Grand Jury Response to 2022-2023 Report "Diagnosing the Crisis in Behavioral Health"

The chronic understaffing in the Behavioral Health Division (BHD) and their contractors is negatively impacting the department’s ability to meet goals and to provide services in a timely and effective manner. __ AGREE _x_ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): The vacancy rate for administrative and clinical positions in the Behavioral Health Division (BHD) has an adverse impact on our ability to meet goals and provide services in a timely manner. However, BHD made a number of hires in the past 18 months to fill vacancies. With 288 funded positions in FY 2022-23, BHD hired 45 new employees and made 62 promotions between January 2022 and June 2023. This data reflects positive efforts amidst numerous challenges that were either not included or not examined as part of the Grand Jury’s report. A longstanding shortage of mental health workers in the country, compliance with Civil Service Rules, standard employee churn, nature of the work, and specific recruitment challenges given Santa Cruz County’s challenging cost of living and lack of available housing all impact the County’s recruitment efforts. Furthermore, the global COVID-19 pandemic profoundly impacted labor markets in ways economists are still striving to understand, leading to unprecedented circumstances such as record quit rates across all job sectors. As outlined below, the County had taken and continues to take numerous and specific efforts to increase the number of new hires while reducing recruitment times. Regrettably, these efforts were either not examined or not included in the Grand Jury’s report.

The County Personnel Department has been slow to respond to the chronic understaffing in the Behavioral Health Division. It has not put measures into place to speed up the hiring process or to create competitive salaries and incentives for the non-medical personnel who staff the BHD positions. Nor have they created connections with nearby universities to groom a clinical workforce. This causes unnecessary delays in hiring mental health professionals. __ AGREE __ PARTIALLY DISAGREE _x_ DISAGREE Response explanation (required for a response other than Agree): In fall 2021, the County Personnel Department and Health Services Agency (HSA) created the HSA Recruitment and Retention Committee. The purpose of the committee was to achieve measurable improvements in recruitment and retention of difficult-to recruit-classifications. As a result, the County created three dedicated positions to support the various functions of HSA’s recruitment and hiring process, resulting in strengthened partnerships with the Health Improvement Partnership and local colleges and universities (Cabrillo College, UCSC, CSUMB) and internal process changes intended to expand recruitment efforts, accelerate time-to-hire durations and reduce vacancies. These tools included: management training; procedural improvements around application review, examinations, interviews and reference checks; conducting continuous recruitments and modifying Civil Service Codes to eliminate undue delays, which were approved by the Board of Supervisors on June 27, 2023. There is a national shortage of health care workers including behavioral health workers. This problem preceded but was exacerbated by the COVID-19 pandemic. A 2018 paper by the Healthforce Center at the University of California, San Francisco found that the gap between supply and demand for behavioral health workers was wide was predicted to grow larger.1 1 https://healthforce.ucsf.edu/sites/healthforce.ucsf.edu/files/publication- pdf/California%E2%80%99s%20Current%20and%20Future%20Behavioral%20Health%20Workforce.pdf The pandemic only exacerbated these issues. The 2022 “State of the Workforce Report”2 by the Santa Cruz County Workforce Development Board found health care in general to be a rapidly growing field, accounting for 28 percent of all County job growth between 2010-2019. But the growing demand for workers was significantly undermined during the pandemic when, the report found, 30 percent of all health care workers either quit or were laid off during the pandemic. While focusing on private sector providers, the report documented high turnover and early retirements, and forecasted industrywide difficulties in replacing these workers. There is no reason to believe BHD is immune from these national, State and local forces, and the Workforce Development Board’s findings are in line with the Grand Jury’s findings. The County operates under a Limited Civil Service System. While this system does not give us the same flexibility enjoyed by the private sector when it comes to hiring practices, it does serve important public policy goals – ensuring fair, equitable and uniform procedures to hire the best-qualified individuals. These requirements include public advertisement of job openings, identification of minimum qualifications, competitive examinations and candidate rankings, all of which expand time-to-hire and may create higher baseline vacancy rates. Furthermore, during 2021 Service Employees International Union (SEIU) negotiations, a committee consisting of representatives from the County Personnel Department, BHD and SEIU was created to expand the Mental Health Client Specialist series, improve compensation for specific skillsets, and create a career ladder to improve the County’s ability to recruit and retain candidates. Additionally, all BHD classifications received a 6% pay increase in 2022 along with improved benefits. Taken together, the Board of Supervisors believes these efforts demonstrate the County’s recognition of the importance of these issues to the community. Prior to the commencement of the Grand Jury’s investigation, our response was significant and focused on addressing issues later identified in the Grand Jury’s report. 22 https://workforcescc.com/wp-content/uploads/2022/05/Santa-Cruz-County-SoW-Final-2022.pdf

