Health and Human Services Committee Maureen Godfrey, Chair Al Alcantara Harry Carson, Sr. Sandra Diaz Virginia Eriksen*

R01-58

THE DEPARTMENT OF AGING AND ADULT SERVICES WORK WITH A GRANT WRITER TO RESEARCH ALL AVAILABLE FUNDS TO SUPPORT THE NEEDS OF THE "NETWORK".

R01-59

THE DEPARTMENT OF AGING AND ADULT SERVICES DEVELOP AN INTERAGENCY PROTOCOL AND CONSENT FORM FOR SENIOR CITIZENS AND DEPENDENT ADULTS TO EXCHANGE CONFIDENTIAL INFORMATION. 2000-2001 San Bernardino County Grand Jury Final Report DEPARTMENT OF BEHAVIORAL HEALTH BACKGROUND Under State law, the Department of Behavioral Health (DBH) provides mental health treatment and prevention services to all residents with mental illness or substance abuse disorders. The department contracts with Arrowhead Regional Medical Center (ARMC) and seven private hospitals for the provision of 24-hour inpatient acute and residential care. DBH has an Outpatient Alcohol and Drug Program (OADP), day treatment clinics, outpatient services, and case management. Behavioral Health has offices in all regions of the County including the High Desert, West End, mountains, east and central valleys. Prior to 1999 Behavioral Health's Hospital Inpatient Unit was administered and funded by DBH. Currently, the Director of ARMC is administering Arrowhead Regional Medical Center Behavioral Health (ARMCBH), but the funding for all inpatient care is controlled by DBH. The Department of Behavioral Health's philosophy is to have one comprehensive community-based interagency system of mental health care that addresses the unique needs and strengths of patients and their families who have diverse cultural backgrounds. The basic premise of system of care is to redirect money into local levels of care in order to maintain clients in the community as much as possible. FINDINGS The system for the transfer of psychiatric inpatients to DBH clinics is not well developed. At the time of the patient's discharge from ARMCBH, hospital staff schedules an outpatient discharge appointment for the patient with a Behavioral Health outpatient clinic in the area in which the patient resides. Patients (also described by DBH as consumers) are supplied with medications for two weeks post-discharge. After their follow-up outpatient appointment, medications are reassessed and reordered, providing the appointment is kept. Statistics show there is an approximate 58% no-show rate for these follow- up appointments. 2000-2001 San Bernardino County Grand Jury Final Report Barriers to mental health care include: 1. Lack of collaboration between inpatient and outpatient treatment regarding case management services. 2. Lack of adequate transportation for outpatients to and from appointments. 3. Lack of childcare facilities in the outpatient clinics. Case Management According to DBH, case management is a difficult concept to define as it is usually used to describe a multitude of activities and services. DBH is responsible for the case management of outpatients, which is an organized approach to evaluating the health care needs of a patient. Case management identifies appropriate services to meet those needs, chooses the most cost- effective setting and providers, coordinates the delivery system by maintaining communications among providers (ARMCBH), patients and payers, and monitors the patient's progress. Case management is not a substitute for treatment services but a way of assuring that services are delivered to those who need them the most in an efficient and appropriate manner, and that other aspects of the patient's life (housing, shelter, work, relationships) are also emphasized so that patients might have a richer, more satisfying life. A case manager would assist the patient to navigate and understand the service systems available and to obtain the following: Cash benefits (Food Stamps, General Relief, Medically Indigent ٠ Aid, SSI, SSA, SDI, SSDI, and Medi-Cal) Housing: placement in licensed facility/independent housing ٠ Transportation ٠ Medications • Employment • Physical health services Dental services Payee services Advocacy/facilitation assistance Crisis intervention Problem resolution to overcome barriers to services/treatment 2000-2001 San Bernardino County Grand Jury Final Report Since 1993 DBH has followed the Rehabilitation Model as prescribed by the California Department of Mental Health. This model is one in which the patient's goals and needs are a priority over the goals of the mental health system. Because case managers provide support and information to patients and their families, they need unlimited access to inpatients and should be contacted immediately by the hospital when a patient is admitted to the hospital. Case managers need to meet the patient within 1-2 work days after admission to the hospital to determine which goals the patient needs to achieve in order for him or her to maximize their functioning in the community. Case managers work with the patient to help him/her with finances, appointment schedules, after-care issues and/or family linkage. Case management is a coordinated strategy for patients with chronic mental illness to obtain the services they need, whenever and for as long as they need them. DBH believes that a case management system does reduce "no-shows" in outpatient clinics. Both ARMCBH and DBH have suggested that a collaborative effort between the two departments is needed to improve the case management system of care for the benefit of the patients. Lack of Transportation for Patients to Appointments Depending on where the patient lives and where the outpatient clinic is located, even if a bus pass is issued, patients might be required to transfer from one bus to another or walk a long distance to get to the clinic. Some patients are not capable of completing this sort of task. For example, in Victorville the clinic is located approximately one mile from public transportation, which discourages patients from keeping their appointments. If a department vehicle were available the patient would be more likely to keep his/her appointment. There are 24 outpatient clinics located throughout San Bernardino County that serve the 30,000 patients seen yearly by DBH. Presently the department has 46 vehicles available countywide (See Exhibit A). DBH could expand its outreach program if it could increase the number of vehicles. 2000-2001 San Bernardino County Grand Jury Final Report Lack of Childcare Facilities DBH does not provide childcare at their clinics. Lack of childcare discourages patients from keeping their outpatient appointments. The waiting rooms at the clinics are not designed to accommodate children. Staff is not available to monitor these children while their parents are in treatment. According to the Board of Supervisor's agenda of March 20, 2001, the Transitional Assistance Department (TAD) established on-site childcare drop-in centers in various TAD offices. The pilot project has been deemed successful and will be implemented countywide. The State Department of Mental Health does not provide funding for childcare services. DBH has trust fund money available for childcare services at present, but new funds would be needed to fund an on-going program. The DBH Perinatal Program does provide child care services. This very successful program is funded by a grant from the Federal government. RECOMMENDATIONS

