Help! My Emotionally Disturbed Child is Incarcerated, What Happens Now?

To demonstrate strengths and weaknesses in the provision of services that address the mental health needs of youth while they are detained and when they re-enter the community.

To critically examine County practices in building a new Children’s System of Care (CSOC) for emotionally disturbed children. PROCEDURES EMPLOYED Site Visits: • Kearny Mesa Juvenile Detention Facility • East Mesa Juvenile Detention Facility. Interviews: • General Manager, San Diego County Public Safety Group • Director, San Diego County Health & Human Services Agency • Probation Chief, San Diego County • Deputy Chief Probation Officer, Institutional Services, San Diego County • Director, San Diego County Mental Health Services • Supervising Psychiatrist, San Diego County Children’s Mental Health Services • Chief, San Diego County Children’s Mental Health Services • Director, San Diego County Systems of Care 178 , 2004) Report 2003/4-13 Documents: • California Forensic Medical Group Contract with County Health & Human Services Agency • Memorandum of Understanding between HHSA and Probation (02/01/03) • California Code of Regulations, Title 15 (Crime Prevention and Corrections), Division 1, Chapter 1 (Board of Corrections), Subchapter 5 (Minimum Standards for Juvenile Facilities), Article 8 (Health Services, commencing with Section 1400) • California Welfare and Institutions Code Section 5850-5851.5 • Performance Contract No. 03-73157-000, July 01, 2003 through June 30, 2004 By the State of California Department of Mental Health with San Diego County HHSA, for countywide integrated mental health services • Young Hearts & Minds – Making a Commitment to Children’s Mental Health, October 2001, Little Hoover Commission • The Administration of Mental Health Systems in San Diego County by Supervising Psychiatrist, Juvenile Forensic Services, Children’s Mental Health Services, March 30, 2004 • Agenda Item Memo to San Diego County Board of Supervisors, June 10, 2003: Provision Of Physical Health Services at Probation Facilities • California Government Code Section 1090-1098 • San Diego County Juvenile Justice Commission Inspection Reports, Juvenile Hall in Kearny Mesa (2003 and 2002) • San Diego County Children’s Mental Health Service (CMHS), February 2004 Update • San Diego County Network of Care, Mental Health Services website, retrieved 4/1/04 from the World Wide Web http://sandiego.networkofcare.org/mh/resource/wraparound.cfm • National Mental Health Association Fact sheet: Prevalence of Mental Disorders Among Children in the Juvenile Justice System retrieved 3/18/04 from the World Wide Web http://www.nmha.org/children/justjuv/prevalence.cfm. 179 , 2004) Report 2003/4-13 COORDINATION OF ROLES AMONG HHSA, JUVENILE PROBATION AND CFMG DISCUSSION There are 3 entities responsible for providing services for minors who are detained in juvenile institutions: California Forensic Medical Group (CFMG), County Mental Health Services (HHSA), and Juvenile Probation. Monthly operations meetings are held involving staff participation from all of these entities enabling staff to develop the best strategies for resolving problems and achieving quality health care for children who are detained in the juvenile institutions. CFMG CFMG began providing contracted health care services, including nursing, at County Probation facilities on January 21, 1999 as a result of a competitive bidding process. Since then, CFMG has been recognized by the California Medical Association as a quality, cost-efficient healthcare provider. County HHSA – Mental Health Services The County Mental Health Services Department employs licensed mental health clinicians including, psychiatrists, psychologists, and social workers to serve detained minors. The mental health clinicians make up the Juvenile Forensic Services Crisis Team. This team provides mental health training and expert consultation to the Probation Department and Juvenile Court. Their role is to assist with the treatment and disposition of minors exhibiting serious mental illness once they are taken into custody and throughout their detention and institutionalization. Juvenile Forensic Services clinicians ensure the provision of mental health services in accordance with Title 15 regulations as follows: • Screening for mental health problems at intake • Crisis intervention • Stabilization of persons with mental disorders and prevention of psychiatric deterioration • Compliance with time frame requirements for mental health consultation when restraints are used • Medication support services • Provision for timely referral and admission to licensed mental health facilities in the community if psychiatric needs exceed those available at the juvenile detention facility 180 , 2004) Report 2003/4-13 • Mental status assessment provided by a licensed mental health clinician for minors who are displaying significant symptoms of mental health disorder or who are receiving psychotropic medication. Juvenile Probation The Probation Department provides the