Both the Personnel Department and the Behavioral Health Division do not have enough analysts to allow an adequate review of their programs and systems, including analyzing the County’s hiring process. This makes it difficult for them to improve services. __ AGREE __ PARTIALLY DISAGREE _x_ DISAGREE Response explanation (required for a response other than Agree): As noted above, the County added staff to assist with HSA recruitment. This team made a number of improvements to recruitment and hiring processes. While we do not accept that the County has not sufficiently budgeted enough staff to provide “adequate” reviews of departmental program and systems, we recognize that the recruitment challenges outlined above can impact a department’s abilities to conduct these analyses. However, County services including services offered by BHD are constantly being reviewed and assessed, and changes through continuous process improvement are common. In recent years, for example, BHD has expanded available substance use disorder beds in the County, secured funding for a Children’s Crisis Stabilization Center, established mental health liaisons to work with local law enforcement, established Mobile Emergency Response Teams for adults and youth, is overseeing expanded jail mental health services, implemented Whole Person Care and is implementing further changes through California Advancing and Innovating Medi-Cal (CalAIM). These examples represent a segment of improvements made during the last few years.

The Crisis Stabilization Program (CSP) has been diverting patients experiencing a mental health crisis to hospital emergency departments too frequently, delaying diagnosis, delaying treatment, and placing an extra burden on the emergency departments, which are already overcrowded. The emergency departments then become responsible for finding an inpatient facility for patients who cannot be safely discharged to outpatient care, which further stretches limited resources. _x_ AGREE __ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): While staffed by a third-party vendor, the CSP has also experienced staffing challenges that adversely impacted staffing ratios. Furthermore, capacity in that program is limited, sometimes leaving local hospitals as the only treatment option for those experiencing a mental health crisis. Since October 2022, steps have been taken to mitigate this issue. By June 30, 2023, diversion of adults deceased from 19% to 6%, and diversion of children decreased from 70% to 21%. As referenced above, BHD is developing a Children’s Crisis Stabilization Center including an eight-bed all youth Crisis Stabilization Unit and 16- bed all youth crisis residential program. On August 22, 2023, the Board of Supervisors approved new two-year agreements with Telecare to operate the CSP and Psychiatric Health Facility. The total value of these contracts is $34.8 million.

The limited hours that the Mobile Emergency Response Team and Mobile Emergency Response Team for Youth operate interfere with a timely assessment of patients in a mental health crisis, negatively impacting patient care. __ AGREE _x_ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): The Mobile Emergency Response Team (MERT) and the Mobile Emergency Response Team for Youth (MERTY) are part of the overall crisis continuum and were not designed to be the sole source for crisis response and transportation in Santa Cruz County. BHD provides a range of services and programs to the community and has numerous avenues for response, including Mental Health Liaisons, Walk-In Crisis services at both of our Emeline and Freedom campuses, and assessment access available 24 hours/day, seven-days-a-week at the CSP. BHD also operates a 24-hour Behavioral Health Services hotline. To meet increased community needs, the County is currently developing a mobile crisis response based on the Crisis Now model to bring 24/7/365 mobile crisis response to the community. The Crisis Now model utilizes peers and mental health professionals, rather than law enforcement, as the first responders to most mental health crises. The County anticipates operating 24/7/365 mobile crisis response by July 1, 2025.

An inadequate number of beds at the Psychiatric Healthcare Facility (PHF) results in the practice of sending patients out of county, which negatively impacts the patient’s care, and is expensive for the Behavioral Health Division. __ AGREE _x_ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): While the PHF services and inpatient care out of county are expensive levels of care, it’s possible that increasing services at lower levels of care, including residential and partial hospitalization, may reduce the need for additional PHF beds. As noted above, BHD is planning Crisis Now, a crisis continuum project funded by Mental Health Services Act (MHSA) Innovations. One of the goals is to understand how sufficient services at all levels of care might improve patient care and outcomes as well as reduce costs to the system.

