the responsibilities of the MHAB ●Attend 10 regular in-person monthly board meetings each year ●Attend Special Meetings from time to time ●Serve on at least one committee and/or serve as a Board Liaison to another entity or organization (usually monthly meetings) Interested in joining? Next Steps For more information about the MHAB click here. If you have questions or would like to apply, please email ACBH.MHBCommunications@acgov.org. Interested individuals are encouraged to attend at least one board meeting prior to application. Members: Brian Bloom Interim Chair District 5 Warren Cushman Interim Vice-Chair District 4 Terry Land District 1 Thu Quach District 2 Loren Farrar District 3 Ashlee Jemmott District 3 Thu A. Bui District 5 Juliet Leftwich District 5 Amy Shrago BOS Representative District 5 ATTACHMENT A 1 Contact the Mental Health Advisory Board at: ACBH.MHBCommunications@acgov.org Members: Brian Bloom Interim Chair District 5 Warren Cushman Interim Vice-Chair District 4 Terry Land District 1 Thu Quach District 2 Ashlee Jemmott District 3 Thu A. Bui District 5 Juliet Leftwich District 5 Abigail West District 5 Board of Supervisors Representative: Amy Shrago District 5 Date: June 21, 2023 Alameda County Board of Supervisors 1221 Oak St., Suite 536 Oakland, CA 94612 Re: Mental Health Services Act FY 23-26 Three-Year Plan Dear Board of Supervisors, The Alameda County Mental Health Advisory Board (MHAB) is pleased to provide these recommendations regarding the Mental Health Services Act (MHSA) FY23-26 Three-Year Plan (the Three-Year Plan). The recommendations are provided in accordance with the MHAB’s role as an oversight and advisory body pursuant to Welfare and Institutions Code Section 5604.2, and are the culmination of our review of the draft Three-Year Plan, discussions with County behavioral health leadership and participation in the MHSA Stakeholder Group. They are also informed by numerous regular and special MHAB board meetings, and by the extensive input of experts and community members. The MHAB thanks the Board of Supervisors in advance for giving our recommendations its serious consideration. The MHAB’s feedback begins with our overarching recommendations, followed by sections with more specific comments on process and the five categories in the report (Community Services and Supports; Prevention and Early Intervention; Innovation; Workforce, Education, and Training; and Capital Facilities and Technology Needs). MHAB RECOMMENDATIONS A.Overarching Recommendations 1.The MHSA was intended to provide funding to people suffering from the most serious, disabling, and persistent forms of mental illness. (See Welfare & Institutions Code Sec. 5600.3(b).) However, many of the programs funded in the Three-Year Plan do not address the needs of the most seriously mentally ill (SMI) individuals in our County. 2.It is unclear how the County decides what programs to fund or what would be required to fill the unmet needs of the SMI. We recommend that the County conduct a needs assessment to better understand these fundamental issues. The needs assessment should include the continuum of care to support this population's complex needs, from acute facilities, crisis programs, step down facilities and ongoing support programs. ATTACHMENT B Alameda County Mental Health Advisory Board 2 3.The Prevention and Early Intervention portfolio should be reviewed and scrubbed to focus investments in programs that address the specific stated goals to avoid being spread too thin and being ineffective. The Mental Health Services Oversight & Accountability Commission (MHSOAC) established priorities for the use of County’s Prevention and Early Intervention (PEI) funds. There are six priority focus areas listed as well as desired outcomes. “PEI programs focus on reducing seven negative outcomes that may result from untreated mental illness: suicide, incarceration, school failure or dropout, unemployment, prolonged suffering, homelessness, and removal of children from their homes.” These priorities provide important guidance regarding what County programs and portfolios should focus on in the PEI area. When looking at the ensemble of our portfolio, however, many do not appear to be specifically focused on these desired outcomes. 4.The Three-Year Plan does not make clear how the County manages the programs to ensure that the goals and outcomes are consistent with meeting the defined needs. It warrants further study, but there may be a disconnect between the goals and stated accomplishments for some of the programs, particularly in the PEI section. The County should develop and implement more purposeful metrics and accountability for delivering on mental illness/health aspects of the program goals. 5.Nearly every Full-Service Partnership (FSP) program mentioned a shortage of housing and staff (clinical case managers, therapists, etc.) to treat individuals in their programs. The County should consider redirecting funds to meet these needs. 6.The Three-Year Plan makes it clear that for those individuals who are able to engage and participate in FSPs, their chances of being hospitalized and/or arrested in the future are reduced. Clearly, FSPs can work for those who engage and are amenable to treatment. The MHAB doesn’t see anything in the Plan that funds programs aimed at people who, by virtue of their mental illness, are not able to engage in an FSP. 7.The Three-Year Plan should anticipate the new direction coming from Sacramento and include funding specifically targeted to treat "homeless persons who are mentally ill." (See Welfare & Institutions Code sec. 5600.3(b)(4)(A).). This would mean funding permanent supportive housing programs. It would also mean ensuring that the County has adequate acute treatment facilities to stabilize people prior to the time they are ready to thrive in supported housing programs. 8.Given the changes to MHSA funding that are proposed by the Governor, we suggest reconsidering any new programs that are not aligned with the proposed changes. 