detention facility and security training for mental health personnel. Probation staff is responsible for the daily supervision of detained minors. The health program at Juvenile Hall has achieved accreditation from the California Medical Association (CMA).1 This is evidence of their ability to provide collaborative health services that exceed minimum standards of care. The accreditation has been a vehicle for maintaining a positive impact on physical and mental health services and relationships among custodial and health care staff. Additional evidence of cooperation is reflected in a Memorandum of Understanding between the San Diego County Health and Human Services Agency and the San Diego County Probation Department, dated April 23, 2003. The purpose of this agreement is to specify the mental health services and staffing levels provided by Children’s Mental Health Services to the Juvenile Detention Facilities. Mental health services are presented in the form of 3 options, dependent on budget and personnel constraints. These options are briefly summarized below: Option 1 – Basic Services: All services mandated by Title 15, 24 hour/ 7 day on-call emergency psychiatric services, prescription and monitoring of medication by a licensed psychiatrist, and provision of Special Education services. Option 2 – Moderate Level of Care: All Option 1 services plus, 8 hours of mental/medical health training for staff every 2 years in accordance with CMA accreditation standards. Option 3 – Complete Service Provision: All Option 1 and Option 2 services plus monitoring and coordination of treatment provided in the County psychiatric hospital, weekly coordination with Probation Department staff, weekly psychotherapy as resources allow, following protocols to minimize suicide risk among youth in detention, and mental health staff involvement in programming on units. The Memorandum of Understanding (MOU) merely reflects a list of “level of care” options or services Children’s Mental Health Services could provide in Juvenile Institutions. It goes on to state that movement up from Option 1 can occur if there are enough funds in the County Mental Health budgets to pay for the more expensive level of service. According to the memo, the decision to move to a different option is 1 Appendix A 181 , 2004) Report 2003/4-13 communicated by the Probation Department to Mental Health Services through their respective representatives. The MOU states, “Arrangements regarding payment, if any, by the Probation Department to the Health and Human Services Agency for services listed herein are addressed in separate fiscal agreements”. When asked for copies of any agreements, staff advised the Grand Jury that a fiscal agreement was not negotiated or entered into. Further investigation has revealed: • There is an apparent conflict between the fiscal emphasis reflected in the MOU and the treatment focus asserted by the Juvenile Forensic Team staff. One glaring example of this conflict is the monitoring of hospitalized minors. The MOU only allows monitoring of hospitalization at the most expensive level. The Juvenile Forensic Crisis Team, which serves the Juvenile Hall, claims they monitor the minor’s progress in the hospital through daily telephone contact. Apparently, clinical staff is providing a more expensive Option 3 service while currently being funded at the Option 1 (lowest) rate. What, then, is the connection between the MOU and actual practice? • The Grand Jury has been informed by HHSA administrators that the Operating Plan (budget) process is done in consultation with Probation, Juvenile Court and the Mental Health Board. While this internal cooperation is commendable, this does not necessarily provide for essential external accountability. County Mental Health Services informed us that the 2003-04 budget allocation to fund mental health positions in facilities is $1,770,653. While this appears to cover more than the minimum staffing required by Title 15, Section 1402 under Scope of Health Care, there was no way for us to verify this. FACTS AND FINDINGS Fact: There are three entities that are responsible for providing services for minors who are detained in juvenile institutions: CFMG – California Forensic Medical Group, County HHSA – Mental Health Services, and Juvenile Probation. Finding: The addition of CFMG health services, along with regular meetings has assisted in maintaining a positive impact on physical and mental health services and relationships among custodial and health care staff. Fact: The health program at Juvenile Hall has achieved accreditation from the California Medical Association (CMA). Finding: The accreditation validates the ability of the mental health program at Juvenile Hall to provide services that exceed minimum standards of care. Fact: A Memorandum of Understanding (MOU) between the San Diego County Health and Human Services Agency and the San Diego County Probation Department specifies 182 , 2004) Report 2003/4-13 the mental health services and staffing levels provided to the Juvenile Detention