R01-60

PROVIDE A TRUE CASE MANAGEMENT SYSTEM IN BEHAVIORAL HEALTH AS PART OF THE DISCHARGE PLANNING, WITH LINKAGE TO THE HOSPITAL AND ONGOING OUTPATIENT TREATMENT.

R01-61

INCREASE THE AVAILABILITY OF TRANSPORTATION то BEHAVIORAL HEALTH OUTPATIENT CLINICS. / 01-62 PROVIDE LICENSED CHILD CARE FACILITIES AT ALL BEHAVIORAL HEALTH OUTPATIENT CLINICS. /01-63 WORK WITH THE TRANSITIONAL ASSISTANCE DEPARTMENT IN FUNDING CHILDCARE SERVICES FOR BEHAVIORAL HEALTH OUTPATIENT CLINICS. EXHIBIT A Department of Behavioral Health VEHICLES AND DRIVERS TRACKING LOG Clinic Number Number Number Name of Vans of Cars of Drivers Agewise 1 Barstow Clinic 1 CalWorks High Desert 1 . CalWorks San Brdno. 2 2 CalWorks Ontario/R.C. CCC - D Street 2 2 CCC - Foothill 1 CCICMS 2 CONREP 2 CSOC 1 1 Homeless 2 IMD 1 Jail Services 2 Phoenix - Home Run Pgrm 1 1 Pisces 1 Property Management 3 R.C. Home run Program 1 2 Referral & Placement 1 2 STAR Program 1 Upland CC - Affirm 1 Victor Valley 2 2 Central Valley 1 2 Perinatal Fontana 2 2 Chino 1 Victorville 2000-2001 San Bernardino County Grand Jury Final Report DEPARTMENT OF CHILDREN'S' SERVICES CHILDREN'S ASSESSMENT CENTER BACKGROUND According to the Children's Fund in San Bernardino County, child abuse is now the leading cause of death of children under the age of four in the United States. When abused children were referred to Child Protective Services they were interviewed individually by multiple agencies involved in the processing or investigation of cases, resulting in unnecessary trauma during the process. FINDINGS In 1992 the Children's Network Policy Council established a task force comprised of designated representatives from Child Protective Services, County Medical Center, Public Health Department, Department of Behavioral Health, District Attorney, Sheriff, Juvenile Court, Family Law Court, County Counsel, Loma Linda University Medical Center, Children's Fund and the Children's Network. Their mission was to explore a method to reduce trauma to the children who were victims of sexual abuse. The task force developed an innovative solution: a public/private partnership between the County of San Bernardino and Loma Linda University Children's Hospital. In 1994 a Child Assessment Center opened, sponsored by Loma Linda University Medical Center and San Bernardino County. One hundred forty- eight (148) children were processed that year and the number has increased by increments of 150 per year, to the present 900 children seen in 2000. Sexually abused children were the primary focus. Since 1998 physically abused children have also been seen. A cooperative effort by the County, the Children's Fund and private benefactors resulted in the present Children's Fund Assessment Center facility on Tippecanoe Street in San Bernardino, which opened in October 1999. Vulnerable children who have become trapped and neglected and who desperately need attention and compassion are seen at this facility. 2000-2001 San Bernardino County Grand Jury Final Report A special effort was made to design the interior of the building to provide Interview rooms are decorated with animal a child-friendly atmosphere. murals hand painted by volunteers. Stuffed animals for the children to cuddle are strategically placed throughout the facility. The Wall of Honor, in the Center's entry, is made of 4" x 4" ceramic tiles which individuals can purchase for a $100 donation. It is not only colorful, but a unique fund-raiser. The design of each tile has an individual donor's name transferred onto the tile for perpetuity. Agency personnel involved in each case can be present in the 2-way mirror observation rooms when specially trained staff forensically interviews the child. A forensic physical exam is performed by a pediatric physician specialist and can be viewed later by videotape. This physician writes a report of the findings and includes photos, and testifies in court as necessary. This facility offers a one-stop multi-disciplinary approach to an investigation. The traumatized children benefit by only being exposed to one complete and quality investigative process. Referrals come from the 13 law enforcement agencies in the County. They currently pay $500 annually for a membership to the Children's Assessment Center and a fee of $50 per exam of a child. Referrals also come from the Department of Children's Services and Family Court. There are monthly multi-disciplinary team meetings to provide an opportunity for these children's cases to be reviewed by team members, ensuring the best system of care for the clients.