Health and Human Services

Health Services Agency –

Division of Public Health – County Clinics –

Division of Mental Health and Alcohol and Drug Abuse –

Central Coast Alliance for Health– Community Clinics –

Coalition for Health Care Outreach –

Local Hospitals – Health Services Agency The Santa Cruz County Health Services Agency (HSA) is the lead agency responsible for a number of services provided directly to low-income persons or by contract with private health care providers and non-profit organizations. Other providers represent collaborative efforts funded from a mixture of tax resources and philanthropic donations. The responsibilities of the HSA include the following: • Assessing the health status of county residents • Managing the health planning process to meet the needs of the entire community • Setting priorities to meet these needs and to serve as advocate for the poor, the disabled, the aged and the disenfranchised • Assuring the active participation of health service providers, consumers of health services and advocates who display a special concern for one or another aspect of health care delivery • Maximizing the impact of scarce public health resources, setting priorities, avoiding duplication and averting competition when it is counter-productive Based on interviews with other providers, the HSA has the respect of community providers essential to carrying out its unique role. The HSA has been an effective advocate for fulfilling the needs of low-income families. It participates in every available categorical program targeted to the poor. The HSA Comparison of Revenue Sources chart below depicts the ability of HSA to use limited county funds to leverage millions of dollars of outside funding for local programs. In addition, county professional staff has successfully competed for a number of demonstration projects awarded for the purpose of testing innovative approaches to people with special and difficult health problems. Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report The HSA employs an experienced, high caliber staff open to innovation, collaboration and committed to public service. Efforts are made to accommodate diversity in language and culture. Bilingual capability in English and Spanish exists in all clinic locations by staff members at every level. County facilities are located and professional staff are deployed to Health Services Agency Comparison of Revenue Sources (in millions $) $90 $82.00 Gross Budget $80 $74.61 $69.22 $66.20 $70 $63.00 $60.82 $67.64 $60 $54.60 $63.41 $49.96 $48.33 $58.59 Non-County Revenues $50 $56.50 $53.30 $51.34 $40 $44.39 $41.86 $37.81 $30 Net County Costs $20 $14.36 $10.52 $10.22 $9.45 $9.70 $9.70 $10.64 $11.19 $8.09 $10 21.76% 16.20% 18.71% 15.53% 15.40% 14.65% 15.37% 15.00% 17.51% $- 92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 00/01 Fiscal Year areas where low-income people reside. HSA is engaged with other public agencies that serve individuals in need of health services support. Examples include public schools in low-income areas, probation, welfare, homeless shelters, child protective services and all county-operated detention facilities. Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report HSA is an active member of the Coalition for Health Care Outreach, a group of public and voluntary health and social service agencies. HSA staff assists the Coalition in the following ways: • Identifying and enrolling families eligible for Medi-Cal and other tax-supported health programs • Obtaining federal reimbursements for outreach activities which qualify for financial support • Assessing unmet needs experienced by coalition members • Participating in coordinated planning efforts to attract new health resources to fill gaps in services • Preparing grant applications to both private and public agencies • Providing technical assistance in case management techniques and in making and receiving referrals • Assisting in the training non-professional outreach staff The Director of HSA sits on the Medical Managed Care Commission that governs the county- operated prepaid plan in Santa Cruz County, the Central Coast Alliance for Health. This position helps her to design performance criteria for county contracts with private providers and to track legislative proposals affecting uninsured families. HSA is currently upgrading its Medical Information Management System (MIMS), to comply with a recent federal initiative HIPPA (Health Insurance Privacy and Portability Act). This legislation is intended to protect information on the health status of insured persons and facilitate the portability of health insurance coverage. Compliance is required by April 2002 as a condition of qualification for federal program reimbursements to providers in all tax- supported health programs. The goals of the new MIMS are as follows: • Improve fiscal management of county-operated programs and increase the rate of revenue recovery from third party sources • Modify the determination of eligibility and integrate clinical services to make them more user-friendly and clinically effective • Facilitate evaluation of professional performance and measure outcomes of treatment • Assess specific health problems in the community by utilizing pertinent data from the recent census and special survey results to refine long term health planning Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report The HSA is making every effort to meet its obligations to low-income persons despite the complexities of health care financing The HSA Director is acutely aware of unmet needs