Facilities. Finding: The Grand Jury has found conflicts between MOU statements and actual practice. In addition, procedures for financial accountability are not stated in the MOU. IDENTIFICATION OF MENTAL HEALTH PROBLEMS DISCUSSION When minors are booked into Juvenile Hall, the Intake Probation Officer (IPO) screens them to determine if they might be unsuitable for placement in Juvenile Hall because of severe mental health symptoms. All Probation Officers in Juvenile Hall have participated in mental health training provided for para-professionals by Juvenile Forensic Services. The screening process involves the use of an Initial Booking and Screening Questionnaire2, which is a perfunctory checklist review. If the Questionnaire reveals mental health symptoms, the IPO requests an “up front” assessment by a licensed mental health clinician from the Juvenile Forensic Crisis Team. The professional assessment evaluates the symptoms exhibited by the youth and includes a mental health diagnosis. The assessment also determines if the treatment should be provided in or outside of Juvenile Hall. If the professional assessment determines that the minor is a danger to him or herself or others, he or she may be sent to the Emergency Screening Unit (ESU) in Chula Vista. At the ESU, an assessment is performed in order to determine if there is a need for hospitalization. Once admitted to Juvenile Hall, a request for referral for an evaluation by the ESU for possible hospitalization can occur at any time. If the IPO does not identify a mental health problem, identification may be made during the next step in the admissions process. This determination could be made when the CFMG clinician performs a physical evaluation of the minor. If the CFMG clinician determines that there is a mental health problem, the minor is referred to the Juvenile Forensics Crisis Team for assessment. This team of Licensed Mental Health Clinicians includes social work, psychological, psychiatric, and nursing staff. It is possible that a mental health problem might not be detected until or unless a minor demonstrates violent or unusual behaviors after completing the admission process. In this case, any Juvenile Hall staff member may refer the minor for a Crisis Team assessment. Youth detained in juvenile facilities who feel that they need mental health support may also request an assessment. Appendix B 183 , 2004) Report 2003/4-13 It is important to note that privacy issues can prevent Juvenile Hall staff from being informed about a child’s mental health treatment history. Notification of the child’s admission to Juvenile Hall to the child’s mental health treatment provider would violate the child’s privacy rights. If an outpatient provider learns of the admission through the minor’s family and wishes to continue to treat the child, the Probation Department and County Mental Health would accommodate the request. With due respect to privacy rights, one of the problems with the current process of identifying a mental health problem, is that this process is reactive rather than proactive. The IPO, as a paraprofessional, lacks the skills to diagnose and recommend specific treatment. These functions need to be performed by a licensed mental health clinician. The assumption indicated by the current perfunctory screening system, is that most minors in the juvenile justice system do not have a mental health problem. This assumption is not consistent with the Juvenile Probation estimates that 80% of the juvenile justice population has dual diagnosis. FACTS AND FINDINGS Fact: Data collected by Juvenile Probation indicates that 80% of the juvenile justice population is dually diagnosed with substance abuse and mental health problems. Finding: It is not clear how frequently existing cases of dual diagnoses are identified by the paraprofessional screening process. Fact: Privacy issues can prevent Juvenile Hall staff from being informed about a child’s mental health treatment history. Finding: It is generally not possible for Juvenile Hall staff to have knowledge of mental health treatment prior to booking. TRANSITION PROCESS FOR MAINTAINING MENTAL HEALTH SERVICES IN THE NEW EAST MESA JUVENILE DETENTION FACILITY DISCUSSION In response to Juvenile Hall overcrowding and the aging of the existing facility in Kearny Mesa (built in 1952), the Chief Probation Officer submitted a grant proposal to the State Board of Corrections. San Diego County was awarded approximately $36 million to build a new East Mesa Juvenile Facility. This facility is scheduled for occupancy in June 2004. The Board of Supervisors authorized an amendment of the California Forensic Medical Group (CFMG) contract in June 2003 to augment physical health services staff to support the new facility. However, the state budget crisis has led to a contingency plan for staffing the new facility. As of April 23, 2004 the Grand Jury was told that the Kearny 184 , 2004) Report 2003/4-13 Mesa Detention Facility may become a “special purpose juvenile hall”. In a special purpose facility, only intake health