Office of the County Administrator County of Marin August 22, 2023 AUG 2 2 2023 Matthew H. Hymel Marin County Board of*

Marin has siloed and fragmented aging services that are not well integrated among County departments, thus creating confusion for older residents and family members. Response: Disagree. Although there is always room to improve the coordination of Aging and Adult services for our residents, we believe that Health & Human Services (HHS) is the appropriate organization to integrate these services among HHS and other County departments. HHS works closely with County departments such as the Marin County Free Library, Parks, Public Works, Community Development, the County Administrator, and the Marin Housing Authority, for example, to ensure collaborative services are delivered to older adults. The Information and Assistance line (accessible by calling 415-473-INFO) eliminates confusion by providing a single phone line to connect older adults and caregivers with services and support. Currently, older adults are the only population with a dedicated resource line operated by the County. Older adult services are integrated into most Social Services programs including CalFresh, MediCal, General Relief, the West Marin Service Center, Veteran's Services, and the Public Guardian. Services for older adults are integrated into The Division of Child Welfare, also within HHS, to provide support for children and caregivers in multigenerational families. The Behavioral Health & Recovery Services Division (BHRS) has a designated Adult and Older Adult System of Care Division as well as Older Adult Prevention and Early Intervention program. Other services for older adults are embedded throughout our systems of care (e.g., Crisis Stabilization Unit/Mobile Crisis, Forensic, Substance Use, Marin Housing Authority, District Attorney, etc.). In Public Health, great efforts have been taken to ensure older adults are cared for and protected. Working with the Aging Division, special clinics for vaccinations were designed during the COVID-19 pandemic, along with special outreach to long-term care facilities. Public Health also works with the Aging Division to identify opportunities for disaster preparedness for older adults both in their homes and in congregate living. Approximately 30% of individuals successfully housed through our Homelessness/Whole Person Care Division are older adults. The Homeless Policy Steering Committee (HPSC) has created an Older Adults subcommittee focused on understanding the unique needs of this population and creating innovative solutions/interventions and collaborations. The County continues to expand investments for older adult services with the goal of further County integration. HHS has worked closely with the County Administrator to propose a number of additional service enhancements that were approved by the Board of Supervisors in this Fiscal Year 2023-2024 budget: 1) $200,000 annually to fund a new, permanent position to support Aging and Adult Services Initiatives County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations "The Coming Wave of Older Adults — Is Marin Prepared?" (May 30, 2023) 2) A new Eligibility Worker position focused on helping In Home Supportive Services (IHSS) recipients with mental or physical impediments to maintain caregiver support. 3) A recommendation to increase the County Living Wage from $16.95 per hour to $18 per hour beginning in 2024. This will primarily benefit IHSS workers and potentially grow the pool of available caregivers in the County. There are other Department initiatives outside of HHS that were approved in the budget which will have a positive impact on integration of services for older adults. These include additional staff to support affordable housing, active transportation planning, and extended funding for non-profit service providers. These investments will support the goal of further integrating county services for older adults, within HHS as well as across departments.

Marin is not prepared to adequately serve the coming wave of Older Adults. Response: Partially Disagree. There is always room to improve integrated services systems. County services are one component of a network of public, private, and community-based services that are critical for meeting the needs of older adults. To further inform this countywide integration, the County procured a consultant, Githens and Associates, LLC., to develop the Integrated Aging Services Study (January 2023). Since the report was published early this year, HHS has been meeting with stakeholders to engage on prioritization and implementation efforts. Marin currently has a well-supported Aging and Adult Services Division that works closely with community partners, advisory boards and commissions, and other social service providers to identify needs and support our growing older adult population. The County continues to focus on improving and enhancing our integrated older adult service system with our partners. For example, as part of the Fiscal Year 2023-24 budget process HHS and the CAO worked closely with community stakeholders to propose budget enhancements for community resources and to support organizational preparedness in the coming years. Funding was approved by the Board of Supervisors to advance community engagement regarding older adult needs, service supports, coalition building, and more. Some examples include: 1) $220,000 for: (a) An intern to work for the Aging Action Initiative (AAI); (b) AAI stakeholder convenings in 2023 and 2024; (c) Commission on Aging funds to support event planning and trainings; (d) Countywide training on agism and ableism for County staff; and (e) the development of a "How to Guide" for older adults living in Marin County. 2) $234,033 for the West Marin Collaborative through a partnership with West Marin Fund. The County is committing these funds to enhance service infrastructure, technical assistance for providers, and grant funding for unincorporated West Marin providers. This effort is supported for three years, with the goal of developing a sustainable and thriving services infrastructure. This proposal directly stems from a