in Santa Cruz County that impact low-income families, These include the following: • Lack of access to health care services for working families without health insurance • Lack of dental treatment resources, especially for children, including many of those with Medi-Cal eligibility • Lack of primary mental health care services for families and children • Lack of sufficient resources to accommodate pregnant adolescents who need intensive peri-natal care • Lack of evening hours at county clinics to accommodate working people A recent report to the Board of Supervisors by the HSA, entitled Report on the Uninsured and Access to Health Care, is especially pertinent to those in a position to shape health care in the public arena. The report may be obtained on request from the Health Services Agency or at http://www.santacruzhealth.org/pdf/Uninsured_Access_Rpt.pdf. Physician recruitment efforts demonstrate serious competition from Bay Area Counties and Monterey County. Monterey County has placed physicians in county service into the Public Employment Retirement System (PERS), whose strong benefits have proven attractive. Skilled nurses are in short supply. Local hospitals and long term care facilities are offering higher salaries than the county. Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report Division of Public Health The Division of Public Health is organized and operated to assure the integration of public health and preventive measures into primary clinical care. The Health Officer and the Director of Public Health Nursing are responsible for all programs in this divisionDivision that deal with low-income families. These range over a broad spectrum and include • Communicable disease control and immunizations • Peri-natal care for adolescents and other high risk mothers and infants • Health education and nutrition • Case finding, referral and outreach, concentrated on low-income families • Case management for difficult or chronic health problems • Family planning • Education and control of sexually transmitted diseases • Care for high-risk infants and preschool children • Health services for families who are homeless • Intensive case finding and health care for AIDS and TB patients The California Department of Health considers the programs in Santa Cruz dealing with AIDS to be an outstanding model for other counties. Public health nurses are the mainstay of public health practice. Although assigned to categorical programs, these nurses engage in general practice and apply their skills wherever a need is encountered. Their motto is “take care of people instead of paper.” The public health nurses provide critical support to the clinicians who operate county clinics. They make visits to homes for the purpose of assuring that treatment instructions are understood and carried out and that follow-up appointments are kept. They also provide case management services for clients with difficult and recurring problems. When an outbreak of infectious disease threatens, the nursing staff is mobilized to control its spread. A special unit of the department, Homeless Persons Health Project, deals entirely with homeless families and individuals. It operates a clinic at a Santa Cruz shelter, but the nursing staff is frequently on the streets at other locations serving the homeless. This unit is a successful example of attracting funds for demonstration purposes. A recent assessment of this program by federal evaluators drew praise and a conclusion that it should serve as a model for other county public health jurisdictions. Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report Other programs in the division reach beyond routine clinical care, including • Vital statistics • Accident prevention especially for children (bicycle helmets-seatbelts etc) • Lead poisoning screening and control • Optimizing immunization rates • Dental disease control and targeted treatment • Tobacco education and cessation of smoking • Hepatitis C and tuberculosis control targeted to new immigrants and HIV patients • Other preventive programs The Health Status Profile, below, shows from 1996 to 1998 this county performed above average in nearly all categories as compared to other California counties and National Objective benchmarks. However, according to the Public Health Officer, there is a high and persistent incidence of alcohol and drug abuse in Santa Cruz County compared to other California counties of similar population. Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report Santa Cruz County Health Status Profile 1996-1998 3-Year Average Statewide Average National Objective 2000 Better Worse Better Worse Indicator Than Than Than Than Motor Vehicle Deaths xxxx xxxx Unintentional Injury Deaths xxxx xxxx Firearm Injury Deaths xxxx xxxx Homicide Deaths xxxx xxxx Suicide Deaths xxxx xxxx Deaths, All Cancers xxxx xxxx Lung Cancer Deaths, xxxx xxxx (2nd best in state) Breast Cancer Deaths, Women xxxx xxxx Coronary Heart Deaths xxxx xxxx Cerebrovasicular Dis. (Stroke) Deaths xxxx xxxx Drug-Related Deaths xxxx xxxx AIDS Incidence xxxx xxxx Measles Incidence xxxx xxxx Tuberculosis Incidence xxxx xxxx Syphilis Incidence xxxx xxxx Infant Mortality Rate, All* xxxx xxxx Hispanic Infant Mortality* xxxx none established % Low Birth Weight Infants xxxx equal to national Teen Pregnancy Rates xxxx none established % Onset Prenatal Care, 1st Trimester xxxx xxxx # % Adequate Prenatal Care xxxx xxxx % Breastfeeding/Early Postpartum xxxx xxxx (Best in state) * 1994-1996 3-year average # National Objective for Year 2010 Data/Report released April 3, 