Issue How can San Mateo County improve the coordination of services for medically ill and

Additional Recommendations 1

These recommendations are not explicitly linked to specific findings.

• R25-44
  age ranges are probably low paid, non-salaried workers (i.e., employed in minimum wage jobs or less) and are likely to be vulnerable to loss of employment in the current economic situation. These groups are most at risk for future homelessness and resulting poor health within the County. Alarmingly even prior to the pandemic, the WPC reported that the ill homeless participants died at three to six times the rate of their housed peers.85 Given the double hit of COVID-19 and the economic slowdown, the County may expect a severe increase in the number of residents who slide into poverty, homelessness, and potentially illness and death. Now is the time for San Mateo County to assess why everyone is working on homelessness, at what cost and to what effect. With resources likely to be strained for the foreseeable future, it is vital that the current overlapping, confusing, expensive conglomerate of services be re-evaluated with the goals of finding synergies and efficiencies. The following section summarizes the key findings of this investigation and recommendations critical to addressing the County’s current, and likely increasing, problem of caring for our vulnerable homeless population. FINDINGS F1. There is no County department or division, which coordinates the County’s efforts to comprehensively address the issues faced by the homeless or ill subset. Currently, the County has at least seven departments or divisions – including HSA, the Department of Housing, SMMC, the Division of Public Health, Policy, and Planning, BHRS, and the Sheriff’s Office – involved in some part of the lives of ill homeless people. The Governor has suggested that “private wealth” step up to help fill the funding gap in homeless services; see Appendix A. 84Census Bureau ACS-5 year estimate (2017). https://datausa.io/profile/geo/san-mateo-county-ca#economy, retrieved 8/13/2020 85 Grand Jury Interview. Data varied depending on which semi-annual or annual report was analyzed. F2. City police officers with duties as Homeless Outreach Coordinators and County Sheriff’s deputies who work with the Psychiatric Emergency Response Team (PERT) play a significant role in identifying the homeless, de-escalating potential conflict involving the homeless, and linking the homeless to services, including providing transportation to medical treatment entities and shelters. Some police have been trained by BHRS to work with outreach teams in the field to help deal with homeless who may be a danger to themselves or others. F3. Determining the financial cost to the County for treating the ill homeless is extremely difficult given the various treatment alternatives (e.g., hospitals, clinics, vans, shelters, respite care options and care delivered “on the street.”) and other programs which are managed across numerous County departments and divisions. The County’s Budget, Policy, and Performance unit estimated that approximately $54 million dollars was directed by the County to help ameliorate homelessness in 2019. According to the latest housing census, there were 1,512 homeless individuals in SMC. F4. The County invests heavily in outreach teams within and across agencies for finding the ill homeless and linking them to necessary treatment before hospitalization is required. However, it is not clearly set forth on any public website or document how these teams coordinate or interact or how their effectiveness is determined. F5. Of the discharge housing options available, there is a lack of appropriate shelter for individuals who are well enough to leave the hospital but still require some help to recover fully. Several County organizations, including HPSM, are funding various pilot studies for “respite” or “recuperative” care that show promise to meet this need. However, at this point, the County lacks a comprehensive plan for this service. F6. There is only one County shelter (Maple Street) that has a nurse on staff to provide a level of health care support for ill and recovering homeless. Grand Jury interviews revealed staff are sometimes put in the difficult position of having to decide to take or refuse some ill homeless patient due to their very precarious health status. Only Maple Street and two other single adult shelters are now open to residents 24/7 which allows the ill homeless a safe, clean environment to sleep and recover from illness. F7. Most hospitals in the County, BHRS and WPC reserve (and pay for) beds at Maple Street Shelter or Samaritan House for their homeless patients requiring recuperative care. There is a lack of consistency in how to access these beds: some entities use the County’s Coordinated Entry System while others are able to by-pass this risk assessment interview. There are no data evaluating the cost effectiveness of this strategy in terms of county funding or agreement about the cost paid by different entities for these beds. F8. The County is in the planning stages for relocating and rebuilding the Maple Street Shelter. This will provide the County with an opportunity to reassess the needs of the homeless in general and the ill-homeless in particular. The ill