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HomeMy WebLinkAboutmhab-annual-report-fy2021-2022 Contact the Mental Health Advisory Board at: ACBH.MHBCommunications@acgov.org Members: Lee Davis, Chair (District 5) L.D. Louis, Vice Chair (District 4) Christina Aboud (District 1) Terry Land (District 1) Grant Quinones (District 2) Thu Quach Co-chair, Adult Committee (District 2) Warren Cushman Co-chair, Adult Committee (District 3) Loren Farrar (District 3) Ashlee Jemmott (District 3) Brian Bloom Co-chair, Criminal Justice Committee (District 4) Thu A. Bui (District 5) Juliet Leftwich Co-chair, Criminal Justice Committee (District 5) September 19, 2022 Alameda County Board of Supervisors 1221 Oak Street, #536 Oakland, CA 94612 Re: Mental Health Advisory Board Annual Report FY 2021-22 Dear Alameda County Board of Supervisors: The Alameda County Mental Health Advisory Board (MHAB) is pleased to provide this Annual Report for FY 2021-2022. As discussed below, the MHAB has worked diligently over the last year to carry out its statutory duties. In accordance with its primary role as an oversight and advisory body, the MHAB sets forth ten recommendations to the Board of Supervisors in this report. These recommendations are the culmination of numerous regular and special MHAB board and committee meetings and are informed by the extensive input of experts and community members. The MHAB urges the Board of Supervisors to seriously consider and publicly discuss these recommendations. MHAB Statutory Authority and Expertise The MHAB’s authority is established by California Welfare and Institutions Code Section 5604 et seq. In accordance with Welfare and Institutions Code Section 5604.2, the Board is statutorily 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. • Review any county agreements entered into 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. Alameda County Mental Health Advisory Board 2 • Perform such additional duties as may be assigned to the Board by the Board of Supervisors.1 The MHAB is composed of a diverse group of individuals with differing backgrounds and expertise who bring unique perspectives to the complex issues associated with the provision of behavioral health services in Alameda County.2 As we have in prior years, the MHAB is again providing a variety of recommendations to the Board of Supervisors for their thoughtful consideration and implementation.3 The MHAB appreciates the invitation to present the preliminary findings of its Ad Hoc Data Committee, discussed below, at the joint hearing of the Board of Supervisors’ Health Committee and Public Protection Committee on October 24, 2022. The MHAB hopes that the upcoming hearing, together with the recommendations contained in this report, will help create the opportunity for increased engagement between the Board of Supervisors and the MHAB moving forward. Overview of MHAB Activities in FY 2021-2022 Much of the MHAB’s work over the last year focused on ways to help implement the Board of Supervisors’ directive to reduce the number of seriously mentally ill (SMI) individuals at Santa Rita Jail. The MHAB commends the Board of Supervisors for its public commitment to shift priorities from incarceration to evidence- based behavioral health treatment, as embodied in its “Care First, Jail Last” resolution. The MHAB is represented on the Care First, Jail Last Task Force and looks forward to its monitoring role once the Task Force’s work is completed.4 In addition to the regular monthly meetings the MHAB held last year, it convened two special meetings, an annual strategy meeting/retreat, and monthly meetings of its Executive Committee, Criminal Justice Committee and Adult Committee.5 The MHAB also formed two new ad hoc committees: the Ad Hoc Data Committee, to gather and analyze data about the SMI population at Santa Rita Jail, and the Ad Hoc Legislation Committee, to create a process for the MHAB to consider recommending that the Board of Supervisors take positions on 1 State law also authorizes the MHAB to review and make recommendations on applicants for the appointment of the Alameda County Behavioral Health Care Services Director, review and comment on the county’s performance outcome data, and assess the impact of the realignment of services from the state to the county on services delivered to clients and on the local community. 2 Short bios of each member of the MHAB, as well as their committee assignments, can be found at: https://www.acbhcs.org/mental-health-advisory-board/ 3 As noted by the Alameda County Civil Grand Jury in their most recent annual report: “The MHAB has written thoughtful letters to the BOS over the last several years about relevant issues, such as the Santa Rita Jail issues and the need for more transparent data, but the BOS has not responded to those letters nor invited members to present at a BOS meeting. Thoughtful communications deserve a response.” (See Alameda County Grand Jury Final Report (2021-2022) (“Grand Jury Report”)) at p. 25. The report also notes that “[t]he Mental Health Advisory Board, which has strong, knowledgeable, and experienced members and generates excellent ideas, is not used effectively by the Board of Supervisors.” (See Grand Jury Report at p. 27.) 