1000, California Department of Health Services Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report County Clinics The county operates two primary care clinics, one at the Emeline Health Center of the Health Services Agency and another near downtown Watsonville. These facilities are attractive and well maintained. They provide a dignified environment for the mostly low-income individuals and families who rely on them as their principal source for medical care. At present, clinic operations are confined to daytime schedules with no lunchtime or evening hours. Santa Cruz County Clinics Utilization Statistics Actual Actual Actual Projected FY 97-98 FY 98-99 FY 99-00 FY 00-01 Santa Cruz Clinic Visits Primary Care Clinic* 13,417 13,373 14,402 15,000 Prenatal Clinic 568 254 294 100 Family Planning Clinic 995 1,116 1,217 1,200 Tuberculosis Clinic 351 320 343 325 CHDP Clinic 497 389 577 550 Immunization Services 3,487 3,747 4,000 4,200 Laboratory Procedures 26,968 28,226 28,840 30,000 X-ray Procedures 2,237 2,240 2,329 2,400 Prescriptions Filled 75,297 67,686 63,837 68,000 Watsonville Clinic Visits Primary Care Clinic 11,355 11,406 12,240 12,500 Prenatal Clinic - - - - Family Planning Clinic 3,761 3,758 4,343 4,500 Tuberculosis Clinic 898 732 801 800 CHDP Clinic 1,298 1,290 1,173 1,300 Immunization Services 5,927 6,250 6,436 6,700 Laboratory Procedures 9,644 13,062 14,229 1,400 X-ray Procedures 1,067 1,050 1,202 1,200 Prescriptions Filled - 11,785 23,591 30,000 * Includes Orthopedic Clinic, Travel Clinic, Occupation Health Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report Physicians trained in primary care specialties staff the clinics with support from allied health specialists, such as nurse practitioners, physician assistants and technicians. Patients are not assigned a designated primary care provider whose primary purpose is to assure continuity of care. Both clinics enjoy the status of federally qualified health clinics (FQHC), an official federal designation that raises reimbursement rates for services it provides. Renovations are under way to enhance productivity and improve patient traffic within the Emeline County Clinic. A plan is also under consideration to add capacity in mental health services to support the family clinicians Medi-Cruz The Board of Supervisors created this program to supply medical care for those who are without health insurance and without money needed to pay for essential medical care when it becomes a necessity. A complete description of the strategy employed by Medi-Cruz to accomplish a great deal with limited resources is available in the recent report to the Board of Supervisors, Report on the Uninsured and Access to Health Care. Medi-Cruz operates on a tight budget due to repeated reductions of state funds for health care for indigent adults. This reduction in funding places a burden on single indigent adults who reside in the county and do not have access to health insurance. Division of Mental Health Services and Alcohol and Drug Abuse Programs The Division of Mental Health Services and Alcohol and Drug Abuse Programs serves people who suffer severe mental health or substance abuse problems, both acute and chronic. Most of its clients are adults and seriously emotionally disturbed children. The division organizes its interventions as a system of care to cope with major and persistent disabilities associated with mental dysfunction. The staff is organized into treatment teams to fulfill this primary charge in both North and South County. An inpatient facility is operated under contract at Dominican Hospital’s Behavioral Treatment Unit. Individuals in need of voluntary or involuntary commitment for acute mental health or drug detoxification problems are admitted to this unit. Psychiatrists under contract with the Mental Health Division tend county patients. Most of these admissions are short term, with discharge to residential care or follow-up in an outpatient facility. Components of the system include outpatient clinics, residential facilities, and day treatment programs, all of which are supported by a mobile crisis team. The division provides mental health services to each county detention facility. Programs for children are presently confined to seriously emotionally disturbed children. This model program was awarded special demonstration funding. It uses a multidisciplinary approach to troubled children who face the prospect of foster home placement. The program includes personnel from schools, courts, probation department, child protective services, police agencies, drug and alcohol professionals and others. Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report This system of care, now in its tenth year, has demonstrated success in many ways • Reduced costs for state hospital admissions • Extended treatment and case management services provided in the least restrictive environment with mobile crisis support • Lowered utilization of acute mental hospital beds • Improved special education programs • Reduced costs for foster and group home placement • Improved family reunification for children returning home from protective custody Both parents and young people served in this program are very satisfied with its results. Primary mental health services to families and children are unavailable in both county and community clinics. This also holds true with Central Coast Alliance for Health programs because mental health benefits have been removed from coverage in the county prepaid plan. Funding for mental health services is allocated to County Mental Health instead. As