Contra Costa County Civil Grand Jury Report No. 2102

Prior to the Covid-19 pandemic, tele-mental health and audio-only services available through BHS were a small portion of the outpatient services provided (7% in 2018; 8% in 2019). Response: Respondent disagrees partially with this finding. Our data indicates that 12% of services in 2018 were tele-mental health and audio-only services, and almost 13% of services in 2019 were tele-mental health and audio-only services.

During the Covid-19 pandemic, BHS did not offer training to prepare clinicians or clients for effective and confidential use of tele-mental health services. Response: Respondent disagrees wholly with this finding. The use of telehealth has been the subject of Behavioral Health Services (BHS) staff meetings and BHS has provided a variety of materials and training for both clinicians and clients promoting the effective use of tele-mental health services during the COVID-19 pandemic, including a 14-page telehealth user guide for staff (Attachment A). The user guide includes procedures for identity verification, instructions for using multiple devices (e.g., phone, tablet, computer), instructions to assist patients, and how to use interpreters while using telehealth. There are also training materials for patients in both Spanish and English to assist them with telehealth sessions. Telehealth tools utilized by BHS clinicians are compliant with HIPAA privacy rules.

During the Covid-19 pandemic, BHS tele-mental health services continue to be underutilized. While audio-only increased to 52% of all outpatient services, tele-mental health was 18% of outpatient services delivered. Response: Respondent disagrees partially with this finding. The number of clients who chose to receive telehealth or audio-only services increased significantly during the onset of COVID-19 for obvious reasons of health safety. BHS rapidly adapted to this need and heavily used both telehealth and phone modalities. It is important to note that County clients are provided a choice in terms of modality for services provided by BHS. There has been a shift in preferred modality during COVID-19. With vaccines available, less community spread, and broader acceptance of mitigation measures such as masks and social distancing, there has been an increased demand for in-person services. Quarter three data comparison between 2020 and 2021 indicates audio-only outpatient services decreased from 38.2% to 34.7% and telehealth outpatient services decreased from 25.5% to 14.0%. The graph below reflects the change in demand: significant increase for in-person services, and lowered demand for telehealth and audio-only services.

At the outset of the Covid-19 pandemic, tele-mental health and audio-only services decreased the number of missed appointments. Response: Respondent agrees with the finding.

Tele-mental health services are appropriate for clients who are more stable, verbal and insightful. Response: Respondent agrees with the finding.

Tele-mental health services are appropriate to use with clients displaying symptoms of anxiety and depression. Response: Respondent agrees with the finding.

The greater use of audio-only services has the limitation of not offering visual cues, which provide clinicians with important clinical information. Response: Respondent agrees with the finding.

Tele-mental health services are not appropriate for a. Homeless populations b. Patients presenting with chronic schizophrenia with a limited capacity to manage the tasks of daily life c. Patients prescribed controlled substances or injectable medication. Response: Respondent disagrees partially with this finding. There could be instances where engagement with homeless populations is more accessible using telehealth or audio-only modalities. In-person services can sometimes be disadvantageous to clients due to logistical barriers such as transportation or timing. In these cases, engagement with clients via telehealth can be the preferred modality, perhaps as an adjunct to in-person services. On the other hand, telehealth and audio-only is likely to be ineffective with patients described in b and c above. In-person service is required for clients who are prescribed controlled substances or injectable medication.

BHS has not incorporated tele-mental health into a comprehensive service delivery model to offer a broad range of opportunities for underserved populations to receive mental health services. Response: Respondent disagrees wholly with this finding. Following protocols set forth in the California Department of Health Care Services (DHCS) Behavioral Health Information Notice No: 20-009, tele-mental health is firmly incorporated into the behavioral health service delivery system in Contra Costa. Clients are given the option of service modality, and BHS has the hardware and software necessary to render tele-mental health services to clients electing to receive it. Services available via tele-mental health include mental health services, crisis intervention services, targeted case management, therapeutic behavioral services, intensive care coordination, intensive home-based services, medication support services, and components of day treatment, intensive day rehabilitation, adult residential treatment services, and crisis residential treatment services.

Access to outpatient mental health services in Contra Costa County suffers from difficulties with transportation to clinics, long wait times for appointments, and insufficient availability of after-hours appointments. Response: Respondent disagrees partially with this finding. Transportation issues have been long-standing challenges for mental health clients. Contra Costa is a large county and access to public transportation is a common issue. To address this challenge BHS has been involved in the “Barriers to Transportation Project,” hiring two Community Support Workers as Commute Navigation Specialists (CNS) in March 2017. The program is a systematic approach to developing effective family and peer-driven transportation navigation support to the entire mental health system of care. Regarding long wait times, BHS is well within DHCS standards (70% threshold): • Overall clinical timeliness to meeting the first offered appointment standard (10 business days) was at 96.3% for FY 20-21 • Overall psychiatric timeliness to meeting the first offered appointment standard (15 business days) was at 92.2% for FY 20-21 Contra Costa County clients have access to after-hours and weekend services at the Miller Wellness Center.