homeless are complex, suffering from a variety of physical and mental disorders which impact their ability to access and maintain housing. Female homeless individuals and the elderly are especially at risk for future homelessness and resulting poor health. F9. Beginning in 2015, the Medicare/Medi-Cal funded “Whole Person Care Pilot” (WPC) project offered an opportunity and significant funding for SMC to develop an integrated health care plan for vulnerable individuals, including the ill homeless. As a result of WPC, the County began implementing significantly improved collaboration among partners and developing of new programs as well as expanding existing programs for treating the target populations. F10. WPC goals related to addressing Medi-Cal churn as well as HIPAA confidentiality concerns have not yet been achieved. Furthermore, The County’s WPC project lags behind other counties with regard to data sharing capabilities to support care coordination. F11. In order to receive and maintain Medi-Cal benefits, a home address is required. By definition, the homeless do not have one, so they substitute temporary locations such as the SMMC, shelters, or someone else’s address. As a result, homeless individuals often do not receive important insurance and medical documents and become uninsured. This causes a critical gap which results in potentially insurable patients not being treated or the County health services unable to obtain reimbursement. F12. Within the County, there is a lack of affordable permanent housing of various types (e.g., Board and Care type facilities, supervised group homes, single room occupancy hotels) for the homeless with chronic or long- term conditions that require support (e.g., stable mental illness, diabetes, cancer, heart disease). Without such options, the ill homeless will likely recycle back into encampments or the streets and again rely on emergency departments for needed treatment obviating any reduction in health care savings. F13. While the County should be applauded for reaching out to grant agencies for funding programs that support the ill homeless, it appears that such programs may not be sustainable after grant funding ends. Given that the County support system is already complex, the addition and subtraction of pilot programs without institutionalization provides only a finger in the dike and potentially adds to client and provider confusion about resources. RECOMMENDATIONS Regarding Pre-Hospitalization R1. The County Board of Supervisors (BOS) should direct the County Manager to develop a clear outline of the departments, agencies, and community partners who receive county funds involved in assisting the homeless and the specific subset of the ill homeless focusing on points of overlap and duplication of services. The Board should also direct the County Manager to report back to the Board in a public meeting, what efforts are being undertaken to better coordinate County efforts and potentially reduce bureaucracy and costs. This report from the County Manager should be publicly presented to the Board by December 31, 2020. R2. The BOS should direct the County’s Budget, Policy, and Performance unit to annually determine the actual costs for helping the homeless and the specific subset of the ill homeless to the County by December 31, 2020. R3. Because the homeless move from place to place, the BOS should request that the County Sheriff and Police Chiefs convene a task force to increase cross-jurisdictional coordination and communication. As part of this collaboration, they should determine if the number and training of officers is sufficient to address homeless outreach and crisis management in those localities where homelessness is the biggest problem. The task force should hold an initial meeting by December 31, 2020 and regularly thereafter to exchange information and best practices. Regarding hospitalization, discharge options and SB 1152 R4. By June 30, 2021, the County’s Human Services Agency (HSA) should collaborate with the Governing Board of the Health Plan of San Mateo (HPSM) to create a standard option as a housing address proxy for the homeless and ill homeless so County hospitals and services can be reimbursed for services. R5. The County should develop a comprehensive plan for medical respite/recuperative care for the ill homeless by including key representatives from appropriate County departments to collaborate with the Health Care for the Homeless and Farmworker Program and the Hospital Consortium by June 20, 2021. R6. HSA should allow the CES assessment to be more available outside of normal business hours and standardize its inclusion into all hospital or shelter discharge plans by October 31, 2020. R7. The County should conduct an overall evaluation of the County’s homeless shelters through the lens of the ill homeless, e.g., ability to assist with a range of medical needs and 24/7 availability of housing by June 30, 2021. R8. In the planned design and rebuilding of the Maple Street Shelter, the BOS should direct the County Manager to work with departments to prioritize addressing the needs of ill homeless, especially vulnerable women and the elderly by December 31, 2020. R9. The County’s Department of Housing should evaluate the feasibility of securing added board and care type housing facilities