Butte County Grand Jury Report This 29th day of June 2012

Recommendations 28

• R1

  Page 40
  That DBH continue and enhance where possible, programs such as WIN, WRAP® and CIT.
• R2

  Page 19
  Every district surveyed develop and adopt a plan to ensure continued compliance with ethics training requirement of AB 1234. The following failed to respond to that recommendation: Biggs West-Gridley Water District Drainage District #200 Butte Water District Durham Recreation & Park District Chico Area Park & Recreation Feather River Park & Recreation District District Drainage District #1 Paradise Recreation & Park District Drainage District #100 Rock Creek Reclamation District Earlier during the 2010-2011 investigation, these agencies either claimed exemption from the ethics training or claimed that they were in compliance with the requirements. However, a formal response to the final report is required by law. It should also be noted that the recommended ethics training is available free of charge via the internet. The requirements of AB 1234 are that officials renew the training every two years, so the request that agencies develop a plan for continued compliance was a reasonable one. xiii (This page intentionally left blank.) 2011 – 2012 Butte County Grand Jury Reports (This page intentionally left blank.) FOREPERSON’S OVERVIEW OF THE FY 2011-2012 GRAND JURY REPORT The FY 2011-2012 Grand Jury has served during a particularly challenging time for local government. The financial challenges of the 21st century have been considerable, including the deepest recession since the Great Depression. The budget challenges at the federal, state and local levels have been ongoing for so long that negative impacts, which have not previously been seen by most persons living today, are being experienced. In Butte County, the results can be seen throughout the cities and towns. There are rental signs on residential and commercial properties. There are fewer jobs and ever-larger numbers of homeless individuals and families. Growing numbers of people are using hospital emergency departments as a primary source of health care. The result of these circumstances is a greater demand for services from the public and nonprofit social organizations. Early in the term the FY 2011-2012 Grand Jury identified three areas of focus. These were:  The potential impact on the community of the State realignment of the criminal justice, behavioral health, public health and social services programs;  Follow-up on previous grand jury investigations where the responses by the agencies investigated were inadequate or identified remediation's had not been confirmed;  Complaints from citizens received or passed on by the previous Grand Jury. It soon became apparent that all three of these areas of interest overlapped. The first four reports in this section focus on two of the realigned departments: Behavioral Health and the Sheriff's Office. As these reports are read it becomes clear that the problems identified affect more than these two departments. They impact other health and human services programs in the county, both public and private, including hospitals. Many of these problems are due to a lack of staff after years of declining funding. Many attempts by agencies to cope with funding shortfalls have simply transferred the cost elsewhere. A reduction of resources in one agency forces persons in need to other agencies, which in turn have to find additional funding often by moving resources from one service to another to meet the additional need. This creates yet another gap in services. The Grand Jury is not convinced that our County lacks the professional and financial resources to meet the needs of the community. However, it will be necessary to change the approach to these problems. Consequently, many of the Grand Jury reports recommend expanding the scope of and participation in planning and coordination efforts. Butte County has a $4 billion economy supported largely by agriculture, manufacturing, higher education, health care and government spending. The Grand Jury was given with technical assistance by the Center for Economic Development (CED) at California State University, Chico which allowed a better understanding of the components of the County's economy. Data was provided to show the economic stimulus to the County's economy of spending by the County of Butte and the proportion of that spending made up by the three health and human service departments (Behavioral Health, Public Health, and Employment and Social Services). The stimulus provided by the County’s spending was compared to that provided by manufacturing and healthcare. The results of this study show that the entire county economy produces 94,733 jobs while generating a total of $4,158,000,000 in labor income. Of this total, 6700 jobs and $366,000,000 in labor income is created by the budget spending of the County of Butte. By way of comparison, manufacturing in the county accounts for 7600 jobs and $363,000,000 in labor income. Analysis of spending by the three health and human service departments of the County shows they account for 51% of the County of Butte budgetary spending and 72% of the total economic impact generated by the County of Butte. Healthcare spending throughout the county accounts for 19,363 jobs (20.4% of the total county jobs) and $1,016,000,000 in labor income (24.4% of the total county labor income). Of the total healthcare spending in the county, 4800 jobs and $252,000,000 in labor income, is generated by the spending of the three County health and human services departments. Even though a great deal of money is being spent, lack of coordination and planning between the public and private sectors hinders efficient use of the funding available. The Grand Jury's report on Recreation and Parks Districts suggests a model for correcting the health services issues described in the first four reports. The Recreation and Parks Districts have also been affected by the downturn of the economy. However, they have generally done a much better job of cooperating with other private and nonprofit organizations to meet the missions of their districts. There are two Grand Jury reports on cities, Oroville and Gridley, which had been investigated by previous grand juries. The FY 2011-2012 Grand Jury was impressed with the progress of Oroville in improving the manner in which they conduct their business despite these difficult financial times. Gridley continues to make progress, but many issues remain to be addressed by their leadership. Kenneth Fleming, Foreperson 2011-2012 Grand Jury 2 2011-2012 BUTTE COUNTY GRAND JURY REPORT BUTTE COUNTY DEPARTMENT OF BEHAVIORAL HEALTH SUMMARY Due to the complexities of services provided by the Butte County Department of Behavioral Health (DBH) and the tremendous financial challenges this department faces, the 2011-2012 Butte County Grand Jury examined the administration and programs of the Department to determine status and progress following reports made by Grand Juries in 2008-2009 and 2009- 2010. Further incentive to review the Department came from complaints and comments from the public. Challenges faced by the Department are impacted by ever increasing service demands stemming from the growing numbers of citizens in our society with debilitating psychiatric and substance