4 In addition to the Care Fist, Jail Last Task Force, the MHAB was also represented on the county’s Justice Involved Mental Health Task Force (JIMH), which concluded its work in early 2021. The MHAB is also currently represented on Alameda County’s MHSA Stakeholder Committee, the MHSA Community Program Planning Process Committee, and ACBH’s Budget Stakeholder Advisory Committee. 5 Each month, the MHAB full board meets on the third Monday 3:00-5:00; the Executive Committee meets on the second Thursday 3:30-5:00; the Adult Committee meets on the fourth Tuesday 4:00-5:30, and the Criminal Justice Committee meets on the third Wednesday 4:30-6:00. All of these meetings are open to the public and public comment and participation are encouraged. Past agendas, minutes, and presentations at these meetings can be found at: https://www.acbhcs.org/mental-health-advisory-board/ Alameda County Mental Health Advisory Board 3 behavioral health-related state legislation.6 The COVID pandemic has underscored how existing inequities are further exacerbated during times of crisis. Accordingly, the MHAB has discussed exploring ways to consider behaviroal health issues with an equity lens, emphasizing how factors such as cultural, language and disability barriers further impact access to quality mental health services. Furthermore, the MHAB discussed concerns regarding the unprecedented mental health provider shortage in the midst of significant growing demand for mental health services, both in terms of people needing such services and the depth of services needed for untreated illnesses, caused in large part by the pandemic and increasing violence. Summaries of the work of the MHAB’s Criminal Justice, Adult and Ad Hoc Data Committees are provided below. MHAB Committee Work Criminal Justice Committee Last year’s meetings of the Criminal Justice Committee meetings were well attended and included robust participation by a variety of groups, including mental health care providers from the County as well as from Community Based Organizations (CBOs); family members of those suffering from serious mental illness; and members of various law enforcement agencies. Discussion topics included, among other things, litigation against Alameda County alleging appalling conditions for mentally ill people incarcerated at Santa Rita Jail, increased opportunities for diverting defendants out of the criminal justice system and into the medically appropriate level of community-based mental health treatment, and the need for better discharge planning when defendants leave Santa Rita Jail and/or John George Psychiatric Hospital and re-enter the community. The Committee appreciated the variety of expert speakers who helped inform these discussions, including, but not limited to: • Kara Jannsen, lead counsel for plaintiffs in the Babu v. Ahern et al litigation, who discussed the Consent Decree and subsequent expert monitoring reports filed in the case; • Dr. Noha Aboelata, CEO of Roots Community Health Center, who spoke about the Safe Landing Project, a program that offers services to newly released inmates via a trailer parked outside of the jail; • Juan Taizan and Yvonne Jones, Director and Associate Director, respectively, of ACBH Forensic, Diversion and Re-Entry Services, who discussed forensic and non-forensic Full-Service Partnerships in Alameda County. • Department of Justice Attorney Jessica Polansky, who spoke about the April 22, 2021 Report of the U.S. Department of Justice Civil Rights Division, “Investigation of Alameda County, John George Psychiatric Hospital and Santa Rita Jail,” which describes serious gaps in the County’s mental health care system and details the unsafe conditions at Santa Rita Jail. • Francesca Tannenbaum, director of Patients Rights Advocates in Alameda County, and her colleagues, who discussed the treatment of mentally ill Santa Rita inmates who are “5150’d” to John George, the impact “Murphy” conservatees have on county resources, and the potential for LPS conservatorships to be a “diversion route” out of jail and into long-term, community-based mental health treatment. The Criminal Justice Committee also dedicated one of its meetings to a discussion of important mental health- related state legislation, leading to the creation of the MHAB’s new Ad Hoc Legislation Committee, and another meeting to formulating some of the recommendations set forth in this report. 