screening by either health care personnel or trained child supervision staff is required. An interpretation of Title 15, Section 1302, indicates that it is feasible to operate a special purpose juvenile hall at the Kearny Mesa facility with this health-staffing configuration. This would allow for the transfer of current health staff from the old to the new facility, saving the cost of a second fully staffed health program. County Mental Health Services has informed the Grand Jury that comprehensive physical and mental health services will be provided proportional to the number of children detained in each facility. In order to orient staff to the facility and set up the clinic, CFMG is prepared to start shifting staff 30 days prior to the date of opening. Probation staff is in the process of purchasing all equipment. They are working with HHSA on a monthly basis to learn what supplies to order. One year ago, a letter was sent to the State Board of Corrections projecting a daily average population of 500 in Juvenile Hall. At that time, the plan was to send 50% or 250 children to the new East Mesa facility and to transfer staff. The plan called for 40 staff, including mental health and support staff, to serve the needs of 250 children. Most of this staff will be moved from the Kearny Mesa Facility. Support staff such as warehouse workers, cooks, and booking clerks will need to be hired for the new facility. With more severe budget cuts, the Probation Department would only leave 30 beds open at the Kearny Mesa facility and further reduce the total detained population by focusing more on home monitoring and by making more referrals to community programs. This does not seem entirely feasible given the plans to reduce the capacity of some community programs. The intake process, including booking, may remain at Kearny Mesa for the time being. The original plan was to open East Mesa and to start booking operations there after 90 days. Also being considered is utilizing teleconferencing or video conferencing booking. Negotiations between the Probation Department and HHSA have resulted in a commitment to the following mental health staff at East Mesa, if resources allow: • One Psychiatrist • Two Psychologists • One Nurse • One Licensed Mental Health Clinician • One Mental Health Consultant • One Part Time Clerk. 185 , 2004) Report 2003/4-13 FACTS AND FINDINGS Fact: The Kearny Mesa Detention Facility could become a “special purpose juvenile hall” where only intake health screening by either health care personnel or trained child supervision staff is required by Title 15 regulations. Finding: Designating Kearny Mesa as a special purpose facility will allow for the transfer of current health staff from the old to the new facility, saving the cost of a second fully staffed health program. Under this plan, the only fully staffed health clinic will be located at the new East Mesa Juvenile Detention Center. However, comprehensive physical and mental health services will be provided proportional to the number of children detained in each facility. PROVISIONS FOR CONTINUITY OF MENTAL HEALTH TREATMENT AFTER RELEASE DISCUSSION The ability of Juvenile Probation staff to ensure follow-up services for minors with mental health problems depends in great part on whether the minor is released to the community or transferred to another Probation facility. Of all the cases that go to another Probation facility, the staff ensures that the medical files follow the child approximately 85% of the time. In the other 15% of these cases, Probation staff does not always know the release date in advance because the court determines this. When this occurs, the child is sent to a placement with little notice and the Probation staff sends the medical file as soon as possible. If the child is released to the community, that is, if he or she is returned to their family or placed with a foster family, the follow-through is less certain. Approximately 2 years ago, a “red flag” protocol was added at Juvenile Hall. Currently, if a child is on psychotropic medication, this is “red flagged”. When the child is released, the nurse or mental health worker ensures that a responsible person is informed. Prescriptions can be taken to the County pharmacy, or the family is provided with a holdover supply of medication. In order to address post-release health issues of detained minors, County HHSA and Public Health staffs have begun to have joint meetings. Identification of problems has resulted in voluntary access by detained minors to TB screening and testing, HIV testing, and HIV education in Probation institutions. Other services oriented to post-release aftercare include: Wellness Team -- The purpose of this team is to provide education to all detained minors about community resources that assist in abstinence from tobacco products. The team is operated by Children’s Hospital and Health Center -- San Diego and funded by tobacco revenue. 