The Mental Health Services Act in San Diego County Unspent Funds, Ongoing Needs

HHSA has substantial funds available to expand services. USE OF FUNDS: APPROPRIATE PROGRAMS On one hand, MHSA has a very clear focus: “To define serious mental illness among children, adults and seniors as a condition deserving priority attention, including prevention and early intervention services and medical and supportive care” (Section 3(a)). On the other hand, MHSA includes vague and ambiguous language that allows very broad interpretations of how to spend MHSA funds. The result is that San Diego County uses MHSA for a wide variety of programs only tangentially related to those with, or at risk of, serious mental illness. For example, over $500,000 in MHSA funds goes to the domestic violence program “Families as Partners,”5 for “families at highest risk of child abuse and neglect”. This is clearly an essential public health concern, fully deserving of public support. It has no explicit connection with serious mental illness, but is nevertheless included in the Prevention and Early Intervention category. 5http://www.sandiegocounty.gov/HHSAa/programs/bhs/documents/Children_PEI_Program_Reports_FY20 12-13.pdf 3 Another example relevant in San Diego County is expenditure for “reduction in stigma associated with either being diagnosed with a mental illness or seeking mental health services” (WIC 5840(b)(3)). The 2015-2016 MHSA Program Summary lists twenty-five in-patient and out-patient drug and alcohol treatment programs receiving MHSA funds to “Reduce stigma associated with mental health concerns” at a cost of over $3,000,000. Though this is completely legitimate according to the letter of MHSA, it dilutes the county’s response to those people MHSA was designed to help most, those suffering serious mental illness.6 A 2013 report7 (described as a “hatchet job” by one interviewee not employed by the county) is highly critical of three programs in San Diego County for being inconsistent with MHSA: gang violence reduction8, Triple P Parenting9, and outreach to Alzheimer’s patients. The Grand Jury also questions the Mobile Hoarding Program in the Innovation category, whose goal is to “diminish long term hoarding behavior in older adults”. While seriously mentally ill people may be hoarders, hoarders are not by definition seriously mentally ill. It must be noted that the large majority of MHSA-funded programs in the county serve the seriously mentally ill and at-risk population. The Grand Jury encourages HHSA to sharpen its focus on the original intent of MHSA in order to meet the most pressing needs of seriously mentally ill children, youth, and adults. FACTS AND FINDINGS Fact: MHSA states that the purpose of the Act is to decrease the severity of serious mental illness in children, youth, adults and those at risk. Fact: MHSA does not include drug and alcohol abuse treatment. According to minutes of one state oversight board meeting, MHSA was written specifically to exclude substance abuse as a category: “Vice-Chair Van Horn commented that there are not a lot of evidence-based practices yet in the PEI arena. He also pointed out that the reason co-occurring disorders were not mentioned in the MHSA was because during the Proposition 63 focus groups they were informed that using that language would lead to the defeat of the proposition. It is clear that co-occurring disorders need to be dealt with at the same level.” Mental Health Services Oversight and Accountability Commission Meeting Minutes September 22, 2011 7California’s Mental Health Services Act: A Ten Year $10 Billion Bait and Switch. Mental Illness Policy Org., August 15, 2013. 8 “Community violence response team and services to siblings of identified gang members in an effort to increase community resiliency and combat the negative effects of violence”. 9 http://www.triplep.net/glo-en/find-out-about-triple-p/triple-p-in-a-nutshell/ The Triple P – Positive Parenting Program ® is a parenting and family support system designed to prevent – as well as treat – behavioral and emotional problems in children and teenagers. It aims to prevent problems in the family, school and community before they arise and to create family environments that encourage children to realize their potential. Fact: Significant funds (between $3 million and $4 million) are spent on “Co-occurring Disorders” with “reduce the stigma” language. Fact: Several MHSA-funded programs do not serve the seriously mentally ill.

While legally allowable within the ambiguous language of MHSA, some MHSA-funded programs are not consistent with the stated purpose of MHSA to serve the seriously mentally ill. USE OF FUNDS: PROCESS Five percent of MHSA funds are to be applied to Innovation in services for the seriously mentally ill. In San Diego County, a new funding cycle begins every three years. HHSA, in consultation with the public and stakeholders, identifies major concerns, then potential responses to those concerns, develops requests for proposals from providers, and awards grants. This process takes twelve to eighteen months. The programs operate for three years and are evaluated annually, with a final evaluation to determine the program’s effectiveness (which can take up to a year). The entire Innovation cycle, then, lasts over five years. In several interviews, service providers spoke of how cumbersome the Innovation process is, while lauding HHSA for its collaborative efforts. A sign of the challenges facing implementing innovative programs is that, in the past five years, the county has appropriated an average of 44% of MHSA Innovation funds, leaving 56% unspent. Mentally ill people could benefit from compressing the innovation cycle and funding more programs, even at the risk of funding programs later found to be ineffective. FACTS AND FINDINGS Fact: Multiple interviews referenced HHSA and BHS slowness to act. Fact: For fiscal years 2012-2013 through 2016-2017, MHSA Innovation expenditures average 44%, leaving 56% unspent. Fact: Multiple interviews confirmed collaboration among stakeholders, including HHSA and BHS, service providers, and advocates.

Building on HHSA’s collaborative efforts, streamlining the innovation cycle would benefit the county’s seriously mentally ill and at-risk population. EDUCATION At multiple interviews, the Grand Jury heard that San Diego County has definite difficulties recruiting and retaining public-funded mental health professionals. MHSA designates funds for Workforce Education and Training (WET), which, in San Diego County, provide stipends, subsidies, loan repayments, and educational programs totaling $2.6 million dollars in 2015-2016 for students in fields ranging from early childhood 5 education to psychiatric residency, social work, and marriage and family therapy. HHSA and participating schools have made particular efforts to increase the diversity of the mental health workforce with “culturally competent” employees (WIC 5822(j)); given the county’s diverse population, this remains a challenge. Approximately two-thirds of WET funds go to mental health staff development and to students already enrolled in professional programs. Exposing more community college and even high school students to mental health careers through work-study and internships could increase the number and diversity of mental health professionals in the future. FACTS AND FINDINGS Fact: MHSA sets a standard of “culturally competent” mental health care. Fact: County WET funds are weighted to professional development and to students in professional programs, including psychiatric residency, social work, and marriage and family therapy.

Providing incentives and opportunities earlier in students’ education could increase and diversify the pool of potential mental health professionals in the county.