6 The MHAB Children’s Committee is currently on hiatus. Alameda County Mental Health Advisory Board 4 Adult Committee The MHAB Adult Committee focuses on adult and/or older adult systems of care. The Committee’s monthly meetings over the last year included discussions of a variety of topics, including: • State legislation to establish “Care Courts;” • Pathways to Wellness Clinic’s history and current services; • Deaf Community counseling services; • California Advancing & Innovating Medi-Cal (CalAIM); The Adult Committee was grateful for the informative presentations it received by Kate Jones, ACBH’s Adult and Older Adult System of Care Director, and by leaders of NAMI (National Alliance of Mental Illness) Alameda County. The different presentations have highlighted a key theme around equity, and how disability and cultural and linguistic factors impact access to and receipt of quality mental health services. The Committee is exploring how to incorporate an equity framework in its ongoing discussions, analysis and recommendations, to ensure equitable mental health services for vulnerable populations, including but not limited to communities with disabilities, limited English proficient individuals, and communities of color. Ad Hoc Data Committee Alameda County’s efforts to reduce the population of seriously mentally ill individuals at Santa Rita Jail will not be successful unless it understands the unmet treatment needs of those individuals, particularly the group of “high utilizers” who cycle in and out of jail, John George Psychiatric Hospital and homelessness. The MHAB Ad Hoc Data Committee was formed to gather and analyze information about this group, with the ultimate goal of using the information to: (1) evaluate the efficacy of existing programs intended to reduce recidivism; and (2) create a dashboard allowing public access to the data. ACBH and other Alameda County agencies collect a tremendous amount of data. Although there are gaps in the data, and information has historically been siloed within different agencies, what is most notably missing is robust data analysis. Tough questions are not being asked, and meaningful connections are not being made between the data that exists. The data is also not made public and transparent so that the community can participate in the process of systemic improvement. At the committee’s request, ACBH provided de-identified individualized data on the high utilizer population as defined by the Committee.7 The Committee’s work is ongoing, but some initial observations are clear: the data reflects key gaps in access to services for African Americans and individuals with a dual diagnosis of substance abuse disorder and mental illness (so-called co-occurring disorders). This de-identified data also suggests barriers to treatment access for those incarcerated at Santa Rita Jail and in need of psychiatric crisis stabilization at John George Psychiatric Hospital. Aggregate data allows us to see broad trends, but asking the right questions about de-identified individualized data could provide a key to seeing disparities in a tangible way and, as a result, allow for systemic changes that could lead to better outcomes. This kind of data analysis could be used, for example, to explore the efficacy of different FSPs, the relationship to housing status on outcomes, or be applied to any number of different queries. This data could allow us to assess not only where we are currently, but track potential improvements over time. The MHAB found several areas in which ACBH could not provide data. It appears that currently ACBH and Santa Rita Jail do not effectively track housing status for high utilizers. ACBH also was not provided data from the Jail on the severity of charges for these individuals. The MHAB Ad Hoc Committee found these gaps 7 The Committee greatly appreciates the invaluable ongoing assistance it has received from Chet Meinzer of Alameda County Data Services, who assisted the Committee in providing requested data and refining the Committee’s data requests. Alameda County Mental Health Advisory Board 5 significant in evaluating solutions. Accordingly, housing status should be collected at intake and discharge from the jail and from John George. The Ad Hoc Committee’s work to date has informed several of the recommendations set forth below. MHAB Recommendations The MHAB urges the Board of Supervisors to do the following: 1. Conduct a comprehensive needs assessment and evaluation of existing programs serving the seriously mentally ill in Alameda County. An overarching concern of the MHAB - one it has expressed repeatedly over the last year and in years past - is the lack of data regarding county-wide service gaps in the full continuum of behavioral health care, as well as the efficacy of current programming for those suffering from serious mental illness. Without this crucial data, the county simply has no way to determine how to allocate funding in the most meaningful and cost-effective manner. This concern was echoed in the Grand Jury report which concluded that “there is not a recent broad-based, Alameda County mental health needs/gaps assessment that explores where in the county there are service needs, equity disparities [including but not limited to race/ethnicity, language and disability barriers, immigration status], successful interventions, and that reviews current best practices and gaps in service availability, both inside and outside MHSA. One witness described funding choices by ACBH as shooting in the dark.”8 An assessment of unmet needs must be conducted through an equity lens so that the county can eliminate the unjust disparities in mental health services for African Americans and other marginalized communities in the high utilizer category. Specifically, the county should evaluate the extent to which these individuals were receiving appropriate, clinically indicated