186 , 2004) Report 2003/4-13 Help Outcome Team -- This team is collaboration between The Wellness Team, the Juvenile Hall mental health staff, and the Probation staff to set the child up with Medi- Cal services. This enables the minors to access health care in the community. There are several programs that aim to divert juveniles from incarceration while they are on probation: Breaking Cycles – This program provides links to substance abuse treatment, and youth and family counseling. This is a Probation program funded by the Juvenile Justice Crime Prevention Act (JJCPA) and the County General Fund. There has been a $92,272 reduction of JJCPA funding for FY 2004-05. Reflections Day Treatment -- This is a program that is coordinated under Breaking Cycles. Reflections provides family-based services to adolescents who have been diagnosed with a mental / emotional disturbance and their families. Services include support groups, positive peer selection, violence prevention, and alcohol and drug treatment and education. The program is funded by Medi-Cal, other state funds and a contribution from the County General Fund. Repeat Offender Prevention Program (ROPP) - This Probation program served first offenders and their families. Services included psychological assessment, clinical consultation, intervention, referrals, parenting classes, and drug intervention. As of this writing, the ROPP program has been eliminated. Spectrum – This program serves juveniles who are detained in Juvenile Hall or are on probation. The program is contracted out by County Mental Health Services to a community nonprofit organization, which provides mental health counseling and chemical dependency recovery services. Funding for FY 2004-05 is stable at $650,000 to $675,000. Building Effective Solutions Together (B.E.S.T.) -- This program provides mental health case management for seriously emotionally disturbed dependents, delinquents, and their caregivers. Access to the program is only through referral by Probation or Children’s Services. The program will be merged with Community Intensive Treatment for Youth (CITY) and the Child, Youth and Family Network (CYFN) as part of the recently authorized proposals to integrate services. State funding for this program may be reduced due to budget constraints. Estimates are that 100 fewer families will receive services. The Grand Jury has learned that community-based programs, Juvenile Drug Court, and other prevention efforts are working. This has been revealed by a reduction in the census in the Juvenile Detention Facility. In April 1998, there were 649 youth in the facility. By December 2003, there were only 399. It is reasonable to assume that providing these services to a large number of youth will continue to lighten the burden on our juvenile facilities. This will be essential if state budget cuts are severe enough to reduce the number of available beds at the Kearny Mesa facility. 187 , 2004) Report 2003/4-13 As a response to state budget cuts, the County HHSA is reducing treatment programs. These reductions are occurring even as Probation is planning to refer more children and youth to treatment programs as an alternative to detention. The Grand Jury has observed that HHSA staff sees cutbacks as the only possible response because they are paralyzed by a need to preserve the existing, expensive, bureaucratic system of services. Difficult times call for new ways to provide services. A cost effective mental health system that will be more responsive to the needs of our detained youth, would necessarily include the broad involvement of families. Families who have been denied treatment may bring a wealth of new ideas and energy for the provision of expanded services. This is an untapped resource. Many children and families are denied treatment because the Juvenile Detention Facility staff is limited in its ability to follow through on aftercare for juveniles with mental health problems. Limitations are caused by budget and personnel restrictions, as well as by difficulties in tracking and monitoring juveniles who do not remain in the system. Although the Juvenile Detention Facility has no designated discharge coordinator position, collaborative efforts address basic legal and medical obligations. CFMG nursing staff consults with the Juvenile Forensic Crisis Team and the Probation Department regarding recommendations for continued health treatment for the child and family. The Grand Jury has seen no verification of the provision of follow-up treatment plans by the Juvenile Forensic Crisis Team. Grand Jury interviews revealed other problems for youth who leave Probation’s jurisdiction and programs when they attempt to get continuing treatment from County funded community mental health programs. If a child who was diagnosed with a mental health problem and received treatment while in Probation facilities is not eligible for Medi-Cal reimbursement, there is a low probability that the treatment can continue. We were told that these youth “don’t compete well with kids coming out of hospitals or who have Special Education needs”. This means there are not enough treatment services for mentally ill juvenile