abuse issues and from the increase in demand for services for an aging population. There was evidence of significant improvement in the management of the Department associated with the hiring of a permanent Director. New programs such as WIN, WRAP®, and CIT are experiencing positive results. Staff members have expressed appreciation for the style and professionalism of the new Director. The Citizens’ Advisory Board is playing a more significant role in monitoring the activities of the Department. Collaboration among County departments seems to be more substantial, and the professionalism and commitment of DBH staff deserve positive recognition. At the same time, the Department continues to face significant challenges. For a number of years there has been a lack of long-term planning. The recruitment of medical leadership and psychiatrists continues to be a serious problem. The resulting utilization of techniques such as tele-medicine accentuates cost challenges. The relationship between the Department and local hospitals, including Enloe, continues to be a challenge as noted in previous Grand Jury reports. The organizational communication between the Director and program staff is seen by the latter to be a continuing problem. The lack of consistent utilization of the data system AVATAR by staff presents a service and financial challenge. The Grand Jury was quite surprised and concerned to note the lack of a comprehensive drug and alcohol treatment system in the county. The challenges associated with communication among county entities concerning the treatment needs of inmates released from both the county jail and state institutions must be noted. The Grand Jury while expressing concern for these challenges, also notes a broad range of possible solutions coming from the comments of citizens and the professional perspectives of staff. Progress noted in the development of a strategic plan for the Department should incorporate many of these proposed solutions. GLOSSARY  AVATAR - Software program used by Butte County Department of Behavioral Health. This system is one of two widely used in California. Its name comes from the name of the company which developed it. 3  CIT - Crisis Intervention Team - A joint program between DBH and the Butte County Sheriff’s Department which provides training for law enforcement personnel and others who might encounter persons with mental illness. The goal of this training is to enable responders to de- escalate crisis situations.  Consumer - A citizen who is the recipient of DBH assistance.  CSU - Crisis Stabilization Unit. A facility of DBH, also called a 23-hour facility. Consumers with issues that can be dealt with in a short period of time can be brought to this facility. Stays there are limited to 23 hours or less as the licensing requirements differ when longer admissions are necessary.  DBH - The Department of Behavioral Health for Butte County.  ED - Emergency Department of a hospital.  HAP - Hospital Alternative Program. An intensive treatment program aimed at keeping youth from acute psychiatric hospitalization by providing alternatives. Youth in this program are served by a multi-disciplinary team. During the first six months of 2011, 87% of the youth in this program were able to avoid hospitalization.  Medi-Cal - The State program that provides health, including mental health services for low- income citizens. Payment under this program is approximately 50% state provided and 50% federal. Federally, this program is known as Medicaid.  MHSA - Mental Health Services Act. The passage of Proposition 63 in November 2004 provided the first opportunity in many years for the California Department of Mental Health to provide increased funding, personnel and other resources to support county mental health programs. This Act, also referred to as the millionaires tax, levied an additional tax of 1% on incomes of over one million dollars. In the current fiscal year, Butte County received over 8 million dollars from this source.  MCT - Mobile Crisis Team. A team of DBH employees with the responsibility to respond to area Emergency Departments and assess the condition of persons brought in with mental health issues to determine if in-patient care is needed.  NAMI - National Alliance on Mental Illness. The local chapter of NAMI provides a variety of services to support their mission of improving the lives of individuals and families affected by mental illness.  PHF - Psychiatric Health Facility. The in-patient facility operated by DBH. This is a 16-bed facility, licensed by the state, for the treatment of consumers requiring in-patient services.  Section 5150 - Also referred to as 5150. California Welfare and Institutions Code sections 5150 - 5157). This portion of California Law specifies conditions under which a person deemed to be “a danger to himself or other” may be detained for a mental status evaluation. These code sections can be viewed at the following: www.leginfo.ca.gov  TBS - Therapeutic Behavioral Services- Intense services provided for mental health consumers under the age of 18. This is another alternative to hospitalization. The consumer and his/her family are provided with intensive support in order to avoid hospitalization.  WIN - Working Innovations Network - A team DBH staff and volunteers who attempt to ease the transition for consumers coming out of in-patient treatment and needing to connect with out- patient resources.  WRAP® - Wellness Recovery Action Plan - A nationally recognized program implemented at some DBH sites. The WRAP® is designed by the consumer in practical, day-to-day terms, and holds the key to getting and staying well. It does not necessarily replace traditional treatments, but can be used as a compliment to other treatment options. A Note on terminology: Over time there have been a variety of terms used to refer to persons needing mental health services. The presently accepted term of reference is “consumer”. While members of the Grand Jury did not find this term to be particularly accurate, because of its current use and apparent acceptance by the “consumers’ themselves, it will be used in this report. BACKGROUND The Grand Juries of 2008-2009 and 2009-2010 conducted intensive investigations of the Butte County Department of Behavioral Health. Both reports were critical of this Department. Since the most recent report was issued, there have been significant changes in the management of this Department. This Grand Jury decided that a new investigation was warranted to determine if the changes in management have resulted in correction of previously reported deficiencies in the Department. The Department is one of three human services departments in the County slated by the State of California for realignment. While realignment is touted to provide more flexibility to the counties, it will increase the challenges to management and staff. Further motivation for this investigation came from complaints received by the Grand Jury. The magnitude of the problems to be dealt with by DBH is almost overwhelming. According to the California Department of Mental Health statistics (based on 2000 census figures):  Approximately 6.5% of the total state population is identified as having either serious emotional disturbance or serious mental illness.  