services prior to incarceration, and if so, what was lacking in the treatment that contributed to the individual becoming justice-involved. Similarly, the county must assess, and improve where necessary, the quality of discharge planning and re-entry services both from jail and from John George. The county should also provide data regarding the economic cost of high utilizers in the behavioral health system. The cost of frequent incarceration in Santa Rita Jail and multiple, recurring stays at John George Hospital amongst the high-utilizers should be quantified and compared to the cost of upstream investments in services and infrastructure to fill the identified gaps in the full continuum of behavioral health care. The incarceration of so many mentally ill individuals is not only morally objectionable but also is arguably not cost-effective. The MHAB is aware that the Board of Supervisor’s “Reimagining Adult Justice Initiative (RAJI)” is currently in the process of acquiring and analyzing some, but not all, of the data referred to herein. By way of a public-facing “dashboard,” and other such transparent means, the county should promptly make available to the public the work of the RAJI, as well as the study of unmet needs and cost-effectiveness recommended above. 8 See Grand Jury Report at p. 21. The Grand Jury Report also noted that the problems it identified were with the system and not with the people working within it. The MHAB agrees completely. Our meetings and communications with a wide variety of mental health providers and ACBH personnel have consistently shown them to be dedicated, hard-working professionals who care deeply about the people they serve. Alameda County Mental Health Advisory Board 6 2. Fully fund ACBH’s Forensic Plan. The MHAB was encouraged when, at the budget hearings in June 2022, the County Administrator was directed to bring to the Board of Supervisors a proposal for fully funding ACBH’s 50 million dollar “Forensic Plan” to “reduce forensic involvement with behavioral health clients.” As reported in the Grand Jury report, the county appears to have sufficient available funds from MHSA, CalAIM and other sources to fund Dr. Tribble’s thoughtful and comprehensive request. As documented by the Grand Jury Report, as well as by various lawsuits and legal settlements, we suffer in Alameda County from a shortage of services to prevent, respond to, manage, and support recovery and stability for persons with serious mental illness and substance use disorders. The situation will not improve without focused attention from the Board of Supervisors and additional funding. ACBH’s Forensic Plan now before the Board of Supervisors is a necessary first step, and will help the county serve the unmet needs of those who are suffering. 3. Expand the capacity of court-based and other diversion programs. As the Board of Supervisors has acknowledged by unanimously passing the Care First, Jail Last resolution last year, jails are no place for people who suffer from serious mental illness and/or substance abuse disorders. Yet, because the county has not devoted necessary resources to fund a full continuum of behavioral health care for all county residents, the Santa Rita Jail has become one of the largest providers of mental health treatment in the county.9 Data received from ACBH reveals that people diagnosed with a serious and persistent mental illness make up over 20% of the incarcerated population and the county spends an increasing amount of its resources to improve jail-based mental health services. Notably, the burden of incarcerating mentally ill individuals disproportionally impacts the African-American population in the county. While comprising approximately 10% of the county’s population, African-Americans constitute almost half of the incarcerated population that are receiving mental health services. The MHAB recognizes that the county must provide top quality mental health care to those who are incarcerated in Santa Rita Jail. However, the MHAB recommends that rather than focus on jail-based mental health care, the county should significantly reduce the number of seriously mentally ill people who are incarcerated at the jail (thereby reducing the need to spend resources on jail-based behavioral health care). In addition to various “upstream” solutions described below, one means of accomplishing this goal is for criminal defendants who suffer from serious mental Illness and/or substance abuse disorders to be diverted out of jail and into medically appropriate treatment facilities that can effectively treat their underlying behavioral health needs. Accordingly, capacity in all of the county’s various diversion programs, set forth below, should be expanded. • As the Grand Jury noted in its 2021-22 Final Report, the Behavioral Health Court (“BHC”) in Alameda County is underutilized. The BHC has reduced recidivism and improved mental health outcomes for those who have participated in the program.10 However, the BHC only has capacity for 9 In its 2021 Investigation and Report (“DOJ Report”), the U.S. Dept. of Justice (DOJ) noted that the MHAB has consistently reported to the Board of Supervisors that