Today, finding the resources that an Older Adult or caregiver needs requires navigating a maze of options. There is a compelling need for a seamless and unified County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations "The Coming Wave of Older Adults — Is Marin Prepared?" (May 30, 2023) "doorway" or portal for older residents and family members to navigate to and access County services and referrals to Community Based Organizations for Older Adults. Response: Agree. The Information and Assistance line (415-473-INFO), operated through Aging and Adult Services and funded largely by the County's General Fund, provides this doorway. Staffing has been expanded in 2022-23 to include Vietnamese language services, in addition to the Spanish language services already provided. This multilingual capacity allows Information and Assistance to serve monolingual older adults with culturally and linguistically appropriate services. HHS will continue to explore ways to bolster the Information line. As previously noted, the Board of Supervisors approved funding that will allow HHS to work with older adult advocates and service providers, to create and publish an information guide for older adults and families. This "How-to-Guide" will be a shared effort between HHS, the Aging Action Initiative (AAI), the Commission on Aging, and other local service providers. In addition to the expertise of local providers, as the Commission on Aging has representatives from each Board of Supervisor district, as well as each of Marin's municipalities. Countywide representation and input will support the development of the most robust guide possible. As part of the recently approved MHSA three-year plan, BHRS is dedicating funding to develop system navigation materials, including an interactive map of services and providers. Additionally, BHRS is reviewing public facing materials for clarity and accessibility. Continuum of Care clients frequently utilize the 415-473-INFO line and are referred to homeless service providers. Additionally, there is a specific 415-473-HOME phone line and HHSHome@marincounty.org email to channel clients to immediate assessment and connection with Coordinated Entry and other services.

Based on the percentage of the HHS budget allocated for Aging and Adult Services, and its placement within the HHS hierarchy, the well-being of Older Adults is not reflected as a County priority. Response: Disagree. The budget presented in the Grand Jury report is incomplete. Other parts of HHS serve the older adult community, including programs in Public Assistance, Public Health, Homelessness/Whole Person Care, and Behavioral Health and Recovery Services (BHRS). Although we know the share of budget dedicated to older adults is more than what was identified in the Grand Jury report, it is difficult to extrapolate the exact budget for older adults in many programs. For example, in BHRS, older adult services are integrated into every BHRS program serving adults. However, several line items for older adult services can be identified in the budget: The HOPE Program: A Mental Health Services Act program that provides multidisciplinary, intensive case management for people over the age of 60 living with mental illness ($850,000 annually). County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations "The Coming Wave of Older Adults — Is Marin Prepared?" (May 30, 2023) 2) Prevention and Early Intervention (PEI) for Older Adults: The Older Adult PEI program provides individual and group counseling to older adults to address depression and anxiety, often in connection with their medical issues, loss, or other difficult life transitions. Clinicians engage with older adults through home visits and well as consistent collaboration with family members and health providers ($320,000 annually). 19% of BHRS clients are older adults, so it is reasonable to assess that 19% of the BHRS budget, or $19 million, is dedicated to older adult services. Additionally, a disproportionate share of older adults (compared to the total community) is connected to housing through Whole Person Care programs. These services include temporary shelter, outreach, housing-based case management, and rapid rehousing. As previously noted, approximately 30% of individuals successfully housed through our Homelessness/Whole Person Care Division are older adults, which reflects the largest age group housed within these programs. It is important to note that this data specifically reflects individuals aged 62 and older. Given that, if data were calculated and analyzed for individuals housed aged 55 and older, it should be anticipated that the number of older adults aged 60+ that are served in these programs – as well as those served on the verge of becoming an older adult - are by far the largest cohort and therefore receive the largest ratio of program funds within HHS homelessness programs. These are some examples of program budgets that directly serve Older Adults that were not included in the Grand Jury's report.

There are not sufficient low and moderate income housing options for the Older Adult population, and current options do not fully address needs that range from low-income, and independent living to full dementia and Alzheimer's 24x7 care assistance. Response: Agree. We agree that there are not sufficient low- and moderate-income housing options for older adults, despite considerable gains made by County's housing programs: 1) The IHSS program often allows older adults who are MediCal eligible to maintain their existing housing, thereby preventing homelessness. The new Adult Protective Services Home Safe program is designed to prevent housing insecurity for older adults who are at risk of abuse and neglect. From 2017–2022, 30% of persons housed through Whole Person Care and other County services were aged 62 or older. This represents a total of 156 units of housing secured for older adults over a five-year period. The County has successfully completed several HomeKey projects since 2020, including La Casa Buena, 1251 South Eliseo, and 3301 Kerner. Many of the residents moving into these HomeKey projects are older adults. Additional housing is available at Jonathan's Place and the Vivalon Older Adult Campus which the County has supported financially. 5) Two housing programs have dedicated beds for BHRS clients who are older adults with serious mental illnesses. These are: Fireside Apartments in Mill Valley (five beds) and Victory Village in Fairfax (six beds). Growing housing capacity continues to be a priority for BHRS. County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations "The Coming Wave of Older Adults — Is Marin Prepared?" (May 30, 2023)

Marin relies heavily on Community Based Organizations. Additional County funding is needed by essential Community Based Organizations that partner with the County to do the necessary work for the Older Adults in Marin. Response: Partially Disagree. Partnerships with Marin community-based organizations are essential. The County has increased funding for the Community Services and Nonprofit Partner program by $500,000 over the last three years. Additionally, a significant portion of the HHS budget goes to fund community-based organizations. For example, approximately $75 million of the BHRS division's $100 million budget goes to fund community-based organizations. The County continues to develop new or modified funding approaches to enhance support CBOs. As part of the Fiscal Year 2023-24 budget process, HHS and the CAO worked closely with community stakeholders to bring forward budget proposals to further enhance community resources and supports linked to the Aging Action Initiative (AAI), the Commission on Aging, and the West Marin Collaborative. While new efforts continue developing this upcoming fiscal year, all of these are recent examples of how the County has actively sought to enhance meaningful contributions for CBO services and supports.