In Butte County the figure is 7.11%, giving the County a potential total of over fourteen thousand persons to serve. The percentages are slightly higher for youth (under age 18) than for adults. While private providers fill some of the needs for service, DBH as the “service of last resort” provides treatment for those without other resources. Nearly all of the services provided by DBH are paid for under Medi-Cal.  It was also pointed out to the Grand Jury by sources contacted, that the number of older persons needing mental health services is increasing as the percentage of the population in upper age brackets increases. Caring for these older adults is especially challenging as many have physical as well as mental illnesses. Poverty compounds the problems of caring for those with mental illness. There is a well- recognized correlation between poverty and mental illness. According to the US Census Bureau figures, approximately 18% of Butte County residents have incomes below the poverty level. The County Health Rankings and Roadmaps data shows Butte County with 25% of its children living in poverty compared to the state-wide rate of 22%. Also, California Department of Education data shows 48% of school-age children in the County qualify for free or reduced lunch program. It can be assumed that nearly all of the consumers treated by DBH are represented in this data as nearly all qualify for Medi-Cal. Tobacco use is another issue in mental health. The County Health Rankings and Roadmaps data show Butte County with 21% of adults using tobacco compared to the stat-wide rate of 14%. People living with mental illness have a very high rate of smoking. A study in The Journal of the American Medical Association (http://jama.ama-assn.org/content/284/20/2606.abstract) reported that 44.3 percent of all cigarettes in America are consumed by individuals who live with mental 5 illness and/or substance abuse disorders. Smoking leads to lung disease and is a contributing factor to the lower life expectancy of those with mental illnesses. For the current fiscal year, Butte County DBH operates with revenues of approximately 53 million dollars out of a total county budget of 420.5 million dollars. Nearly all of this money comes from the State of California and the Federal Government. Most of the consumers treated by DBH are eligible for Medi-Cal and thus the services are reimbursed according to Medi-Cal guidelines. Approximately half of the total comes from the State with the Federal Government paying nearly all of the rest. In a complicated arrangement, a very small local (County) match is required. In the current fiscal year this County match is $285,000. State regulations require that mental health services provided to Medi-Cal eligible consumers be paid for through DBH, meaning that a private provider or hospital can be reimbursed for such services only under an agreement with DBH. Another relevant aspect is that according to representatives of law enforcement interviewed by the Grand Jury, approximately 70% of those incarcerated in the Butte County Jail are identified as having either mental health or substance abuse issues, or both. Point-in-time data from the Butte County jail medical staff shows in the month of October 2011 there was an average inmate population of 573 persons of which 199 (35%) were active mental health cases. Of the 199 active mental health cases 84 were new cases. Inmates with a mental health diagnosis required 189 visits by a masters level therapist and 69 visits by a psychiatrist who also did 32 chart reviews. On the last day of the month the inmate population was 577 of which 43 (7%) were receiving psychotropic drugs. Those inmates receiving psychotropic drugs represented 22% of the active mental health cases. This is similar to data regarding state prison inmates with mental illnesses. According to the California Department of Corrections and Rehabilitation, the proportion of inmates with a mental illness increased from 19 percent in 2007 to 25 percent in 2012. These inmates, of course, impact the mental health system while incarcerated and in the community after release. The care of these individuals also impacts local hospitals as those in crisis frequently end up in emergency departments. APPROACH 1. The members of the Grand Jury reviewed documents obtained from DBH and from other sources including, organizational charts, reports prepared by outside agencies, reports of consumers, program overviews for numerous programs, departmental brochures and on-line resources including statistics from the California Department of Mental Health and other sources. 2. More than 49 people were interviewed, some of them more than once. 3. Members of the Grand Jury visited the following: area hospitals, numerous DBH facilities and several contracting agencies. 4. Members of the Grand Jury attended meetings including those of the Citizens’ Advisory Board, DBH Budget Task Force Committee, local chapter meeting of the National Alliance on Mental Illness (NAMI), and the Butte County Board of Supervisors. DISCUSSION This investigation revealed that while a number of positive changes have taken place, the Butte County Department of Behavioral Health continues to face significant challenges. In June of 2010, a new Director was hired for DBH. This Director followed two interim directors who in turn followed a Director who had been criticized in the previous Grand Jury reports. Since the current Director was hired, a number of changes have taken place in the Department. There have also been a number of changes imposed upon the Department due to new State and Federal policy and financing directives. Some of the positive developments in the department since the hiring of the current Director include:  The implementation of new programs such as WIN, WRAP® and CIT. Working Innovations Network (WIN) is a project of DBH funded with Mental Health Services Act (MHSA) funds. The purpose of this program is to provide support for those in transition from in-patient treatment to out-patient facilities. When possible the WIN team makes contact with the consumer while he or she is in the in-patient unit. In some instances, the WIN team provides transportation to and/or from in-patient facilities and the consumer’s place of residence. The WIN team members help with the scheduling of out-patient counseling visits and provide general support until the consumer feels comfortable accessing such appointments. Some consumers are employed by DBH for the purpose of accompanying and assisting DBH staff team members. Many consumers coming out of in- patient treatment reenter a facility within a short period of time. Any effort that reduces this recidivism is not only a cost saving to the County but is a benefit to the consumer. Wellness Recovery Action Plan (WRAP®) is a nationally recognized program that has been implemented at some locations within the department. WRAP® is a part of the overall strategy known as the “Wellness and Recovery Model,” which aims to have consumers live the fullest lives their conditions allow. It is recognized that while some may make full recovery and be able to live independently, many will need at least some degree of support throughout their lives. WRAP® endeavors to assist the consumer in acquisition of life comprehension and adjustment tools and techniques that will contribute to maximum functionality in daily living. The plan, a central part of WRAP®, is one made by the consumer, and lays out steps to take if things begin to destabilize. It sets up who to call, where to go and what steps to take to help avoid a crisis. Crisis Intervention Team (CIT) is a joint effort between DBH, Butte College and area law enforcement agencies. Members of this team have completed a 40-hour course conducted by a Sheriff’s Department employee using Butte College facilities. “The Crisis Intervention Team was developed to help improve the outcome of crisis situations by partnering law enforcement, behavioral health workers, first responders, and emergency departments to provide a safe, attentive, and compassionate system and response to crisis situations. The goal is to respond to the person in crisis in a calm, supportive and respectful manner.” (Quote from CIT brochure) Many local law enforcement individuals have taken part in this training. 