Alameda County places seriously mentally ill people at heightened risk of incarceration due to the lack of alternative appropriate treatment options: “the [MHAB] observed in 2015 that ‘Police officers in the field responding to individuals with mental illness have few options other than bringing them to Santa Rita or John George.’” (See DOJ Report at p. 10, fn. 8). The DOJ Report further noted that since 2015, the MHAB has alerted the Board of Supervisors that “Santa Rita Jail has become a warehouse for people with mental illness. Since there is nowhere to place individuals with mental health disabilities, they languish in jail, often isolated in jail cells. We need to develop a system so that this population can be diverted out of the criminal justice system and into treatment.” (See DOJ Report at p. 19, fns. 21 & 22.) 10 See “Unrecognized and Underutilized Potential: The Behavioral Health Court of Alameda County” (Urban Strategies Council, 2021) at p. 18. Alameda County Mental Health Advisory Board 7 approximately 100 participants at any one time due to resource limitations. With approximately 2,200 people in jail and over 20% of them diagnosed with a serious mental illness, the BHC is clearly not meeting the current demand. Capacity of BHC should be significantly expanded. To accomplish this, the county must increase funding for the community-based and appropriate medical treatment programs with which BHC partners. • In addition to the BHC, the county supports eight separate “Collaborative” Courts (two drug courts, a Veterans’ court, two re-entry courts, and three treatment courts in the family dependency department of the court system) which together are currently diverting from jail and treating approximately 170 participants. These collaborative courts, like the BHC, have proven successful in reducing recidivism, increasing positive health outcomes, and re-unifying families. To thrive and expand, however, these collaborative courts need stable, predictable, and sustained funding. The MHAB recommends that the county make a commitment to fully fund all of the Collaborative Courts. • The C.A.R.E.S. Navigation Center redirects individuals engaging in low-level criminal offenses into support services, mental health and/or substance use treatment and away from incarceration and the criminal justice system. As of now, it is the only point-of-arrest diversion program in Alameda County allowing police officers to bring clients directly to the Center to connect to services and keep people with mental illness and/or substance use disorder out of jail and the criminal justice system. These Navigation Centers should be expanded and fully funded so that residents in all areas of the county have access to them. • The I.S.T. Diversion Programs diverts in-custody felony defendants who have been found by the court to be Incompetent to Stand Trial (“IST”) and who currently languish in jail for up to six months or longer waiting for a treatment bed to become available at the State Hospital. To help reduce the size of the waiting list for state hospital beds, Alameda County received significant funding from the Dept. of State Hospitals to divert these individuals into local treatment. However, as reported to the MHAB, very few of the in-custody defendants who are eligible for this program have actually been diverted. Accordingly, the MHAB recommends that the Board of Supervisors make it a priority to address this problem so that the state monies the county is receiving are used effectively to provide these defendants with the appropriate level of acute or sub-acute treatment in the community. 4. Create Full-Service Partnerships (“FSPs”), Collaborative Courts, and other programs focused specifically on the needs of those who suffer from Co-Occurring Disorders. Frequently, an individual’s substance abuse issues are too severe for BHC and conversely, their mental health needs are too pronounced for Drug Courts or other Collaborative Courts. In fact, over 50% of the high utilizers of county services are diagnosed with co-occurring disorders. The MHAB recommends that the county invest in the kinds of treatment programs which can effectively address the unique needs of this population of people who often fall between the cracks in the existing diversion and other treatment programs. 5. Expand the services and capacity of the Safe Landing Project. The Safe Landing Project (SLP), located in a recreational vehicle parked on the grounds outside of Santa Rita Jail, began in June of 2020. Operated by Roots Community Health Center, SLP provides re-entry support services to newly released inmates. One impetus for the creation of the project was the tragic 2018 death of Jessica St. Louis, an inmate who was released at 1:30 a.m. without transportation or other services and found dead at the Dublin/Pleasanton BART station 4 hours later. SLP currently operates from 2:00- 10:00 p.m. and seeks to connect individuals leaving Santa Rita with a variety of services, including transportation. Based on discussions with, and a presentation by, Roots CEO Dr. Noha Aboelata, the MHAB recommends that SLP be expanded to: 1) provide services 24/7; 2) operate out of a