offenders. It remains unclear whether the “No Wrong Door”3 policies claimed by County Mental Health would provide interim help. When asked about the effectiveness of “No Wrong Door”, County Mental Health services staff proudly replied that there is a website. The Grand Jury maintains that the mere availability of mental health program information on a website does not provide much help to families who do not understand complicated eligibility requirements or who do not have enough information to know whether a particular program is the right one for their child. A website alone does not meet state-mandated goals which require improved access to community mental health programs. These goals are stated in the following documents: 3 A “No Wrong Door” policy refers to providing assistance at whichever county-funded program contacted for mental health services. 188 , 2004) Report 2003/4-13 • The Children’s Mental Health System of Care Regulations (Welfare and Institutions Code). These regulations require that mental health treatment services be made available in homes and neighborhoods convenient for families. The CSOC further requires that these services focus on individual needs. This means that the program should be tailored to the child’s needs. In the current situation, the child must fit the program or take what is available. • The San Diego County HHSA performance contract with the State Department of Mental Health (2003-04). This contract obligates the County to “…integrate the activities of multiple child-serving agencies and systems to ensure the provision of necessary services to include mental health, substance abuse…and increasingly, juvenile justice services.” According to County Mental Health administrators, juvenile justice services are not increasing due to state budget cuts. The Little Hoover Commission Report on children’s mental health services (2001) noted that in 30 years, attempts to redesign the mental health services system have yielded mixed results. Past attempts have failed to achieve the goal of providing the highest quality, most efficient care possible. This failure can be blamed on an ill-advised approach that involved the creation of a “super agency.” The Grand Jury investigation revealed that the San Diego County Children’s System of Care (CSOC) process is focused more on maintaining the bureaucratic structures to the extent that is possible, and less on the unmet needs of children and families. The state has awarded San Diego County $7 million to develop a system of care that is aligned with the Welfare and Institutions Code regulations. We are concerned about the apparent lack of accountability in the CSOC process. The Grand Jury asked, “How are these dollars being spent to build capacity?” We did not received a clear answer. The task of creating a family-friendly system can be difficult when the family sector has no power. The task becomes impossible when families have no opportunity to participate in decision-making. The Grand Jury has learned that only a few, carefully chosen family members have been invited to monthly meetings with the County staffs and nonprofit service providers. For example, there is an organization called the San Diego County Family Roundtable, which is represented at County meetings. According to their website, the Roundtable is comprised of families who have been able to receive services. Although this sounds like an ideal group of family participants, the membership does not represent the large number of families who have trouble accessing services for their emotionally disturbed children. The very reason the system needs to be reformed is that there are so many families who are not able to find and get the services they need. Further, the president of the board of the San Diego County Family Roundtable is a current nonprofit provider of services. This could easily be construed as a conflict of interest. The Grand Jury is concerned that conflict of interest is inherent in the organizational structure of the Children’s Mental Health Services System of Care Steering Committee. 189 , 2004) Report 2003/4-13 This Committee often recommends the awarding of contracts to specific nonprofits and other groups. Many of these nonprofits and other groups turned out to have officers who are also Committee members. Pursuant to California Government Code Section 1090- 1098, this may be a case of members having a financial interest in a contract. Although there are policies of disclosure and abstention from voting where members have even a remote interest, the potential number of self-interested participants almost certainly includes everyone. The Grand Jury admonishes County Mental Health Services to appoint an independent group to perform the function of advising, recommending, and making decisions on the awarding of contracts. The conflict of interest issue is exacerbated by the failure of the CSOC to include a diverse group of families who truly represent the range of opinions in the community. The Grand Jury believes that County Mental Health leaders must