7  Many staff members appreciate the style and professionalism of the current Director.  The current Director is active and pro-active at the regional and State levels.  The Citizens’ Advisory Board, which had become a sounding board for those unhappy with DBH services, now seems to be functioning well. Members of the Citizens Advisory Board appear to get along with the current Director. Only a few minor complaints were expressed by consumers at meetings of the Citizens’ Advisory Board attended by Grand Jury members. Most of those who expressed complaints seemed satisfied by the response received from DBH. Publication of announcements concerning Citizens’ Advisory Board meetings should be expanded. Public meeting act requirements are met by posting notices at DBH office. Announcements are supposed to be, and usually are, posted on the Department website but public awareness would be increased by posting meeting notices on community event calendars in local newspapers. Expanding publicity might help to make the community at large more aware of the work and programs of DBH and thereby increase support for DBH programs and outreach. New brochures prepared and distributed by the Department are a step toward gaining the support of the citizenry.  The collaboration of County Departments in response to the 2011-2012 realignment of the criminal justice system seems to be appropriate, though a complete evaluation of the effects of the State directed realignment and County’s responses to it will not become fully known for several years. Butte County has been proactive in planning for and implementing programs in response to recently enacted State of California realignment directives contained in Assembly Bills (AB) 109 and 117. Butte County is well ahead of the majority of counties in the State of California. Other counties in the State have sought advice and guidance from Butte County as a leader in establishing and enacting programs in response to the directives. To date the program implementation efforts put forth by Butte County are in early stages, and will require future analysis, evaluation and adjustments in order to become fully functional and efficient. By early 2012, it appeared the impact of the State law enforcement realignment directive, which has offenders categorized as “low level” serving sentences either in the County Jail or under the supervised control of the County Probation Department, rather than in State Prison, was happening more rapidly than anticipated. The impact of realignment is as yet unknown, but one area of concern is the need to provide a transition team to work with parolees who have received mental health services while incarcerated but who may fall through the cracks upon release. Unfortunately, many of these individuals may be identified only when they have a mental health crisis or end up reentering the criminal justice system. 8  DBH has many devoted personnel who care about their clients and the public. The Grand Jury was impressed with the dedication and professionalism of DBH staff members who shared their views and concerns during site and facility visits. Positive changes being noted, the Department still faces many significant challenges from both internal and external sources. Since the Department is dependent on State and Federal funding, changes and cut backs at these levels will have affect on how the Department will be able to operate. The 2011-2012 realignment of the State Department of Mental Health is ongoing. The mental Health realignment will make changes in regulations and in how finances are handled. It is advertised as giving counties more flexibility but as the Federal Government provides the funds it also determines the rules. Medicaid (in California, Medi- Cal) is an entitlement program that requires services be provided to any eligible person in need. California Counties are being asked to meet this open-ended obligation without the ability to obtain additional funds if the need is greater than the available funding. Given Butte County has unemployment and poverty rates higher than the State average, its risks may be high. For more information see the Butte County Department of Behavioral Health – Financial Challenges report that is part of this Grand Jury’s consolidated report. Looming in the background, but certain to have an effect on the future functioning of DBH, is the Federal reform of health care. Some of the specifically identified challenges facing the Department include the following:  An apparent lack of over-all long-term planning. The department has begun working on a strategic plan. Hopefully, this plan will meet a long- standing need to identify the most pressing issues and set forth methods for overcoming those issues. A consultant has been selected and work has begun on the strategic plan. In the past, it appeared that many new programs within the Department were driven by the availability of finances rather than by identified need. The Department has been operating for a long period of time without systematically identifying and prioritizing its most pressing needs. Changes mentioned above concerning State and Federal involvement in the Department, can be viewed as an opportunity for long-range planning and evaluation of current practices. With an open planning process involving DBH, other human service private and public providers, the Citizens Advisory Board and other interested citizens, new and innovative solutions to problems can be found. Solutions would be enriched by encouraging input from medical staff, from other professional and para-professional clinical staff, private mental health providers and the community as a whole. 9  Previous Grand Juries reported problems with recruitment of a Medical Director and psychiatrists to work in the Department. In 2011, a new Medical Director was hired for the Department. However, he resigned with less than a year in the position. Clearly, defining the role of the Medical Director and evaluating this position in the organization should precede any new hiring action. The need to reevaluate the position of Medical Director is one of the recommendations found within the 2009-2010 Grand Jury report. Determining the most effective use of this position within the organization remains an important issue. In general, difficulty in hiring psychiatrists is a recognized problem. The number of psychiatrists available is not adequate to satisfy current needs, and counties in California have difficulty competing with the salaries offered by the Department of Corrections. However, this is not a new problem in California’s rural Counties and Butte County has been fortunate over the years in attracting psychiatrists, many of whom have worked with DBH for many years. The current problem seems to be more a matter of retention, as the Grand Jury heard from a number of current and past psychiatrists. Because of this, it is imperative that available psychiatrists be well utilized, reasonably well compensated, and valued for their skills and for the responsibility they accept regarding consumer care.  