a result, individuals with a less serious mental disorder have few options for primary mental health care. There is a critical need for psychiatric evaluations and treatment resources in county and community clinics serving low-income families. In addition, there is a severe shortage of all types of mental health professionals in Santa Cruz County. Skills in short supply are child psychiatry, psychology and other therapeutic modalities dealing with behavioral dysfunctions in the family. Alcohol and Drug Abuse Programs Proposition 36 was passed by voters in 2000. Its intent is to divert convicted drug abusers from detention facilities to supervised treatment programs in their communities. Funds allocated to date under Proposition 36 are being used to plan for diversion of offenders eighteen years old and above. Alcohol and Drug Abuse Programs has been designated as the lead agency since the emphasis of the new law is on treatment. A task force is now at work that includes the courts, probation, district attorney, public defender, the Alcohol and Drug Abuse Programs and providers of local services. In the judgment of the Director of Alcohol and Drug Abuse Programs, the long-range expansion of service capacity will benefit everyone. A significant portion of eligible persons is, in fact, already enrolled in various community treatment programs. He expects that the potential problem of dislocation of non-offenders, if it occurs, will be temporary and can be readily resolved. In addition, he expects the waiting lists that now exist for admission to some treatment programs will grow shorter with the increased treatment capacity expected when Proposition 36 is fully funded. Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report Central Coast Alliance for Health The Medi-Cal reform, adopted in the 1970s, was the driving force behind the enrollment of Medi-Cal beneficiaries into prepaid health plans. It took many years of trial and error and cancellation of contracts with providers before reliable prepaid Medi-Cal plans finally emerged and brought tangible benefits to Medi-Cal families. This result required the enactment of statutes to ensure that prepaid contractors under Medi-Cal meet a number of detailed fiscal and health care standards that protect the interests of enrollees. The Central Coast Alliance for Health is a county operated prepaid plan that serves Medi-Cal recipients and families eligible for the Healthy Families Program. The Alliance came into existence in 1996 as a result of growing concern on the part of public health officials and leaders of the local Medical Society over the lack of participation by local physicians in the Medi-Cal program. The Board of Supervisors established the Medical Managed Care Commission (MMCC) to govern the county operated prepaid plans. The commission seats elected officials, public health officers, private providers and beneficiaries enrolled in the plan. The MMCC holds regular public hearings open to all interested parties to present their positions on the Medi-Cal program and to resolve as many problems as possible at the local level. Prior to the creation of the Alliance, a myriad of problems affected local beneficiaries of the Medi-Cal program. Limited choice of private providers resulted in episodic, unsupervised care, over-reliance on hospital emergency rooms, higher rates of hospital admissions and longer hospital stays. This same pattern of utilization now prevails among uninsured low- income families not participating in the Alliance programs. Analyses of Medi-Cal paid claims data prior to the establishment of the Alliance confirm these patterns in the Medi-Cal population Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report Some of the accomplishments of the Alliance are highlighted below: • Within the framework of state regulation, policy decisions on Medi-Cal have reverted to local public control. • The state provides per capita prepayments for various classes of people eligible for Medi-Cal. These payments place the Alliance at financial risk for the provision of the extensive benefits covered by Medi-Cal. Cost over-runs cannot be reimbursed by the state. • Plan physicians share this risk. When enrolled, families are assigned to a primary care physician of their choice who provides direct services and authorizes referrals to specialists when indicated. Per capita prepayments are made to the physician to cover all services. • An intake assessment is made of the health status of each enrollee on entry to the plan and periodically thereafter. This enables treatment for any detected abnormality and contributes to the maintenance of good health. • Quality assurance procedures are in continuous operation. These consist of several elements: @ Special studies of patterns in the provision of services to measure conformity with statistical standards set for specific types of primary care @ Collaboration with public health professionals in health education and organized programs of prevention targeted to special needs of enrollees @ An internal quality improvement program to upgrade performance of plan physicians and allied health professionals including biannual site visits @ Case management procedures are emphasized for difficult or chronic conditions to assure compliance with treatment regimens and to help prevent complications. • Patient support services include: @ Medical transportation @ Adaptation to language and cultural diversity @ Consultation by phone @ Outreach by bilingual staff to assist in establishing eligibility @ Review of complaints and