The County plans to close the current Crisis Stabilization Program (CSP) to patients under 18 after June 30, 2023, and the new CSP/PHF in Live Oak will not be open until late 2024 or early 2025 compromising crisis care to minors for 18 months or more. _x_ AGREE __ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): The County’s contractor requested, and the County agreed, to no longer admit patients under 18 to the CSP as of July 1, 2023. This was the result of months of negotiations. Considering the design of the physical building and the staffing ratios, admitting one youth into the CSP would remove the capacity of four chairs for adults, which diverted more adults to the emergency departments. Now that the CSP is no longer accepting patients under age 18, the admission of one adult to the CSP removes the capacity of only one chair and other chairs are available for adults up to a total of 12 chairs. Demand for CSP services is higher for the adult population than the youth population. This option, while not ideal, has the least negative impact to the crisis continuum. The County is working closely with a community provider and a local health system on an interim solution for youth CSP. The County has procured a building and is developing a youth only CSP with eight chairs and Crisis Residential with 16 beds to open by July 2025.

The large number of high cost beneficiaries results in additional demands on an already overloaded behavioral health system. __ AGREE _x_ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): As noted in the report, external auditors found that our County’s Med-Cal beneficiaries received more crisis stabilization and intervention services than the statewide average and postulated that it was due in part to more “robust” services than other counties. There is currently insufficient information to understand whether expanding our continuum of care at lower levels to divert beneficiaries from crisis and support them on a recovery path might reduce the need for higher cost services.

The new Sí Se Puede Behavioral Health Center in Watsonville is a big step in the right direction, and will provide significantly increased service capacity, but it is still not enough. _x_ AGREE __ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): The new Si Se Puede expansion will increase capacity. However, it will not completely close the gap.

The lack of step-down care for patients completing both inpatient and outpatient treatment often results in patients relapsing and needing retreatment, which is bad for the patient and increases costs for the Behavioral Health Division. _x_ AGREE __ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): The continuum of care has gaps that adversely impact sufficient step-down capacity and also treatment capacity to intervene and support care to prevent crisis.

The high rate of homelessness and Substance Use Disorder in the County results in the Behavioral Health Division’s clients that are especially demanding and difficult to treat. __ AGREE _x_ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): While the County lacks a strong and affordable recovery path for those who enter treatment, insufficient housing is the main barrier.

The Behavioral Health Division is insufficiently funded and staffed to provide adequate step down care for their patients, many of whom are homeless, and/or recently released from jail, and thus have a need for support. _x_ AGREE __ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): BHD’s budget for FY 2023-24 exceeds $134 million, a 65 percent increase compared to five years ago and more than any division in any department in the County. This commitment reflects the Board’s emphasis on mental health in our community. We recognize that even at these funding levels, gaps in the continuum of care remain. Community mental health remains a priority of this Board, and we will continue to look for opportunities to expand services given the funding challenges faced by the County. As every Grand Jury learns, the County faces structural challenges that make it difficult to compete and compare with other Bay Area counties. These include the County receiving only 13 cents from every property tax dollar, giving Board members difficult choices on how to divide scarce resources, particularly when the County must provide hometown services for half the County population living in unincorporated areas. Despite these challenges, the Board recognizes the importance of and need for adequate step-down care for patients.

Outreach to the Latino/a community is insufficient because of the lack of bilingual and bicultural staff contributing to disproportionate underutilization of mental health services within the Latino/a community. __ AGREE _x_ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): BHD provides bilingual mental health services with bicultural staff in both Santa Cruz and Watsonville clinics for adults and children. BHD also contracts with numerous bilingual community-based providers to provide outreach and treatment services. BHD has done and will continue to do targeted recruitment toward potential candidates who are bilingual and bicultural to expand staffing and outreach to the Latino/a community.

The current pay differential for bilingual staff is insufficient to attract and retain suitably qualified staff making adequate outreach to the Latino/a community difficult. __ AGREE _x_ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): There is insufficient data to make a correlation between differential pay and staff recruitment and retention. However, the County offers services in a broad range of languages, including Mixteco, though Spanish is our threshold language. BHD has done and will continue to do targeted recruitment toward potential candidates who are bilingual and bicultural to expand staffing and outreach to the Latino/a community.