Due to a lack of the availability of psychiatrists, a system of tele-medicine has been implemented. While this system appears to have support of some of consumers who use it, it is very expensive and of questionable long-term utility. This leads to a question as to whether or not monies presently expended to support the psychiatry portion of the tele-medicine system would be better utilized to increased on-staff psychiatrist availability. Tele-medicine was originally envisioned, by some, as a way of serving consumers in remote locations (such as Berry Creek) who cannot readily come to existing facilities. Instead, the tele-medicine system is being used by consumers in a Chico out-patient facility to interact with a psychiatrist in Southern California. Since it is a very expensive service, its use should be limited.  The relationship between the DBH and Enloe Hospital was highlighted as a serious issue in the two previous Grand Jury reports and the situation appears to be largely unchanged. Many of the same problems were observed at other area hospitals. The 2011-2012 Grand Jury was concerned to learn that the relationship between DBH and Enloe Hospital has not improved from what was documented in the report prepared by the 2009-2010 Grand Jury. Many complaints echoed those heard previously. DBH requires many persons entering the mental health system, while in crisis, to go through a hospital emergency department to receive a medical clearance prior to being referred to an in-patient facility. The Psychiatric Health Facility (PHF), operated by DBH, is a psychiatric, not a medical facility. It is not able to treat persons with serious medical conditions. There is 10 some disagreement between Emergency Department (ED) and PHF staffs as to what constitutes a serious medical condition. One area of disagreement concerns levels of intoxication. There are a significant number of persons who require mental status evaluations by the DBH Mobile Crisis Team (MCT) after being brought to the ER by law enforcement personnel. Such persons have been placed under what is referred to as a “5150” - a reference to the section of the California Welfare and Institutions Code which allows law enforcement officers (and some others) to deem a person a danger to himself and/or others or to be gravely disabled, and provides that such an individual may be held, without consent, for up to 72 hours pending evaluation by appropriate mental health professionals. The possible over- use of this procedure can be a contributing factor to problems within emergency departments. The Grand Jury requested and received data regarding behavioral health admissions to three local hospitals' Emergency Departments (ED). Comparable data was available for two years, 2010 and 2011. The three Emergency Departments saw 3104 individuals with a psychiatric or substance abuse related diagnosis during the two-year time span. The breakdown by year for the three ED's is 1493 individuals treated for a behavioral health disorder in 2010 and 1611 treated in 2011. Enloe Hospital, provided data showing the number of persons seen in their ED and evaluated by the Butte County DBH for treatment. The majority of these persons had been detained on a 5150. Over the three years for which Enloe provided data, 2009 through 2011, they reported a total of 1741 persons experiencing a psychiatric or substance abuse crisis entering their ED. Of that number 772 (44.3%) were accepted by DBH for ongoing services. An additional 170 (9.8%) persons volunteered to enter the Enloe Behavioral Health program for treatment. The remainder, 799 persons (45.9%) were released from the 5150 detention by DBH after the completion of a mental status exam. In addition to the 1741 persons evaluated, an additional 140 persons left the ED prior to seeing a physician or against medical advice. ED staff expressed concern regarding the number of persons leaving against medical advice and believe many of them would, or did, return later in crisis. Enloe Hospital also provided data regarding the wait time for a person, in a mental health crisis, was in their ED before being discharged. The average wait time over the three-year period was five hours fifty-seven minutes. The ED staff believe this time to be excessive. However, they have little control over the situation as only the DBH Mobile Crisis Team has the authority to release a person from a 5150 detention and this team’s availability is limited to daylight hours. On the morning that the Grand Jury met with the ED staff, three persons had been kept overnight waiting to be evaluated by the Mobile Crisis Team. The hospitals have a variety of problems as a result of persons experiencing a psychiatric crisis being in their emergency departments for extended periods of time. All of the hospitals expressed concern that persons experiencing a medical crisis might not be seen in a timely fashion if their ED beds and staff have been diverted to persons detained on a 5150 hold. Also, persons experiencing a psychiatric or substance abuse crisis may become combative. Enloe's ED has experienced nine staff injuries over the past three years with several of them requiring extensive convalescent time. This dangerous situation required the Enloe Hospital to provide security personnel on a 24/7 basis for the ED, as well as, additional social workers. This increased the ED's personnel cost for 2011by $232,000 for security and $127,000 for social workers. Additional cost to the Enloe Medical Center ED is the cost of ambulance transfers to/from DBH. The total cost to transport 167 patients in 2009, 178 patients in 2010, and 343 patients in 2011 was $119,712. Enloe Hospital’s total uncompensated cost of treating persons suffering from a psychiatric or substance use crisis was $1,815,744 over the three-year period 2009 – 2010. It was also interesting to note that the individual patient cost was $939 per patient if they were discharged directly from the ED and $2352 per patient if they were transferred to DBH. All of these numbers were provided by Enloe Hospital. Members of the MCT work only during the normal work day and the Grand Jury was told, were not authorized for over-time. The result is some consumers spend excessive time, sometimes more than 24 hours, waiting for a mental status evaluation. The delay in evaluation, and therefore the delay in release or transfer, of mental health patients was the major concern expressed by all area hospitals visited. Under the current procedures followed in Butte County, only the team from DBH can release a person from a 5150 hold. In other counties, qualified physicians (and others) are authorized transfer