9.Cities have firsthand experience dealing with the homeless and calls to the police for 5150 evaluations. The MHSA Director should seek input from city councils and mayors to determine what their communities need to treat those with SMI. 10.While cultural competence and responsiveness is listed as a guiding principle, the Three- Year Plan could be more explicit in how this principle guided the decision-making process of Alameda County Behavioral Health (ACBH). B.Comments on Process 1.The MHAB was not given adequate time to provide meaningful feedback within the public comment period. The Three-Year Plan should have been made public prior to April 1 so that the MHAB could hear the MHSA presentation, ask questions, and provide written feedback by April 30. Alameda County Mental Health Advisory Board 3 2.The Plan is over seven hundred pages, which is too lengthy for the public to review and digest, especially in such a short period of time. A 30-day window for public comment may inadvertently send a message that the comments will not be taken seriously and will not lead to any meaningful changes in the draft document. If the Three-Year Plan cannot be significantly shortened, it should, at a minimum, include an in-depth Executive Summary which covers all the Plan's most significant points. 3.We are not sure the stakeholder process hears the voices of those who are suffering the most in our County. People who are in and out of John George and who traverse the endless cycle of John George/jail/homeless encampments and Santa Rita Jail are not represented in the stakeholder process. C.Comments by Category Section 1.Community Services and Supports (CSS) a.The County should perform an assessment to determine how many FSP programs and slots are needed to meet existing needs. If the current 1,045 slots are not enough, the County should determine how many are needed and whether other MHSA funds can be applied or redirected to meet this critical need. b.State law is clear that the MHSA may fund short-term acute inpatient treatment for clients who are in FSPs. (See 9 Cal. Code of Reg. 3620(k).) Every year in our county, many FSP clients require treatment and stabilization in an acute and/or sub-acute hospital setting. Nothing in the Three-Year Plan, however, appears to fund medically-necessary treatment in an acute or sub-acute setting for FSP clients who are in need of such treatment. c.The Plan should provide funding for the expansion of the Safe Landing Project at Santa Rita Jail so that it: 1) can be located in a permanent structure, rather than in a trailer; and 2) have a presence within the jail, so inmates can be connected to project services prior to the time they exit the jail. 2.Prevention and Early Intervention (PEI) a.Under California law, PEI is supposed to pay for "downstream" RELAPSE prevention for people who already have a severe mental illness. Welfare and Institutions Code section 5840(c) states: "[The PEI program] shall also include components similar to programs that have been successful in reducing the duration of untreated severe mental illness and assisting people in quickly regaining productive lives." We do not see anything in the PEI funding "bucket" of the Three- Year Plan that is aimed at preventing relapse and deterioration for people who are already suffering from serious and persistent mental illness. b.The Plan provides funding for a very large number of programs countywide. Although each of the programs may be worthwhile, many are not focused on providing mental health services or treating mental illness. Many of the programs cite community engagement, social events and general wellness activities as their goal and accomplishment, but it is not clear the extent to which mentally ill individuals are actually connected to mental health services. Nor is it clear whether these programs use evidence-based treatment methods to help people who are suffering from the most severe, disabling and persistent forms of mental illness. Alameda County Mental Health Advisory Board 4 c.Although further study is needed, it appears that some PEI programs may lack focus on serving the needs of those suffering from serious mental illness. In other words, either the program description and/or the accomplishment examples cite general community service rather than serious mental illness and mental health needs. It is unclear whether the focus is on being generally helpful to the community, rather than being focused on preventing SMI or severe outcomes as the MHSA intends. 3.Innovations Allocating $80,000 per CBO may leave strategically important areas underfunded to accomplish their goals. It would be helpful to provide the rationale of why $80,000 per entity was selected and how many entities are expected to be funded, given the intention to commit $10M. This significant funding is too important to spread out thinly and lacks a public-facing strategy on how it is intended to help boost the CBOs as they address the other eligible funding areas. 4.Workforce, Education, and Training (WET) a.The MHAB has the several questions regarding this section of the Three-Year Plan, including: What will ACBH do after the needs assessment is conducted? How will the needs assessment inform priorities? Will there be any commitments to address some of the priority needs? Will the findings be shared with the public? b.While this section only focuses on changes from the previous plan, it should make clear how the proposed psychiatry training partnership are add-ons to the existing training programs. It would also be helpful to identify the current programs, to show how ACBH is investing in the different roles within a robust mental health team (e.g., licensed mental health professionals, peer counselors, case managers, and psychiatrists). c.This section should address what efforts are being made to respond to the severe mental health workforce shortages, including whether seed funding is being provided for CBOs to grow their own pipeline programs, and whether any emphasis is being placed on bilingual/ bicultural professionals, given ACBH’s commitment to cultural competency and responsiveness. 