permanent structure; and 3) have a presence inside the jail so staff has an opportunity to engage with inmates prior to their release. Alameda County Mental Health Advisory Board 8 6. Expand Effective Full-Service Partnerships (“FSPs”). FSPs, which stay faithful to an Assertive Community Treatment model, support people with the highest mental health needs in the county. Almost all of the FSPs in the county are provided for, on a contract basis, by various CBOs. The county must ensure that all FSP clinical teams are available 24/7, that the clinician-to-client ratio allows for as much face-to-face contact as necessary for the clients’ recovery and stabilization, and that there are effective means for keeping clients in treatment and compliant with their medications as necessary. Moreover, FSPs must be able to respond to crises, including coordination of services if a client is 5150’d or incarcerated in jail. FSPs can serve the crucial function of reducing arrest and incarceration, lengthy institutionalization, and emergency room use. However, the FSP capacity in Almeda County is far from sufficient. Currently, Alameda County has funded capacity for approximately 1,000 adults in FSPs at any given time. The MHAB believes the need is far greater, perhaps four times this amount. The MHAB urges the Board of Supervisors to assess the need and increase the capacity of FSPs as appropriate. This assessment should include a quality-of-care review of the various FSPs in the county as well as a review of whether the length of time a client is in FSP services is sufficient to maintain long- term mental health stability and reduce recidivism. 7. Significantly increase the capacity of residential treatment beds countywide (including those at Villa Fairmont) to ensure that effective, humane treatment is available at all levels of need. Alameda County must invest in the expansion of treatment bed capacity to provide a robust continuum of care – from acute crisis facilities to treatment at sub-acute facilities, crisis residential facilities and licensed board and cares – each with the capacity to provide the clinically indicated type and length of treatment. Without the expansion of residential treatment capacity, Santa Rita Jail will remain the county’s primary locked mental health treatment facility. In the immediate term, the MHAB recommends that the county expand capacity at the Villa Fairmont Mental Health Rehabilitation Center (MHRC). Villa Fairmont provides intensive sub-acute mental health and psychiatric treatment services for those in the community who are in need of that level of mental health care. Villa Fairmont is operated by Telecare and is licensed for 97 beds.11 However, Alameda County purchases only 70 of these beds, leaving the remaining 27 beds unavailable to county residents. The MHAB urges the Board to buy back these 27 beds so that the sub-acute treatment portion of the continuum of behavioral health care is sufficient to provide this level of care for those who need it. Specifically, the MHAB recommends that the county consider whether these additional beds could be used to divert those in jail mentioned above who are eligible for IST and other court-based diversion programs but, for lack of a clinically appropriate treatment facility, are languishing in jail. 8. Provide better treatment options for incarcerated individuals who are “5150’d” from Santa Rita Jail to John George Psychiatric Hospital. According to data acquired by MHAB’s Ad Hoc Data Committee, in the 2020 calendar year 131 unique individuals incarcerated at Santa Rita were suffering so severely from mental illness that they met 5150 criteria (gravely disabled, a threat to themselves, and/or a threat to others) and had to be transferred to John George for treatment and care.12 Of these 131 individuals, 68 were admitted to a unit at the hospital. In contrast, during the same time period, 956 high utilizers were admitted from the community to John George PES, with 65 high utilizers being admitted to John George PES more than 10 times during 2020. 11 The county ‘s only other MHRC for the treatment of those diagnosed with serious mental illness is the Gladman MHRC. However, the 39 available beds at Gladman are used primarily for long term patients who are on so-called “Murphy” and regular LPS conservatorships. 12 Data concerning average length-of-stay is still outstanding. For instance, the MHAB does not know the extent to which these individuals received necessary lasting treatment in an acute or sub-acute facility as opposed to being quickly returned to Santa Rita Jail. Alameda County Mental Health Advisory Board 9 During this same time period only 2 high utilizers were open to LPS Conservatorships. This data raises the question: are high utilizers treated differently if they are 5150’d from jail as opposed to if they are coming from the community? And if so, why? Since the jail is not a licensed 5150 treatment facility and has no ability to provide involuntary treatment, there is no clear rational for why John George would treat a referral from the jail would be treated any differently than a referral from the community. As reported to the MHAB, while