prompt adjudication of grievances • Fiscal management of the Alliance includes annual budget development, expenditure tracking and negotiation of contracts with various classes of providers. Audits indicate that fiscal affairs are in good order. The plan has accrued a surplus in each year of operation. Because there is no need for the Alliance to return profits to investors, one of the uses of the surplus has enabled the plan to make additional reimbursements to providers, which helps retain current physicians and encourage other physicians to participate. • The presence of Alliance staff in the community has improved communication between both providers and enrolled members. Inquiries are handled efficiently and responses regarding procedures of the plan are made in a timely fashion. • To foster administrative efficiency, the Alliance expanded coverage to Monterey County in 2000, which is now an integral part of the Alliance. Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report According to Census 2000 data for Santa Cruz County, 26.8% of the population is Hispanic. In their most recent analysis, the Human Resources Agency reported that 49% of Medi-Cal eligible families countywide are Hispanic. Percent of Persons Who Are Hispanic or Latino (any race) Santa Cruz County Census 2000 Map The heaviest concentration of Hispanics is in South County. Persons who are Hispanic or Latino comprise 69% of the population of Freedom and 75% of the population of Watsonville, up from 60% in 1990. The highest rates of growth took place in Watsonville and Scotts Valley. Population Change 1999 – 2000 Santa Cruz County 1990 2000 Increase / % Change % of 1990 % of 2000 Jurisdiction Population Population (Decrease) 1999-2000 Population Population Santa Cruz County 229,734 255,602 25,868 11.3% 100% 100% Capitola 10,171 10,033 (138) -1.4% 4.4% 3.9% Santa Cruz 49,040 54,593 5,553 11.3% 21.3% 21.4% Scotts Valley 8,615 11,385 2,770 32.2% 3.8% 4.5% Watsonville 31,099 44,265 13,166 42.3% 13.5% 17.3% Unincorporated 130,809 135,236 4,517 3.5% 56.9% 52.9% Source: California Department of Finance, Demographic Research Unit, California State Census Data Center Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report In the course of this review, all providers reported a steady increase in demand for health services by low-income families who lack health insurance. Many are newcomers looking for work in farm-related and service occupations that are unlikely to offer health insurance either to the worker or dependents. South County health care providers and housing officials are concerned that newcomers are low-income Hispanic families without health insurance who live in overcrowded, unhealthy conditions. The extent and severity of these problems will be quantified when the Census 2000 data on family income, occupation, housing and health insurance coverage are released in the fall. Coalition for Health Care Outreach This organization was created several years ago to enroll people who qualify for government subsidized health care programs and insurance plans. It focus is on families and children. It received a grant from the Packard Foundation at a crucial juncture in the organization’s history. The current membership of the coalition is as follows: Above the Line Watsonville Adelante Watsonville All Kids by Two Santa Cruz Blue Cross of California San Francisco Central Coast Alliance for Health Santa Cruz Community Action Board Santa Cruz Community Foundation Santa Cruz County Office of Education Capitola Davenport Resource Center Davenport Dientes Community Dental Clinic Santa Cruz Dominican Hospital Santa Cruz Dominican Foundation Santa Cruz DRSC Davenport Families in Transition Santa Cruz & Watsonville Familia Center Santa Cruz Food & Nutrition Service Aptos Growth & Opportunity Watsonville Health Services Agency Santa Cruz Human Resources Agency Santa Cruz & Watsonville Westside Planned Parenthood Santa Cruz Planned Parenthood Watsonville Pajaro Valley Community Health Trust Watsonville Pajaro Valley Unified School District Watsonville Pajaro Valley Shelter Services Watsonville Primary Access Dental Sacramento Salud Para La Gente Clinic Watsonville Santa Cruz County Mental Health Santa Cruz Santa Cruz County Public Health Santa Cruz Santa Cruz City Schools Santa Cruz Santa Cruz Community Counseling Centers Santa Cruz Youth Services Watsonville Santa Cruz Women’s Health Center Santa Cruz Second Harvest Food Bank Watsonville Sutter Maternity and Surgery Center Santa Cruz United Way Capitola Watsonville Hospital Watsonville WIC Watsonville Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report Following is a list of problems being addressed by the Coalition: • Uninsured children whose parents are either unaware of help they may receive or in need of personalized assistance in applying for health programs • Homeless who are in need of help with medical care, mental health disorders or treatment and rehabilitation related to substance abuse • Health screening in Headstart and elementary school health screening and referral • Food and nutrition assistance • Health care assistance to workfare programs • Dental screening and treatment of children • Counseling and case management for a variety of health problems • Residential care programs • Assistance for victims of domestic violence and child abuse Community Clinics We visited three member clinics that provide health care for uninsured, low-income families. • Salud Para La Gente Clinic in Watsonville • Women’s Clinic of Santa Cruz • Dientes Community Dental Clinic in Santa Cruz Salud Para