With its current reporting relationship, Aging and Adult Services is not part of the HHS Executive Team. Thus, Aging and Adult Services does not have the opportunity to participate in cross-functional, and cross-departmental County teams ensuring that the needs of older residents are considered in all County projects, including those outside HHS. Response: Partially Disagree. Aging and Adult Services is currently part of the Extended Executive team of HHS and frequently collaborates with Public Health, Behavioral Health, and Whole Person Care. Effective July 1, 2023, the Division Director of Aging and Adult Services became a full member of the HHS Executive Team.

In nearly all of the other Bay Area counties, the aging services departments report to the highest-ranking or second highest ranking leader in the organization, which is recognized as a critical member of their cross functional executive teams. Response: Disagree. The current structure in Marin, with Aging within the organization of Social Services, is comparable to the structure of a majority of California counties. Aging reports to the Social Services Director, who is an Assistant Director for the HHS Department. The Integrated Aging Study was somewhat misleading in this area. If Marin were to remove Aging from the Social Services umbrella, it would be an anomaly statewide and would result in decreased state and federal revenues available to support Aging programs and administrative staffing. This scenario would lend itself to an increased demand for County General Fund dollars to maintain the AAS services and staffing structure as it exists, reducing the potential for local dollars to be considered for supporting other County and community needs. For example, it could further strain opportunities to put funding toward enhancing Community Based Organization capacity in County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations "The Coming Wave of Older Adults — Is Marin Prepared?" (May 30, 2023) future years, as referenced by the Grand Jury's F6 finding which reflected a need for additional County funding.

With the projected increase of Marin's non-English speaking populations, the County needs to ensure that all of its residents have access to services and information in the language they speak. As was seen during the pandemic, the ability to communicate in one's native language ensures that essential information is accurately communicated to the residents in need of services and information. Response: Agree. The County is committed to hiring bilingual and culturally fluent staff in all areas, and committed to staff proficiency and utilization of language line and translation services. The BHRS Cultural Humility and Responsivity Plan (2022-23) notes that 93.75% of clients received mental health services and 98% of clients received substance use disorder services in their preferred language. 25% of BHRS staff are Spanish bilingual, and 1.6% are bilingual in Vietnamese. This compares favorably to the number of BHRS clients who speak Spanish (7.8%) and to those that speak Vietnamese (1.0%).

Collaborative planning and adequate funding of limited aging services resources within the county is needed to preserve important healthcare options. Response: Agree. Preserving and maximizing resources for a healthy older adult population is a priority for the County. The California Advancing and Innovating Medi-Cal, or CalAIM, is a long-term statewide commitment to transform and strengthen Medi-Cal - offering Californians a more equitable, coordinated, and person-centered approach to maximizing their health and life trajectory. Older adults are a top priority population in these conversations. Marin County HHS is committed to adopting the CalAIM transformations to create a more coordinated, person-centered, and equitable health system for older adults in the County.

Additional resources are needed for West Marin and other isolated areas to address transportation, food delivery, medical services, and making wellness checks and contact with isolated residents. Response: Agree. Under the Social Services Division, services to West Marin residents have expanded significantly over the last year. The current manager of the West Marin Services Center previously supervised the Information and Assistance line in Aging and Adult Services. As a result, she is well versed in older adult resources throughout the County, including West Marin. The County has made West Marin a priority in disaster planning response, given the large and vulnerable older adult population. During the pandemic, HHS operated the Great Plates program (restaurant meal delivery for homebound older adults with no income based eligibility). West Marin had the largest per capita participation rates in the Great Plates program. HHS has County of Marin Response to Grand Jury Findings and Recommendations County of Marin Response to Grand Jury Report Findings and Recommendations "The Coming Wave of Older Adults — Is Marin Prepared?" (May 30, 2023) a dedicated West Marin Behavioral Health Practitioner and an additional bilingual staff member who floats to West Marin on a regular basis. As part of the Fiscal Year 2023-2024 budget process, HHS and the CAO worked closely with community stakeholders to bring forward budget proposals to further enhance community resources and supports for West Marin. One referenced example is through a partnership with the West Marin Fund, where the Board of Supervisors approved a commitment of funds to directly enhance services infrastructure, technical assistance for providers, and grant funding for Community Based Organizations that will be dedicated to unincorporated West Marin, enhancing available supports for older adult residents as a priority population. RESPONSE TO GRAND JURY RECOMMENDATIONS