and/or release authority. The Grand Jury has been told changes to the current policy of restricting the ability of emergency department physicians to make determinations in 5150 cases are being considered. However, correspondence received by the Grand Jury shows this discussion has been going on for years. Despite several “summits” where problems were identified and solutions discussed the same problems remain. Since 30% to 50% of those who enter EDs under the 5150 are released after evaluation, delegating authority to ED physicians to approve release of certain 5150 cases would eliminate some of the problems caused by the delay in evaluation. The Grand Jury understands that some progress is being made toward giving emergency department physicians this authority. Depending on circumstances, there can be a number of possible outcomes to an evaluation conducted by the MCT. o Persons in serious crisis will be referred for in-patient treatment. Such treatment may be at the PHF operated by DBH, or if the PHF is full or not deemed appropriate for the particular consumer, at an out-of-county facility. o DBH also has a Crisis Stabilization Unit (CSU), called a 23-hour facility, where patients can be taken if it is determined that the crisis situation can be dealt with quickly. o Some patients are evaluated and assessed to not need further treatment and discharged from the ED without further treatment. In such cases it would be appropriate for consumers to be referred to primary care providers for treatment or scheduled for appointments at the appropriate DBH out-patient facility or with private mental health providers. Staff in all hospital EDs within Butte County complained that the protocol of laboratory tests required before evaluation of a patient by the MCT is too extensive and therefore unnecessarily costly. The cost of this treatment is billed to the patient or to his or her 12 insurance company, or to Medi-Cal if the patient is eligible. Understandably, patients who have been required to enter an ED facility pursuant to Section 5150 complain about this billing. Patients with private insurance find that sometimes the insurance companies refuse to pay the charges. Hospitals get paid for some, but not all of the costs incurred under these circumstances. PHF staff complained that consumers with medical problems such as pneumonia were sometimes transferred from a local ED to the PHF. Persons in both facilities complained that those in the other facility were at times rude, incompetent and uncooperative. The need to make changes and to make this system work better is once again readily apparent to members of the Grand Jury. California State law requires each county to designate a facility for the assessment of an individual’s mental status under Section 5150 of the California Code. The Butte County Board of Supervisors has designated the Psychiatric Health Facility (PHF) of DBH to meet this requirement. The designated facility must conduct a mental status exam “as soon as possible after he or she is admitted and shall receive whatever treatment and care his or her conditions requires for the full period that he or she is held” (quote from section 5152 of the California Welfare and Institutions Code). It does not appear that there are any provisions that require a medical workup prior to the assessment of the person’s mental status. If during the assessment it is determined the person requires care in a psychiatric or substance abuse inpatient facility, a physical health screening must be provided. The physical exam can be conducted by licensed medical practitioners within DBH or through a memorandum of understanding with a private provider such as a hospital or clinic. It appears that over time in Butte County the order in which these procedures must take place has become confused by DBH and local law enforcement. DBH currently provides 5150 evaluations through its CSU housed in the same facility as the PHF. It has been reported to the Grand Jury that as a result of budgetary problems within DBH the effective hours of the MCT were reduced to daylight hours only. When evaluations are not conducted at the CSU, all persons under 5150 holds are taken to a hospital emergency department. In other counties in California (Tehama County, for example), there are centralized intake facilities where persons in crisis can be evaluated, regardless of the time of day when the evaluation is needed. Such a center could be staffed by licensed mental health professionals and a nurse practitioner or physicians’ assistant, who would conduct the mental status evaluation and give basic medical clearance if necessary. A person determined to have a medical condition requiring immediate treatment could be transferred to an ED. A central intake facility would best benefit those in mental health crisis and it would best serve the interests of the County’s EDs by not placing demands on them to perform functions and services which they are not designated or specifically designed to provide. ED staff would be freed to carryout emergency medical treatment, thereby better serving the public interest. In-patient treatment is another area in which lack of co-operation between DBH and Enloe is troubling. At present DBH is limited in the number of psychiatric beds available. Pursuant to State requirements, the PHF is authorized to have 16 adult beds. There are currently no in- patient beds in the county for persons under age 18. Consequently, DBH is sending patients to expensive out-of-county facilities even though Enloe’s inpatient Behavioral Health facility 13 is rarely full. A co-operative relationship between DBH and Enloe Hospital would allow consumers to receive treatment closer to home and avoid the use of expensive out-of-county placements. The establishment of good working relationships, not only with Enloe but with all hospitals in the County would benefit, DBH, the hospitals, consumers and the community as a whole.  Communication issues between the management team at DBH and some staff, including the medical staff. One issue discussed was the need for an increase in billable hours by the licensed clinical staff. Many on the staff have expressed that their input is not sought or valued in the decision making process. The management style in DBH gives medical and other professional or para-professional employees the impression that their input is not valued. Under the current Director, efforts are being made to solicit input from staff at all levels. The current effort at drafting a Strategic Plan is an opportunity for such input. A management directive to have clinicians and counselors bill for at least 60% of their time has some staff feeling stressed. It is recognized that most clinicians and counselors are doing sufficient billable work, however, sufficient documentation by staff does not always take place. When Medi-Cal eligible consumers are treated, the billing rate is by the minute. It is very easy for a busy clinician to simply not account for the time spent for example on a ten- minute phone call to a consumer. Problems with billing and treatment planning are magnified for those who do not feel comfortable using the computer system. Questions about appropriate use of some staff members have been expressed. Many licensed staff are in strictly supervisorial or managerial rolls. Even though the need for management and supervision is recognized, it would be beneficial for all licensed professionals to devote a reasonable portion of their duty time to direct consumer contact. Not only would that give management a better understanding of the problems faced by staff, but it would also provide a morale boost to non-managerial/supervisorial staff and facilitate the total number of hours available for direct consumer contact.  