La Gente Clinic This clinic was created during the War on Poverty in the sixties. It is now a primary resource for Spanish-speaking patients in both southern Santa Cruz and northern Monterey Counties. Its family physicians speak fluent Spanish and are sensitive to the cultural characteristics of the people they serve. The clinic is spacious and well maintained. All patients are treated without prior determination of eligibility or inquiry into their legal status. This practice is well known in the community and has significantly reduced the use of the emergency room for primary care during clinic hours. It has also reduced serious complications resulting from delays in seeking attention. Advantages of the clinic include • Continuity of care is an important feature of clinic policy has proven to be popular with patients and providers alike • Clinic physicians attend their own patients during hospitalization at the Watsonville Community Hospital • Organized prevention programs that focus on the problems most commonly encountered by the clinicians • Patients are assisted in making application for public programs for which they are eligible in a caring manner; this has increased the number of participating families • Newcomers to the community are likely to use the clinic especially if they are undocumented families • Patient satisfaction is measured regularly • Complaints are settled immediately and without formality Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report Respecting patients and treating them with warmth and dignity is a guiding principle of the clinic. The Women’s Health Clinic of Santa Cruz Findings This clinic specializes in responding to the general health needs of women in a sensitive and caring fashion. Its professional and support staff consists entirely of women, many of whom have worked in the clinic for years. The majority of patients are eligible for Medi-Cal or other tax-supported programs. Their children are also included. A significant percentage of its clients are Spanish-speaking, and most staff members are bilingual. The clinic enjoys strong community support. It has a community board of directors who contribute to both management and fundraising campaigns. Every effort is made to qualify patients eligible for public programs in order to preserve funds expended from its own resources for uninsured people. Clinic administrators meet reporting requirements of city and county government that help finance the clinic. In the words of its director, the administrator are especially adept at “patching together” ways to maximize income from public programs and tailoring them to individual needs. When necessary, clinical support is provided by public health nurses. The Dientes Community Dental Clinic This small clinic provides general dentistry to low-income families in Santa Cruz and enjoys the support of the community. The population it serves is similar to other community clinics. Its director has extensive training in public health. Preliminary discussions are underway between Salud and Dientes for instituting a dental clinic at the Salud facility. Local Hospitals Dominican Hospital Dominican Hospital serves as a principal inpatient resource for Medi-Cal patients from Santa Cruz and north county communities enrolled in the county-operated prepaid plan, the Central Coast Health Alliance. Under contract with the county, it provides the following for uninsured indigents • General hospital admissions • Hospitalization for mental health disorders • Detoxification for substance abuse The emergency service provides patients from both county and community clinics with emergency, urgent and routine medical care at hours when those clinics are closed. Patients admitted through the emergency room are assigned to the on-call physician during their hospital stay. The CEO of Dominican Hospital takes pride in the fact that the hospital has never refused care to anyone over the many years it has served the community. In addition, the hospital operates outpatient clinics to serve low-income mothers and children who choose the hospital as a source of primary care. The prenatal and pediatric outpatient Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report clinics are combined to accommodate this caseload. The Rotary Club and Dominican jointly sponsor a free clinic, “Roto-care”, in Santa Cruz once a week. Dominican Hospital spent $6.774 million dollars on unsponsored community benefits for the year ended June 30, 2000. This represents 5.2% of the hospital’s total operating budget for this period. Approximately $3 million dollars was absorbed by the hospital for unpaid cost of Medicare and other public programs. Although Dominican Hospital is a private institution, its current functions fill the role of county hospital. It integrates low-income individuals and families into all the services it provides. Watsonville Community Hospital This recently opened facility, formally a non profit organization, now owned and operated by a sizable hospital corporation, serves as a principal inpatient resource for Medi-Cal patients in South County. To date, the hospital has pursued an open door policy to accommodate all patients coming to the emergency room and other outpatient services, assigning those needing admission to a physician on call. The hospital has experienced a recent influx of low-income families utilizing its services. Sutter Hospital The hospital administrator was unable to keep a long-standing appointment with the Grand Jury regarding this facility. Time did not permit rescheduling. Conclusions

