Mendocino County Grand Jury
• 2007-2008
Mental Health and Millionaires a Report on Proposition 63 and Mendocino County Mental Health June 17, 2008
⚠️ Aviso de traducción: Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
Findings and Recommendations 40 findings
F1
In 2005/06 the County Chief Executive Officer began the integration of the 3 See http://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders. Public Health Department, Social Services Department and Mental Health Department into a single unit, the Health and Human Services Agency. Each of the former departments now is a branch of the Agency.
No recommendations for this finding
F2
One reason for combining departments into the agency was that clients of one department often were receiving services from another. A second reason was that it allows sharing of funds and personnel across branches. A third reason is that clients do not have to go to multiple places for services.
No recommendations for this finding
F3
The Mental Health Branch has a staff of about 125 and a budget of about $19 million.
No recommendations for this finding
F4
Most of the Branch budget is for core services—24-hour emergency care, hospitalization, institutional care, and board and care.
No recommendations for this finding
F5
About half the budget goes to contractors for hospitalization and treatment programs. The rest is for staff, crisis workers, case management, therapeutic services to youth and their families, vocational rehabilitation, housing assistance, wrap-around services to families with children experiencing emotional disturbances, school-based day treatment for targeted students, early intervention for children ages zero-to-five, monitoring of medication, integrated homeless services, and administration.
No recommendations for this finding
F6
All hospitalizations handled through the Mental Health Branch are at out-of- county facilities, and the cost is included in the branch budget, but may be supplemented beyond Medi-Cal. The only local holding facility, the Psychiatric Health Facility, closed in 2000.
No recommendations for this finding
F7
The branch serves the Mendocino County Jail and Juvenile Hall.
No recommendations for this finding
F8
The branch serves about 2,700 individual clients.
No recommendations for this finding
F9
One growing problem is that many individuals with mental health problems self-medicate. That complicates things for all those, including doctors, law enforcement, family, and mental health workers, who in dealing with a crisis, need to know whether drugs or alcohol are the main problem or are masking mental health symptoms.
No recommendations for this finding
F10
The Board of Supervisors (BOS) appoints members to the Mental Health Board of citizens to advise the County. The Board comprises three members from each County Supervisorial District: one member represents clients, one clients’ families and one the general public. At present, there are numerous vacant positions.
Related Recommendations (1)
R1
the Board of Supervisors and the Mental Health Board make a concerted effort to recruit members to fill vacant positions on the Mental Health Board; (Finding 10)
F11
Prop. 63, known as the MHSA, was created in 2004, and is a 1% tax on personal income over $1 million to be used for mental health services, but it contains many conditions and limitations; one being that these funds cannot be used to supplant existing State or County funds, and current County and State mental health funding cannot be reduced based on the availability of Prop. 63 money. The State shall neither reduce mental health funding nor require an increase in the County’s share of funding without reimbursement.
No recommendations for this finding
F12
Prop. 63 funds are distributed to counties based mostly on the size of their population.
No recommendations for this finding
F13
Prop. 63 has its own budget. It also has its own MHSA Advisory Committee (appointed by the BOS), which includes representatives from each Supervisorial District, stakeholders such as law enforcement, education, ethnic and cultural groups, and consumer (patients), clients’ families and the public.
Related Recommendations (2)
R2
the MHSA advisory committee make a concerted effort to recruit applicants for vacant positions; (Findings 13 and 14)
R3
the Mental Health Branch provide more visibility on MHSA programs and proposed programs; (Findings 13-17 and 19)
F14
The MHSA Committee has various work groups, and meets quarterly with the Mental Health Board. Meetings were previously each month, but lack of attendance was a problem. Work groups create proposals and negotiate with affected parties who may provide input. All meetings are public and require public notice.
Related Recommendations (1)
R3
the Mental Health Branch provide more visibility on MHSA programs and proposed programs; (Findings 13-17 and 19)
F15
The State set up three year programs, emphasizing innovation, but because innovation does not guarantee success a program might be discontinued. The first year was to be for planning, training, capital improvements which include technology needs, and some administration; however, the program was not instituted quickly enough. The three year program may be extended.
Related Recommendations (1)
R3
the Mental Health Branch provide more visibility on MHSA programs and proposed programs; (Findings 13-17 and 19)
F16
Staff stated there is a lack of communication and guidance on policies and planning from management.
Related Recommendations (1)
R3
the Mental Health Branch provide more visibility on MHSA programs and proposed programs; (Findings 13-17 and 19)
F17
Documents show the Mental Health Branch is unresponsive to requests for meetings with providers, who are concerned about their funding. Staff states that upper management is unresponsive to their requests for input and guidelines on programs.
Related Recommendations (1)
R3
the Mental Health Branch provide more visibility on MHSA programs and proposed programs; (Findings 13-17 and 19)
F18
The branch issues Requests for Proposals (RFP) for new programs. Prospective contractors respond. In Mendocino County, last year, the existing programs did not require a review for continued funding through Fiscal Year 2007/08. There were no RFPs put out last year for new programs, and as of May 15, 2008 no RFPs had been put out for the coming fiscal year.