learn the skills needed for effective community development. Knowledge of community development strategies would help these administrators understand how to engage families in a positive reform effort. There are proven methods that work to inspire a better planning process. For example, The Anne E. Casey Foundation has provided funding and expertise to a number of states and localities to help make their public service systems work better for children, families, and communities. An evaluation by this or a similar organization, could lead to a course correction that will achieve a cost effective system of care. Only by paying attention to cost and effectiveness will the County be able to stem the tide of criminal and violent behavior exhibited by our untreated, emotionally disturbed children and youth. It is especially important to maximize our human resources when funds are in short supply. This is a much more positive approach than the current preference for maintaining outdated and awkward structures that limit services. Excluding family members because they might demand more services ignores the benefits that they offer. Family members as partners may well replace the self-limiting “we can’t afford to do more” excuse with a “can do” enthusiasm. Family members are motivated. They want to create opportunities for their children to live productive lives. They also want to contribute creative ideas that tend to minimize costly bureaucratic red tape and will provide services and support. FACTS AND FINDINGS Fact: The CFMG nursing staff coordinates with the Juvenile Forensic Crisis Team and the Probation Department regarding recommendations for continued health treatment for the child and family after release from Juvenile Hall. Finding: The Juvenile Detention Facility staff is limited in their ability to follow through on aftercare for juveniles with mental health problems. These limitations are caused in part by budget and personnel restrictions, as well as by difficulties in tracking and monitoring juveniles who do not remain in the Probation system. 190 , 2004) Report 2003/4-13 Fact: Due to state budget cuts, the County is cutting the capacity of mental health treatment programs in the community that serve juvenile offenders. Budget cuts are also driving plans to drastically reduce the number of available beds in the Kearny Mesa Juvenile Detention Facility. Finding: The County is reducing the capacity of community programs to serve mentally ill juvenile offenders, even as County administrators announce plans to increase the number of referrals to these programs. The stated purpose of increased referrals is to provide an alternative to incarceration in the Juvenile Detention Facility. Fact: The CSOC for seriously emotionally disturbed children and youth represents a state mandated effort to make mental health treatment services available in the home and in the neighborhood, and concentrate those services around the needs of the youth and family, rather than the needs of the bureaucracy. Finding: Many children and youth, who have mental health problems, do not receive treatment services after release from Juvenile Hall. This is the direct result of County policies that maintain costly bureaucratic structures. As a result, this County is limited in its ability to build the capacity of juvenile diversion and treatment programs that have a successful track record. Fact: The San Diego County HHSA performance contract with the State Department of Mental Health Services (2003-04) requires the County to integrate systems that provide necessary mental health and substance abuse services and juvenile justice services. Finding: Families who have been denied services are highly motivated to provide cost- saving ideas and practical assistance for expanding the capacity of community programs to address the dual diagnosis needs of children and youth who are released from Juvenile Hall. This is an untapped resource. Finding: San Diego County is out of compliance with the state mandated concept of facilitating access to services and involving families as partners. The County is pursuing a policy of limiting broad family partnership in the system reform effort (CSOC). The County is supporting Family Roundtable leadership by a service provider, which can easily be construed as a conflict of interest. Fact: The Children’s Mental Health Services System of Care Steering Committee often recommends the awarding of contracts to specific nonprofits and other groups. Finding: According to California Government Code Section 1090-1098, the action of recommending the awarding of contracts to members of the Committee who have financial interests in the contracts constitutes a conflict of interest unless the interests are remote or constitute non-interest. 191 , 2004) Report 2003/4-13 Finding: The County is reluctant to share power with family/consumers, resistant to incorporating new perspectives for cost-effective community participation, and apparently unskilled or unwilling to utilize effective community development strategies.