There is a pressing need for primary mental health and dental services at county and community clinics and in the county operated prepaid plans. Credentialed mental health professionals can effectively manage common behavioral problems under the guidance of a psychiatrist. Group therapy can be employed to expand access to mental health care. The use of these strategies may eventually improve access to care in the entire community and contribute to an expansion of the pool of mental health professionals available to low- income families.

The Health Services Agency is the logical entity to close critical gaps in the local community health care system.

To be effective, the complex network of services to low-income persons requires a high level of mutual trust and cooperation between HSA, private providers and collaborating agencies. The Grand Jury commends the efforts of the HSA.

The successful recruitment and retention of credentialed health professionals into county service is seriously impaired by the rising costs of housing, goods and services in Santa Cruz County. Review of Health Care Services for Low-Income Families in Santa Cruz County 2000-01 Santa Cruz County Grand Jury Final Report

The Medical Information Management System (MIMS), being developed by the County Health Services Agency, is essential to the improvement of its management of health care programs and the refinement of comprehensive health planning and evaluation.

The style, reputation and effectiveness of Salud Para La Gente Clinic demonstrates that open access to primary and preventive health services can be both cost effective and compassionate. The Grand Jury commends Salud Para La Gente Clinic for the manner in which they find and enroll eligible families.

With his experience in public health dentistry, the Dientes Community Dental Clinic director could be a valuable resource to the County in planning and implementing a full service dental program for Medi-Cal eligible individuals.

The ingenuity and commitment of public health nurses in both case finding and referral and their refusal to be intimidated by the rigidity of the rules and regulations attached to categorical health programs are commended by the Grand Jury.

Segregation of hospital care for the poor does not exist in Santa Cruz County due to the accommodation of county patients at community hospitals. All participating parties can take credit for this accomplishment which is recognized by this Grand Jury.

The growing population of uninsured families in South County is having a major impact on the ability of health care providers to continue to offer high quality health care service.

Members of the 2000-01Grand Jury attended board meetings where derogatory remarks were made by one director regarding the general manager’s job performance.

The BCR&PD operated at a loss for fiscal year 2000-01. This shortfall was covered by district reserves.