The implementation of the AVATAR computer program is in its third year and still an incomplete process. Some recent progress has been made with medical staff increasing use of the portion of AVATAR which enables the e-prescribing of medications. According to a State report prepared in August of 2010, all staff except physicians were using AVATAR for progress notes, treatment plans and assessment. When a counselor or clinician meets with a consumer, the minutes spent must be recorded and the action documented. AVATAR is the means by which this is accomplished. During interviews, the Grand Jury determined it is still the case that some staff are more comfortable and better able to use the system than others. Not surprisingly, those whose general level of computer skill are higher are better able to use the system than those lacking these skills. The full implementation of this system will have the advantage of improving communication and will make processes such as the transfer of consumer records from in-patient to out-patient facilities quicker and less error 14 prone. This will increase the quality of service provision and will improve billing. DBH is underfunded and capturing the financial resources available to them is essential. Implementation of the AVATAR system should eliminate other problems observed which relate to intake procedures that vary from site to site and problems involving the transfer of a consumer’s records from an in-patient to an out-patient site. It appears, that often, a new intake is done when a consumer transfers from one site within DBH to another. It was noted by the Grand Jury and acknowledged by staff that the clinics run by DBH throughout the County operate as if they were independent entities. This impedes the Department’s ability to implement AVATAR and other system wide procedures. The ability for consumer records to be transferred by computer from site-to-site would be more time efficient, cost effective and place less of a burden on staff thereby increasing available clinical hours. Continued training and supervision of staff will be necessary to bring about full implementation of the AVATAR system. The fact that this system is at times slow and cumbersome to use, especially in clinic sites without adequate high-speed Internet service, does not diminish its importance in supporting the Department’s clinical activities. It is essential that it become fully implemented as quickly as possible.  The lack of significant programs for Alcohol and Drug Treatment was identified a serious problem. There are few opportunities for substance abuse treatment within DBH. It appears that many of those receiving such services have been given a dual diagnosis (psychiatric as well as chemical dependency) and are served by the mental health program. It is unclear how individuals with severe chemical dependency are served within DBH. In a County where substance abuse has been an issue for many years, there are few facilities and a shortage of treatment options. It appears that there are far fewer resources for substance abuse treatment that there were a decade ago. When a committee of the Grand Jury visited a facility for the treatment of alcohol and drug addiction in October, they found that the facility, while treating consumers from DBH, had no signed contract for the fiscal year that commenced on the first of July. This agency was awaiting payment for all services that had been provided since the beginning of the fiscal year. Problems such as this make those providing substance abuse services on contract with DBH financially vulnerable. It was later learned that the contract was signed in the months following the Grand Jury's visit to the site.  The Grand Jury found that procedures in place for actions following the death of a consumer were inadequate. County behavioral health programs usually have in place a “psychological autopsy” process which allows staff to better understand the circumstances of the death, deal with their own feelings and facilitate improvement of clinical practices. If procedures for the staff to review circumstances applicable to the death of a consumer are in place, they are not readily apparent. The form used by DBH in such circumstances is brief and seems to be more 15 oriented toward providing information which allows for the closing of the chart. Allowing for closure by staff, for review of procedure and practice, and for the opportunity to identify shortcomings should be a formal part of the overall review process. For the most part the Grand Jury was unable to gather significant information concerning consumer deaths. The Department reported 15 deaths among its consumers in 2009, and 16 in 2010. The consumers involved ranged from those waiting for a first appointment to those who had been under the care of DBH for more than two decades. Several of the deaths were suicides. Other deaths were complicated by chronic illnesses.  Many inmates released either from the Butte County Jail or from State Prison back to the County, were identified while incarcerated as having mental health issues. Data provided by the Director of Health Services for the County jail shows that approximately one-third of those persons incarcerated, on average, have behavioral health issues. Following release from custody, few procedures are in place to facilitate continued mental health services for inmates who received treatment while incarcerated. Many inmates receiving medication through the jail health services are not discharged with enough medication to meet their needs while waiting to be assessed for DBH services. Consequently, they often appear at a hospital ER having de-compensated psychologically. In the worst case they are re-incarcerated for a crime committed due to their inability to access ongoing services. Many of these released inmates come to the attention of DBH only because of a developing crisis. There is a need for a system that identifies these persons and attempts to connect them with the appropriate out-patient facility immediately upon release. At present there appears to be limited communication between those who take care of the mental health needs of consumers while incarcerated and those who provide the services after release. In conjunction with law enforcement officials and private providers, DBH must develop a program that can assist such persons. This is another situation where the lack of funding has transferred costs from the appropriate provider, DBH, to other institutions, law enforcement and emergency departments. CONCLUSION The Grand Jury recognized the Director of DBH for the positive actions taken in the time she has been in her position. Though serious challenges are yet to be faced, compared to the Department examined two years ago DBH is much improved. Continued improvement is a goal the citizens of the County should expect to be achieved.
• R3