Related Recommendations (3)
R4
Mental Health Branch issue RFPs for Prop. 63 funds in a timely manner; (Findings 18-20 and 34-36)
R5
Mental Health Branch extend current contracts one more year, through Fiscal Year 2008/09; (Findings 18-20 and 34-36)
R6
the Mental Health Branch, the Mental Health Board and the Mental Health Services Act committee, begin work on the Fiscal Year 2009/10 programs. (Findings 18-20) Comments Some forms of treatment cost more than others in the short term. However, if they are effective in the long term, they will save money over the long haul. Only experimenting with treatment protocols will demonstrate this. But, a change in protocols may threaten some jobs or types of work. The branch’s regular budget largely depends on “billable minutes” to Medi-Cal and others. If clinical staff can bill for 70% of their time, the reimbursement will support the entire branch budget. If Prop. 63 treatment modes work, there is a threat to the branch’s funding. The public wants to help the mentally ill. But it doesn’t want to see them. Any Recovery Model assumes the mentally ill will be among us. That’s part of the treatment. Funds available for treating those with mental disorders have always been insufficient, and the mental health workers are underpaid relative to the technical skills required of them. People enter this field in spite of these obstacles because the deposit they make into their emotional bank is great.
F19
There is a plan to issue a new RFP for the adult community program soon. The branch expects to fund the existing programs temporarily until the process is complete.
Related Recommendations (3)
R4
Mental Health Branch issue RFPs for Prop. 63 funds in a timely manner; (Findings 18-20 and 34-36)
R5
Mental Health Branch extend current contracts one more year, through Fiscal Year 2008/09; (Findings 18-20 and 34-36)
R6
the Mental Health Branch, the Mental Health Board and the Mental Health Services Act committee, begin work on the Fiscal Year 2009/10 programs. (Findings 18-20) Comments Some forms of treatment cost more than others in the short term. However, if they are effective in the long term, they will save money over the long haul. Only experimenting with treatment protocols will demonstrate this. But, a change in protocols may threaten some jobs or types of work. The branch’s regular budget largely depends on “billable minutes” to Medi-Cal and others. If clinical staff can bill for 70% of their time, the reimbursement will support the entire branch budget. If Prop. 63 treatment modes work, there is a threat to the branch’s funding. The public wants to help the mentally ill. But it doesn’t want to see them. Any Recovery Model assumes the mentally ill will be among us. That’s part of the treatment. Funds available for treating those with mental disorders have always been insufficient, and the mental health workers are underpaid relative to the technical skills required of them. People enter this field in spite of these obstacles because the deposit they make into their emotional bank is great.
F20
Proposed plans must be first approved by the State, then by the MHSA committee. Then, the Mental Health Board and the Mental Health Director compile and approve the components in a public hearing. Lastly, the Board of Supervisors holds a public hearing, and votes on the total plan.
Related Recommendations (3)
R4
Mental Health Branch issue RFPs for Prop. 63 funds in a timely manner; (Findings 18-20 and 34-36)
R5
Mental Health Branch extend current contracts one more year, through Fiscal Year 2008/09; (Findings 18-20 and 34-36)
R6
the Mental Health Branch, the Mental Health Board and the Mental Health Services Act committee, begin work on the Fiscal Year 2009/10 programs. (Findings 18-20) Comments Some forms of treatment cost more than others in the short term. However, if they are effective in the long term, they will save money over the long haul. Only experimenting with treatment protocols will demonstrate this. But, a change in protocols may threaten some jobs or types of work. The branch’s regular budget largely depends on “billable minutes” to Medi-Cal and others. If clinical staff can bill for 70% of their time, the reimbursement will support the entire branch budget. If Prop. 63 treatment modes work, there is a threat to the branch’s funding. The public wants to help the mentally ill. But it doesn’t want to see them. Any Recovery Model assumes the mentally ill will be among us. That’s part of the treatment. Funds available for treating those with mental disorders have always been insufficient, and the mental health workers are underpaid relative to the technical skills required of them. People enter this field in spite of these obstacles because the deposit they make into their emotional bank is great.
F21
Prop. 63 money must stay in the county, so it cannot be used for placements to out-of-county facilities.
No recommendations for this finding
F22
One goal of the MHSA is the “recovery vision” for mental health consumers. Prevention and early intervention are other goals.
No recommendations for this finding
F23
There are various models for treatment. For example: • The Medical Model—using drugs to allow patients to manage their condition, • The Recovery Model—providing services to allow patients to gain self sufficiency with a choice of whether to use drugs, or peer support, assuming that some mental illness, like some physical diseases, may be managed without being fully cured, • The Peer-to-Peer Model—letting current or former patients participate in the treatment protocol, based on an assumption such a person knows things a non-patient couldn’t know, and that such a person can gain more rapport with a patient. • Other models include alternative medicine, food based or mega-vitamin based.
No recommendations for this finding
F24
MHSA requires that funded plans be consumer driven and include the Recovery Model, which it refers to as the “Recovery Vision.”