Of 6,136 voters registered within Boulder Creek Recreation and Park District, 4,633 voted on November 7, 2000 in the BCR&PD board of director’s election. This represents greater than 75% voter turnout. Review of Boulder Creek Recreation and Park District 2000-01 Santa Cruz County Grand Jury Final Report Conclusions Some incumbent directors demonstrate ill will towards each other that impedes their ability to cooperate. This has had a negative impact on the ability of the district to move ahead with a number of proposed projects, including such simple projects as painting a four square court or hopscotch on asphalt. The lack of a current, comprehensive Policies and Procedures Manual, to which the directors and the general manager adhere, has fostered an atmosphere of extreme animosity at the board meetings. This contributes to endless discussions at board meetings. Updating and editing policies and procedures at meetings of the board of directors is poor utilization of meeting time and is an impediment to handling the business of the district. This approach to updating the policies and procedures has created agendas with an unwieldy amount of unfinished business, most of which is related to changes in policies or procedures. Compilation of updated policies and procedures has been haphazard and there is no way to know what changes have been made. The general manager’s ability to perform is impeded by the lack of an approved job description and the absence of annual performance evaluations. This has intensified the ill will between directors who feel the job is being performed adequately and those who feel it is not. The letter of intent to resign by an incumbent director was made public immediately after election results were posted in November 2000. The Grand Jury questions the timing of this action. This letter states that the general manager withheld knowledge of the incumbent’s intent to resign from the other directors. When this letter was made public, the fact that the general manager had known of the intent to resign was revealed, which gave the appearance of impropriety on the part of both the incumbent director and the general manager. This further undermined the relationship between the general manager and the other directors. Limitation of the public at the podium on any one agenda item has improved the ability of the board to move ahead in meetings.

After the formation of the SSC, the chairperson’s communications with parents showed a wider variety of communication techniques. Communication Method Frequency School Newsletter 16 Meetings 4 School Bulletin 6

According to the School Site Council Handbook, “After the SSC is first formed or new members are selected to ongoing councils, the school/district should provide training and ongoing in-service to the members to assist them in carrying out their responsibilities. The training provided to the SSC should be on a regular basis, and the training should be appropriate to the tasks at hand.” Training is not being provided to all site councils in Santa Cruz County.

In the committee’s interview with the County Superintendent of Schools, it was stated “We are now looking at doing training for participants.” Review of the Organization and Structure of Site Councils in Santa Cruz County Public Schools 2000-01 Santa Cruz County Grand Jury Final Report

Upon request, training support is available through the County Office of Education.

Survey responses revealed that in many cases parity between school personnel and parent/student representatives was not achieved. Parity was reported by18 of 31 principals and 5 of 16 chairpersons.

Respondents stated that Hispanics and other minorities in many communities are under represented on school site councils.

Some of the methods used to count votes have the appearance of impropriety. While appearance does not constitute wrongdoing, it can still undermine the integrity of the voting process. Conclusions Communication to parents and the local community regarding the school site council, and nominations in particular, needs to be improved. Even though it is not required by education code, nominations to fill seats on site councils should be conducted in accordance with democratic principles. Security of the voting process is non-existent in some schools. • A secured ballot box is not utilized at each school. • Some parents are eliminated from the voting process by missing an election meeting. • Votes returned by students may get lost in transit or misplaced. • Voting process should be established in accordance with democratic procedures. Training should be provided annually to the school site councils. School site councils are not adequately publicized. Too much dependence is placed on the school newsletter for communication. Most schools indicated that they had difficulty obtaining new SSC members. Participation greatly contributes to the success of a school site council; therefore, in order to stimulate interest, more creative efforts should be used. While the Education Code provides for specific oversight of school plans, it is ambiguous regarding the structure and organization of school site councils.

Since the establishment of the CPRB, the Internal Affairs investigation reports have increased from a typical 5-page report to a possible 25-page report. These reports must now be written in laymen’s terms for the CPRB members, rather than police terminology. Conclusions The number of complaints made to the Santa Cruz City Police Department is extremely low. The existing training provided to CPRB members does not involve adequate training in the Police Department’s practices and procedures. An established procedure is in place at the Santa Cruz Police Department to investigate citizen complaints and an additional level of review increases the complaint resolution time. The chief of police is not bound by the recommendations of the CPRB but agrees with their findings in most cases. A review board has the potential to provide a new perspective and serve as a checks and balances on the police department’s complaint review process. Page84 Review of the Citizens’ Police Review Board of the City of Santa Cruz 2000-01 Santa Cruz County Grand Jury Final Report