A Disjointed System

The continuum of care for justice-involved people who have committed low-level crimes due to their behavioral health disorder is disjointed between BHSD, CBOs, community programs, the Court, and Custody Health. The County and its partners’ programs and services are too siloed, resulting in a lack of coordinated care. Response to Finding 1 The County partially agrees with the finding. The County has established and continuously expanded a coordinated continuum of care for justice involved persons with behavioral health disorders. For example, the County’s San José Reentry Resource Center (SJ RRC), includes integrated medical and behavioral health services to serve as a “health home” for justice-involved persons. These services are provided in coordination with housing, shelter, public assistance, and employment services, some of which are directly accessed through multi-agency staff located at the SJ RRC. Additionally, each year the BHSD plans, implements, and coordinates reentry services for approximately 300 individuals who participate in the Mental Health Diversion and Behavioral Health Treatment Court. Services for these individuals are coordinated with justice system partners like the Court, County Departments like Custody Health Services and the Office of Supportive Housing, and community-based organizations (CBOs) that are under contract with the County. The challenge is to develop and sustain a system of care with enough capacity to serve all individuals who are booked into the jail, especially those with behavioral health conditions and to increase communication and coordination between in- and out-of-custody services. The California Advancing and Innovating Medi-Cal (CalAIM) Justice Involved initiative presents an opportunity for the County and its partners to devote significant additional resources and focus to meeting this challenge. The County is currently in Board of Supervisors: Sylvia Arenas, Cindy Chavez, Otto Lee, Susan Ellenberg, S. Joseph Simitian County Executive: James R. Williams Adopted: 08/13/2024 discussions with the California Department of Healthcare Services (DCHS) to implement the CalAIM Justice Involved initiative, a program that provides 90-day pre-release services for justice-involved individuals, which includes behavioral health linkage and warm handoff processes. In preparation for a proposed October 2024 go-live date, the County and its partners have ramped up communication and collaboration to ensure that the programs and services do not operate in vacuums and all stakeholders are readily involved and informed for effective coordination. Through new funding opportunities and process improvement requirements, the CalAIM Justice Involved initiative gives the County an opportunity to substantially restructure the continuum of care for justice- involved persons. Over the next several years, County Departments will work with justice system partners to develop a system that can serve more people, has a spectrum of services tailored to levels of need, and begins the discharge/reentry planning process as early as possible.

BHSD staff in Collaborative Court and Custody Health do not systematically collaborate to support the clients they have in common, resulting in clients spending unnecessary time in custody. Response to Finding 2 The County partially agrees with this finding. For every individual in Collaborative Court receiving a discharge plan, BHSD staff works with Custody Health staff to coordinate and execute the plan to ensure efficient release into community treatment. Custody Health and BHSD collaborate on all Collaborative Court cases on a weekly basis. They conduct regular multidisciplinary case consultations involving medical social workers, mental health staff, and Collaborative Court managers to develop individualized discharge plans that address the complex needs of individuals. For all Collaborative Court participants, BHSD is also in direct communication with the Office of the Public Defender, the Office of the District Attorney, other justice system partners (e.g., Probation Department) and nonprofit organizations to ensure continuity of care post-discharge. Once the Collaborative Court determines the conditions under which a participant can be released from jail, the primary reason for someone remaining in jail is the lack of available behavioral health treatment facilities and/or capacity in intensive outpatient treatment programs. Increasing the capacity of both is an ongoing priority for the County. And through the efforts described in the response to Finding 1, we anticipate making significant progress in increasing coordination and communication.

The current system does not allow for discharge planning for people accused of low-level offenses with behavioral health disorders soon after arrest and booking. Response to Finding 3 The County partially agrees with the finding. Many individuals who are accused of low-level offenses are released from custody within hours of being booked, before there is an opportunity for BHSD or Custody Health to plan for discharge.