No recommendations for this finding
F25
In the Medical Model the doctor is in charge of the treatment, the patient has little input, but may refuse or discontinue use of a medication.
No recommendations for this finding
F26
The Recovery Model emphasizes patient control and participation in decisions.
No recommendations for this finding
F27
The Peer-to-Peer Model is a subset of the Recovery model; and the peer counselor is or has been a client.
No recommendations for this finding
F28
The MHSA requires major public and stakeholder participation in designing and setting up programs and awarding contracts.
No recommendations for this finding
F29
There are two classes at Mendocino-Lake Community College which would train and qualify peers to be therapeutic counselors.
No recommendations for this finding
F30
There are passionate advocates of the different models. Some advocates support a combination of models.
No recommendations for this finding
F31
There are also various definitions of the terms. Recovery for some advocates would mean less hospitalization and less need for services. For others, it means full recovery and reintegration into society. Some believe that recovery is impossible. Some say if severely schizophrenic patients recover, they weren’t really schizophrenic at all.
No recommendations for this finding
F32
For last year the County will receive approximately $400,000 from the Prop. 63 emergency reserve to replace vetoed money for the homeless, since many of the clients are the same.
No recommendations for this finding
F33
Prop. 63 funding is by age group. Because it still is being rolled out, not all groups have funded programs yet. Some funding is for children. Other money goes to the transition age group, 16-24 years old, especially youth who move out of foster care at 18. There are adult, elder care and other categories.
No recommendations for this finding
F34
The largest contract is for an adult program, named “A Healing Cooperative.”4 There has been contention between the Health and Human Services Agency and the contractor’s executives about the program. Part of the problem is a poorly worded contract, although the plan was approved by the State. Another problem is the difficulty in measuring results. This Cooperative operates facilities in Ukiah, Willits and Fort Bragg, and provides walk-in centers, group treatment and training. It is strongly peer oriented.
Related Recommendations (2)
R4
Mental Health Branch issue RFPs for Prop. 63 funds in a timely manner; (Findings 18-20 and 34-36)
R5
Mental Health Branch extend current contracts one more year, through Fiscal Year 2008/09; (Findings 18-20 and 34-36)
F35
Although not required, the Cooperative has created a report to measure progress for individuals, called a “Rubric for Mental Health Recovery.”5 Staff members rate clients upon entry to the program and track changes.
Related Recommendations (2)
R4
Mental Health Branch issue RFPs for Prop. 63 funds in a timely manner; (Findings 18-20 and 34-36)
R5
Mental Health Branch extend current contracts one more year, through Fiscal Year 2008/09; (Findings 18-20 and 34-36)
F36
A Healing Cooperative will probably lose some funding, partly because the State requires that 51% of funds go to a “Full Service Partner,” that is, a client who is assessed with an Axis I disorder. It is unclear how many users of A Healing Cooperative’s services qualify as “Full Service Partners.” Also, the County must put 50% of the MHSA communities services budget into prudent 4 http://www.ahealingcooperative.org/templates/System/default.asp?id=41568 5 http://www.ahealingcooperative.org/clientimages/41568/rubricforrecovery.pdf reserve.
Related Recommendations (2)
R4
Mental Health Branch issue RFPs for Prop. 63 funds in a timely manner; (Findings 18-20 and 34-36)
R5
Mental Health Branch extend current contracts one more year, through Fiscal Year 2008/09; (Findings 18-20 and 34-36)
F37
Most programs funded under Prop. 63 are grant contracts, with a fixed term, perhaps three years. It’s not certain what will happen when grants end. One reason for grants is that many programs are experiments, and the state wants to be able to stop those that don’t work.
No recommendations for this finding
F38
Programs are evidence based. That is, there must be some way to measure what is working, and whether it is worth the cost in money or personnel. The County and community have authority and obligation to maintain what is working or redesign to address unmet needs.
No recommendations for this finding
F39
Prop. 63 requires that the County maintain the 2004 level of mental health care funding for the regular services (plus a factor for inflation). However, there is no accommodation for the increase in population or for increase in the number of clients generated by outreach.
No recommendations for this finding
F40
To date, the County has received all the money it is entitled to under Proposition 63. Any unspent money rolls over to the next year.
No recommendations for this finding
Comments 1
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CO1Some forms of treatment cost more than others in the short term. However, if they are effective in the long term, they will save money over the long haul. Only experimenting with treatment protocols will demonstrate this. But, a change in protocols may threaten some jobs or types of work. The branch’s regular budget largely depends on “billable minutes” to Medi-Cal and others. If clinical staff can bill for 70% of their time, the reimbursement will support the entire branch budget. If Prop. 63 treatment modes work, there is a threat to the branch’s funding. The public wants to help the mentally ill. But it doesn’t want to see them. Any Recovery Model assumes the mentally ill will be among us. That’s part of the treatment. Funds available for treating those with mental disorders have always been insufficient, and the mental health workers are underpaid relative to the technical skills required of them. People enter this field in spite of these obstacles because the deposit they make into their emotional bank is great.