to provide long-term care, staffed with appropriate medical personnel, for homeless with chronic medical and mental illness needs by December 31, 2020. Regarding WPC R10. The County Manager’s Office should work with the relevant County departments to determine if it is possible to permanently fund the integration of psychiatric personnel into all outreach efforts/teams given the high presence of mental health issues among the homeless, and should have the relevant County departments publicly report the results of this effort to the Board during a regularly scheduled Board meeting by March 31, 2021. R11. The County Manager should prioritize the completion of the integrated data systems (i.e., Health Information Exchange and Enterprise Data Warehouse) which were begun under the auspices of the WPC and report back to the Board in a public meeting by December 31, 2020, whether the funding of such integration is possible and, if so, by which date it will be completed. REQUEST FOR RESPONSES Pursuant to Penal Code Section 933.05, the Grand Jury requests responses from the following:  County Board of Supervisors: R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11 The governing bodies indicated above should be aware that the comment or response of the governing body must be conducted subject to the notice, agenda, and open meeting requirements of the Brown Act. METHODOLOGY Documents  Reviewed the 2017 and 2019 San Mateo County One Day Homeless Count and Survey which identified and categorized the homeless in the County.  Reviewed the Whole Person Care grant proposal and Mid-Year 4 and Year 4 Annual progress reports.  Reviewed the 2014-2014 Marin County Grand Jury Report “Homeless in Marin-A Call for Leadership,” Public Release Date: April 23, 2015.  Reviewed the Policy Guidelines of the San Mateo Medical System “Discharge and Transfer” which outlines compliance guidelines for SB 1152 for homeless patients (02/27/2020).  Reviewed San Mateo County Health Care for the Homeless and Farmworker Health Program 2018 Annual Report. Site Tours  Visited the Maple Street Shelter, San Mateo Medical Center and Santa Clara Valley Medical Center. Interviews Reports issued by the Civil Grand Jury do not identify individuals interviewed. Penal Code Section 929 requires that reports of the Grand Jury not contain the name of any person or facts leading to the identity of any person who provides information to the Civil Grand Jury. During the course of the investigation, the Grand Jury conducted 24 interviews including meetings with representatives from: ● Multiple County departments involved with health and/or the homeless ● Police officers ● Homeless shelter staff members ● A Health Maintenance Organization ● A community organization serving many of the County’s homeless including providing shelter beds ● A representative from the Whole Person Care (WPC) grant ● Personnel from three area hospitals including San Mateo Medical Center, Stanford Hospital and Santa Clara County’s Valley Medical Center. The Grand Jury identified the following San Mateo County agencies as significantly interacting with the ill homeless: ● City Police and Sheriff’s officers ● The San Mateo Medical Center (SMMC) ● Behavioral and Human Recovery Services (BHRS) ● Department of Public Health, Policy and Planning ● Human Services Agency (HSA) Department’s ‘“Core Agencies” (including Samaritan House, the lead of the Core) and the Center on Homelessness ● The Health Care for the Homeless Program and Farmworker Program ● The Hospital Consortium ● The Health Plan of San Mateo (HPSM) BIBLIOGRAPHY E. Chuang, B. O’Masta, E.M. Alberston, I.A. Hale, C. Lu C., and N. Pourat N. Whole Person Care Improves Care Coordination for Many Californians. 2019. Los Angeles, CA: UCLA Center for Health Policy Research County of San Mateo, Health Care for the Homeless & Farmworker Health Program, 2018 Annual Report, 1-8 Robert A. Hahn, “Two Paths to Health in all Policies: The Traditional Public Health Path and the Path of Social Determinants,” American Journal of Public Health, Vol 109, No. 2 (2019): 253- 254 Cynthia Hubert. “Homeless Patients Were Left On The Streets By Hospitals. This Law Could End ‘Dumping. The Sacramento Bee, October 09, 2018 Marin County Civil Grand Jury report 2014-2015 –"Homeless in Marin-A Call for Leadership. " http://www.marincounty.orgdepts/gj/reports-and-responses/reports-responses/2014-15/homeless- in-marin San Mateo County Health System. “Mid-Year Report PY4.” State of California - Health and Human Services Agency Department of Health Care Services Whole Person Care Grant. September 6, 2019 San Mateo County Health System. Whole Person Care Grant Application, 2015. https://www.dhcs.ca.gov/provgovpart/Documents/SanMateoWPCApplication.pdf San Mateo County Health Services Agency, Center on Homelessness Mateo County: 2019 One Day Homeless Count and Survey, https://hsa.smcgov.org/sites/hsa.smcgov.org/files/2019%20One%20Day%20Homeless%20Count %20report.pdf “Special Initiatives.” The Health Plan of San Mateo. Accessed March 25, 2019. https://www.hpsm.org/special-initatives Stacie Weeks, Marie Zimmerman, and Jennifer Ryan. Medicaid’s Critical Role in Addressing the COVID-19 Pandemic (blog). http://www.harbageconsulting.com/medicaid-critical-role-in- addressing-the-covid-10-pandemic/. March 19, 2020.