  Page 40
  That DBH implement policies that make long term planning a priority. As a part of the planning procedure DBH identify gaps in services, needs for prevention/education, staffing and financial resources.
• R4

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  That DBH design and implement procedures for conducting a psychological autopsy following the death of a consumer. 18
• R5

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  That DBH improve working relationships with area hospitals, especially with regard to the use of emergency departments by those in mental health crisis situations. That DBH review of the function of the Mobile Crisis Team and expand its availability and response capability.
• R6

  Page 41
  That DBH, together with area hospitals and the Board of Supervisors, develop a policy that will allow emergency department physicians to release 5150 holds.
• R7

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  That alternatives for those entering the mental health system in crisis be explored, including the possibility of establishing a central intake facility.
• R8

  Page 41
  That as part of an improving relationship between the DBH and Enloe Hospital, opportunities for better use of the Enloe Behavioral Health be explored.
• R9

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  That opportunities for the expansion of drug and alcohol treatment programs be explored.
• R10

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  That DBH work with corrections officials and any other involved agencies to establish procedures to insure that those being released from incarceration are connected with out- patient mental health services in a timely manner.
• R11

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  That DBH and all area law enforcement agencies work together so that policies and practices concerning the application Section 5150 are appropriate.
• R12

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  That DBH continue efforts to fully implement the AVATAR system, including the training and supervision of all appropriate staff.
• R13

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  That DBH continue efforts to minimize the need for costly out-of-area placement of youth and adults needing in-patient care. DBH may need to provide the leadership necessary to initiate discussions with nearby counties to establish a facility to provide in- patient treatment for youth.
• R14

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  That DBH explore, with area hospitals and other entities, the possibility of the establishment of a facility for treatment of geriatric patients with mental health issues.
• R15

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  That DBH publicize its programs to increase public awareness and support for its work and the services it provides. This should include placing meeting notices in newspapers, on appropriate websites, on community calendars, and utilization of other media as appropriate. 19
• R16

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  That before the 2012-2013 budget is adopted, the City Administrator and the Finance Officer follow through on actions taken in the 2011-2012 budget to resolve the Planning Department budget allocation issue as it relates to the 2030 General Plan update by making appropriate inter-fund budget transfers.
• R17

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  That the City research, reconstruct, and attain an accurate record of the events, inclusive of expenditures and inter-fund transfers, that have either contributed to or caused the on- going allocation of funds issue pertaining to the Planning Department budget.
• R18

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  That the property owner reimbursement plan for the Eagle Meadows Maintenance Assessment District be implemented by summer of 2012, and that past and present Eagle Meadows subdivision owners be notified by the City of Gridley with an explanation of the details of the reimbursement plan.
• R19

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  That in order to best serve the public, the plan for reimbursement of Eagle Meadows Maintenance Assessment District overcharged assessment fees be a product of very close coordination between the City Council, City Attorney, City Administrator and City Finance Officer.
• R20

  Page 92
  That the City continue, and intensify, efforts to obtain an adequate response from AT&T, which will allow the City to determine a course of action to bring the outstanding AT&T bill issue to a conclusion.
• R21

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  That the City not address its correspondence seeking information from AT&T “To Whom it May Concern,” but instead address correspondence to a specific named point of contact. 70
• R22

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  That the City establish a General Fund reserve for contingencies with a goal of containing and maintaining not less than an amount which would cover contingency cost expectations based upon previous annual General Fund expenditures.
• R23

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  That the City Administrator establish and implement procedures that will inform City staff of reasons for inter-fund transfers and changes in budget allocations as they occur.
• R24

  Page 93
  That department heads and Finance Department staff receive additional MOMS training.
• R25

  Page 93
  That prior to providing utility connections and services to businesses, the City properly formalize all connections and services agreements, and create and enter the proper billing codes into the City financial management system.
• R26

  Page 93
  That the City identify, evaluate and apply available alternative funding sources to offset RDA funding losses.
• R27

  Page 93
  That the City install a technologically appropriate and efficient sludge flow measuring/monitoring unit with backup at the juncture of the City’s sewer system waste water intake point and the waste water outlet point of any party suspected of discharging sludge into the City sewer system.
• R28

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  That in the event the City determines the offending party responsible for excessive sludge discharge into the City sewer system, the City seek full reimbursement of all costs incurred by the City.