The current countywide system is not conducive to justice-involved clients with behavioral health disorders establishing a personal connection with a service provider who can help them navigate all available services for the long-term. Such a personal connection could increase the likelihood of clients participating in treatment plans and transitioning more smoothly to the community. Response to Finding 4 The County partially agrees with the finding. The County provides significant in-reach and system navigation services for many justice-involved clients with behavioral health disorders, including all Collaborative Court participants. BHSD contracts with provider agencies that provide in custody outreach (in-reach) and engagement services to individuals in custody. Upon receiving a referral, the contractors physically meet the individual in custody and orient them on the services offered by the agency. Utilizing the information gathered via the screening and referral process and additional information gathered during the in-custody visit, staff from the agencies determine the transitional needs of the individual and ensures services are in place prior to the individual’s release into community. This determination includes ensuring that prior to release an intake and medication evaluation appointment are scheduled, medications and any follow-up medical appointments have been secured, placements to services are made, their case manager will be outside the doors of the jails when the individual is released, and that transportation to their scheduled appointments and placements have also been secured. However, there are substantial opportunities to improve and expand these efforts, which is an ongoing focus for Custody Health and Behavioral Health leadership.

County services do not have a central repository for client digital records. This impedes coordination of care. Response to Finding 5 The County agrees with the finding.

Collaborative Court judges are often forced to rely on clients bringing paper copies of their CSRs to court to be able to assess their adherence to program requirements. This is a cumbersome barrier toward program graduation and reentry into the community. Response to Finding 6 The County agrees with the finding.

Insufficient staffing and an increased workload of BHSD in FDR has negatively impacted staff morale and led to longer wait times for clients who are incarcerated to enter treatment programs. Response to Finding 7 The County agrees with the finding, although the County has budgeted for more positions than are currently filled, we have faced persistent challenges filling vacancies due to the overall shortage of qualified behavioral health workers and even more limited pools of applicants wanting to work in criminal justice.

Innovative programs such as PARR successfully reduce time incarcerated for their clients. Response to Finding 8 The County agrees with the finding. In June 2023, data scientists at UC Berkeley’s California Policy Lab (CPL) published a policy brief detailing their findings from a study of Santa Clara County’s PARR program. CPL reported two key findings1: 1. Arrested individuals who received PARR services were detained in jail, on average, for 23 fewer days relative to comparable people who did not receive PARR services (6 total days vs. 29 total days). This reduction reflects both reductions in pretrial detention, as well as potential reductions in the probability and length of incarceration imposed at sentencing. 2. PARR participants were more than twice as likely to have their cases dismissed altogether, thereby avoiding a criminal conviction. Specifically, receiving PARR services reduced the probability that an individual was convicted by about 75% relative to comparable people whom PARR did not serve.

Custody Health’s current procedure for mental health screening and assessment allows too many incarcerated people with non-acute behavioral health disorders to go undiagnosed and untreated. Response to Finding 9 The County partially agrees with this finding. The County’s current procedure for mental health screening during the intake process includes automatic flags and notifications to Nursing to refer any patient with a documented history of self-harm behaviors in their chart, reviewing medication histories, and referrals made by the arresting agency or Sheriff’s Office Custody Bureau staff for any patient observed with concerning presentations. However, the Nursing screening questions do rely on patients to self-report for suicide risk, symptoms of potential psychosis, history of psychotropic medication treatment, and any history or mental health or emotional issues. Patients can sometimes be hesitant to provide the foregoing information. Patients with certain criminal charges who are known to have an increased risk of suicide or self-harm are automatically referred for a mental health assessment and are placed on 15-minute checks until they can be assessed by a mental health clinician. Moreover, after the initial intake process, anyone can refer a patient for mental health services, including but not limited to the patient, their families, their counsel, other incarcerated individuals, patient advocates, and Custody Health and Custody Bureau staff.

Custody Health does not consistently check clients’ court schedules, leading to scheduling conflicts of court dates and medical appointments. Response to Finding 10 The County agrees with the finding.