at John George, incarcerated people must remain in a locked room under armed guard, and therefore are not provided with the milieu therapy and other treatments that are available to all other patients at the hospital. Moreover, it appears that too many of these individuals are simply medicated and returned immediately to the jail without receiving the necessary treatment that would be provided to a non-incarcerated person suffering from serious mental illness and in need of acute treatment. The MHAB recommends that the county assess the quality of the care provided to incarcerated persons sent to John George, including continuity of care between John George and the jail, the types and the quality of services provided to incarcerated clients and subsequent outcomes including any subsequent suicide attempts or further 5150s. 9. Support the repeal of the IMD (Institution for Mental Disease) Medicaid Exclusion. The IMD exclusion is the federal law that prohibits Medicaid reimbursement for treatment provided in a mental health treatment facility of more than 16 beds. Since the 1960s, this law has effectively denied patient care, disproportionately discriminating against poor and other marginalized communities. Medicaid reimbursement for inpatient care for our most ill citizens should be available no differently from inpatient care for heart disease, cancer, and other severe illnesses. The IMD exclusion, which discriminates against persons with mental illness, should end immediately. The MHAB urges the Board of Supervisors to support federal legislation, such as H 2611, which calls for the outright repeal of the IMD Exclusion. Moreover, we urge the Board of Supervisors to encourage its state partners to apply for the “IMD waiver” which would develop federal funding for the more acute levels of care needed by county residents who suffer from the most advanced stages of serious mental illness. 10. Prioritize strategies to address the mental health workforce shortage. In the midst of the greatest demand for mental health services, our state is experiencing the greatest provider shortage. While there are efforts at the state and local levels to overhaul our mental health system, it would be hard to create transformative change if we do not address this crippling provider shortage. The workforce crisis was happening well before the pandemic, and has since worsened significantly. Training programs are not producing enough accredited providers, many providers are leaving jobs at county mental health departments and community-based organizations (CBOs) to go to higher-paying jobs or create their own private practice. Even if they remained, there are not enough providers to meet the significant increase in demand. Those providers who remained have increased workload, leading to burnout. This urgent situation requires both long-term and short-term solutions. Salary increases for both county providers and those at CBOs are necessary for recruitment and retention. Additionally, there needs to be more investment in training programs at all stages of career development that would produce more therapists, especially culturally and linguistically competent trainees who can provide such care to vulnerable populations. Furthermore, we need to consider team-based models that move away from sole reliance on licensed therapists, but also includes case managers, peer providers, community health workers and others, who can help support in the comprehensive mental health care for the clients. While some CBOs have been using these team-based models, the payment structure does not always (sufficiently) reimburse for services provided by these lay mental health professionals. CalAIM is just beginning to recognize the work of community health workers, including providing some reimbursements for their services. We need to expand on this concept to help spread the work in caring for each client. Not only will this meet the increasing demand in services, but will also help to balance out the workload for existing mental health providers, and help to reduce their risks of burnout. Alameda County Mental Health Advisory Board 10 Conclusion The MHAB is proud of its work over the last year and appreciates the opportunity to be of service to the Board of Supervisors and to the community. As noted in the Grand Jury Report, the Board of Supervisors should better utilize the expertise and perspective of the MHAB. Most important, at this juncture, the MHAB urges the Board of Supervisor to fill the vacant MHAB positions, including the position of the Board of Supervisors’ representative to the MHAB, so that the MHAB is in the best position to exercise its statutory obligations.13 The MHAB looks forward to working more collaboratively with the Board of Supervisors in the future, and asks that the Board provide a response to the recommendations contained in this report. Sincerely, Lee Davis, MHAB Chair L.D. Louis, MHAB Vice-Chair 13 In addition to the vacant slot for the Board of Supervisor’s representative (which is mandatory pursuant to Welfare and Institutions Code section 5604(a)(1), Supervisorial Districts 1,2, 4 and 5 all have one opening apiece on the MHAB.