BHS has a limited number of clinicians who can provide culturally and linguistically sensitive services to diverse minority groups. Response: Respondent disagrees wholly with this finding. BHS has devoted considerable resources into ensuring the diversity of clinicians to provide culturally and linguistically sensitive services to diverse minority groups. An in-house Ethnic Services Manager/ Ethnic Services Coordinator who helps ensure that the workforce has the background and training to work with diverse groups and develops the Cultural Humility Workplan, a living document with clear focus areas and goals. Additional resources include an ongoing training plan, differential pay for bilingual staff, and a Language Line with Health Care Interpreter Network (HCIN) for interpretation services. According to the Network Adequacy Certification Tool (NACT) for documenting network adequacy, the BHS has a 97% compliance rate for cultural competency training, 180 providers who are fluent in Spanish, and fluency by providers in numerous other languages including Farsi, Tagalog, ASL, Vietnamese, and Mandarin. The latest Consumer Survey (June 2020) indicates that 94% of patients received services in their preferred language, and 91% stated they agreed or strongly agreed that their provider was “respectful and supportive of my culture, values, beliefs, life ways, and lifestyle” (this includes race, religion, language, gender/gender expression, sexual orientation, or disability). Providers are also matched with patients for specialty areas, including LGBTQ, Ethnic Minorities, language, and location.

Increasing access to mental health services is a priority for Contra Costa County BHS. Response: Respondent agrees with the finding.

The FCC reported 99.2% of Contra Costa County residents have access to internet broadband for greater use of tele-mental health services. Response: Respondent disagrees wholly with this finding. Although 98+% of Contra Costa residents may have access to broadband services, it is not true that 98+% are subscribing to broadband. These are entirely different issues, and there is a significant number of BHS clients who do not have broadband. Access to public computers is not reflective since the use of a public computer is not conductive to receiving telehealth services. As indicated in the Grand Jury report, in Contra Costa County over 98% of individuals have access to broadband; however, only 72% have broadband as indicated in this article on broadband use across the counties. https://www.thecalifornian.com/story/news/2021/07/07/gda-broadband-local-ca-psas/47204929/ Interactive Map: https://datawrapper.dwcdn.net/9LhSS/8/ Moreover, this number is substantially less when considering the demographics of BHS consumers. The mandate for the Mental Health Plan (MHP) is serving Medi-Cal eligible citizens of Contra Costa with serious mental health and/or substance use issues. Individuals and families must be low income to qualify for Medi-Cal, and income is correlated with having broadband access, as shown in the data below from research conducted by Pew Research1. In 2021, only 57% of individuals who earned less than $30,000 per year used broadband from home.

BHS has not followed the directives of the California Telehealth Advancement Act of 2011 to develop telehealth services to better meet the needs of underserved populations in the community. 1 https://www.pewresearch.org/internet/fact-sheet/internet-broadband/?menuItem=2ab2b0be-6364-4d3a-8db7- ae134dbc05cd Response: Respondent disagrees wholly with this finding. As mentioned in the response to Finding 9, BHS has a full array of services available to meet the needs of the underserved in the community. The Telehealth Advancement Act of 2011 and several Notices from DHCS (Behavioral Health Information Notice No: 21-047; Behavioral Health Information Notice No: 21-047), have removed telehealth barriers and ensured parity between in-person services and tele-mental health services. BHS has fully embraced tele-mental health. Evidence of the commitment of BHS to tele-mental health is evident in the memo sent to BHS staff and contract providers on March 20, 2020: “Guidance Regarding Provision of Services During COVID-19”. The memo is included in this report as Attachment A.

The Congressional Consolidated Appropriations Act of 2021 expands Medicare services to allow tele-mental health services to be integrated with in-person sessions, and to be received by beneficiaries in their home without geographic limitations. Response: Respondent agrees with the finding.

BHS lacks an adequate electronic data system to evaluate the efficacy of outpatient mental health services provided. Response: Respondent disagrees partially with this finding. BHS utilizes the Contra Costa Health Services Electronic Health Record system, which has enabled streamlined documentation, collection of assessment and outcome measures, client- centered medical records, program level aggregate data, reporting tools, and performance dashboards. Current electronic data systems are used for generating reports include Objective Arts for the CANS (Child and Adolescent Needs Assessment), ANSA (Adult Needs and Strengths Assessment), PSC-35 (Pediatric Symptom Checklist), and QLIK for dashboards. However, the current system is bifurcated between two different systems: one for the clinical record (Epic/ccLink) and the second for practice management (Echo/ShareCare). This configuration has been necessary due to unique BHS billing rules, which are due to expire in July 2023. BHS is heavily engaged in finding a solution for a truly integrated system that will capture clinical and practice management data and support evaluation of the effectiveness of mental health services.

BHS does not collect clinical data from network providers, which limits accountability for the outpatient mental health services provided to county residents. Response: Respondent disagrees partially with this finding. BHS collects a variety of clinical data from network providers, including the CANS, ANSA, and PSC-35. These are entered into the online Objective Arts system. BHS is working to identify solutions that will have direct entry for other measures from network providers, for a consolidated, centralized data repository available in real time for ensuring accountability and measuring effectiveness. RESPONSES TO RECOMMENDATIONS: By June 30, 2022, it is recommended that Contra Costa Behavioral Health Services