5.Capital Facilities and Technology Needs (CFTN) a.CF2: Respite Bed Expansion. This is an important project that is focused on previously unmet needs. The Plan states that the funding is ending, but does not state whether current needs are being met or whether additional funding is needed to meet those needs. b.CF5: African American Wellness Hub. While there is general support for this project, the MHAB is concerned that the plan does not include an onsite psychiatrist. CONCLUSION The MHAB appreciates this opportunity to provide our recommendations to the Board of Supervisors regarding the Three-Year Plan. We hope the recommendations are helpful, and ask that you take them into serious consideration during your deliberations about the MHSA Three-Year Plan moving forward. Alameda County Mental Health Advisory Board 5 Please do not hesitate to contact us know if you have any questions. Sincerely, Brian Bloom, Interim Chair (on behalf of the Mental Health Advisory Board) 1 June 21, 2023 Alameda County Board of Supervisors 1221 Oak Street, Suite 536 Oakland, CA 94612 Dear Board of Supervisors: On May 9, 2023, the Board of Supervisors adopted a Resolution designating $26,662,922 of county match funding to construct a Mental Health Program and Services Unit Project (“MHPSU”) at the Santa Rita Jail (“SRJ”). As explained in the Resolution (which accompanied the Agenda as Attachment #51), the full cost of this Jail Expansion Project is just over 81 million dollars, to be financed with $54.3 million dollars from the State of California and $26.6 million from Alameda County. The Resolution further suggests that the new building at SRJ is needed to accommodate increased staffing which will provide behavioral health care at the jail.1 On May 18, 2023, Senator Nancy Skinner wrote to the Director of the State Dept. of Finance requesting that a number of questions about the proposed project be answered before the State approved the project. Senator Skinner set forth twelve questions that she wanted Alameda County to answer and the Joint Legislative Budget Committee to review before the matter was brought before the State Public Works Board for consideration. Pursuant to our oversight and advisory duties as set forth in Welfare and Institutions Code section 5604.2, the Mental Health Advisory Board (“MHAB”) has read and discussed the proposed Jail Expansion Project and Senator Skinner’s letter to the Dept. of Finance. It appears to the MHAB that the Jail Expansion Project is 1 The jail expansion plan originated in 2015 with a proposal to construct a new unit at the jail at a cost of $61.6 million dollars, with the state of California providing $54.3 million and Alameda County providing an additional $7.2 million. The new plan greatly expands the scope and design of the original plan. ATTACHMENT C 2 antithetical to the principles set forth in the “Care First, Jail Last” Resolution which your Board unanimously enacted in April 2021. Furthermore, the MHAB believes that such a significant investment in a new building at the jail is at odds with the goals of the Care First Task Force which your Board created over a year ago to implement the Care First Resolution. As the Board knows, the Task Force -- which includes a representative from the Mental Health Advisory Board -- has been working diligently to design a full continuum of behavioral healthcare that aims to significantly reduce the number of people with mental illness, substance abuse and co-occurring disorders in our jail. In light of this, at our monthly board meeting on June 21st, the Mental Health Advisory Board (“MHAB”) voted unanimously in favor of a motion that the Jail Expansion Plan should not go forward at all, or at the very least, should be put on hold until the Care First Task Force concludes its work and makes its recommendations to the Board of Supervisors in April 2024. Rather than spend 26.6 million dollars to construct a new building at Santa Rita Jail (which would constitute a “Jail First” policy), the MHAB believes that the County must invest in the kind of facilities and programs which will both divert mentally ill people out of jail and into medically appropriate treatment and will support those who are at risk of becoming incarcerated.2 Moreover, the MHAB questions the rationale of building the new MHPSU to accommodate the additional ACBH staff at the jail. According the most recent figures from the experts who are assisting in the Babu Consent Decree, as much as 70% of ACBH positions at the jail are still vacant, three years later. Finally, while Santa Rita Jail has a rated capacity of over 3,700 incarcerated people, it is currently half-full, today holding less than 1,800 individuals, with proposals to reduce that number through the Reimagining Adult Justice initiative and no evidence that the population will increase in the future. Notably, the original staffing analysis on which the Babu settlement was based assumed a jail population of as many as 3,000 persons. The MHAB questions whether all the unused space at the jail could be repurposed and redesigned, as opposed to constructing a new 81-million-dollar building. 2 For instance, on an annual basis, 26.6 million dollars would fund 760 Full Service Partnerships , 152 sub-acute treatment beds, or 143 Crisis Residential treatment beds. 3 For all these reasons, the MHAB recommends that the Board of Supervisors put the Jail Expansion Project on hold and instead prioritize investments in community- based services that have been proven to reduce crime and recidivism. Please don’t hesitate to contact the MHAB if you have any questions. Respectfully, Brian Bloom, Interim Chair of the Mental Health Advisory Board (on behalf of the Mental Health Advisory Board)