San Luis Obispo County Health Agency*

R1

List one toll-free number for hotline access to all mental health services on the county website. Response: The recommendation will not be implemented because it is not warranted. There are two separate functions for the two separate toll-free numbers. The Behavioral Health Department Access Line (800-838-1381) is required by California Code of Regulations (CCR) Title 9, Section 1810.405(d) as follows: "Each Mental Health Plan (MHP) shall provide a statewide, toll-free telephone number 24 hours a day, seven days per week, with language capability in all languages spoken by beneficiaries of the county, that will provide information to beneficiaries about how to access specialty mental health services......" Department Managed Care (access) staff answers this line during work hours. Transitions Mental Health Association (TMHA) manages the SLO Hotline. SLO Hotline staff responds after hours and on weekends/holidays. SLO Hotline staff acts as the required live response access line (callers to the 800-838-1381 have the choice to either leave a voice message or request to speak to a live operator). If the caller agrees to leave contact information, SLO Hotline staff send the information to the County Managed Care staff for call back the next business day. The SLO Hotline number (800-783-0607) is a registered suicide prevention hotline staffed primarily by trained volunteers. Its primary function is to provide emotional support or help

R2

Establish a system to allow both the county and Transitions Mental Health Association staff and volunteers to schedule appointments while maintaining HIPAA confidentiality requirements. Response: This recommendation will not be implemented as it is not warranted. The statutory rights to privacy which prohibit the Transitions Mental Health Association (TMHA) SLO Hotline volunteers from accessing the Department's Electronic Health Record (EHR) system to schedule appointments may be reviewed as additional scheduling elements in the current EHR system are implemented. Currently the scheduling function of the EHR allows access to all parts of an individual's medical record. This could lead to breaches of confidentiality, either intentional or unintentional. In the future, patient portals or other advances in the EIIR may allow for a change in this procedure. Also, TMHA SLO Hotline staff may give information to callers about available times for walk-in assessments.

R3

If a solution is not developed to allow Transitions Mental Health Association's volunteers to make the appointment, the county should contact the caller within the next business day to schedule. Response: This recommendation has been implemented. The TMHA SLO Hotline volunteers send a message to Managed Care staff for a call back to the individual on the next business day.

R4

Reconfigure the juvenile entrance to the PHF so that adult patients do not need to be cleared when a juvenile is admitted. Alternatively, separate the juvenile population to a separate site away from the adult population of the PHF. Response: This recommendation will not be implemented because it is not warranted. Currently, the process to clear the floor of adult patients while a juvenile is brought through the unit for admission is functional. However, as other projects to remodel areas of the PHF are processed this option will be evaluated.

R5

A Crisis Stabilization Unit should be established to handle those in crisis for up to 23 hours, which could alleviate some of the capacity pressure at the PHF and save the county money if diversion from the PHF is achieved. Response: This recommendation will not be implemented because it is not reasonable. The estimated operating cost to run a four bed Crisis Stabilization Unit (CSU) is approximately $1.3 million annually with a projected offset from Medi-cal of $480,000. This figure does not include the capital cost of building new or renovating existing space. An incremental reduction in PHF census would not result in a significant savings due to the fixed costs and staffing ratios required by the PHF licensure. However, opening a CSU continues to be analyzed as a clinically effective and efficient program for community and client benefit,

R6

To decrease wait time for patients and potentially handle greater caseloads, the county should increase psychiatric support staff, such as psychiatric nurse practitioners, physician assistants and therapists. Response: This recommendation has not yet been implemented but will be implemented in the future. The Department included several Budget Augmentation Requests (BARs) in its FY 2015-16 requested budget that will add clinical staff in all regions to facilitate intakes and increase treatment capacity, and reduce wait time for new and existing clients to within the 14 day standard. The County Administrator's recently released Recommended Budget includes funding for several of those BARs. Assuming approval by the Board of Supervisors in early June, we plan to have these positions filled by early fall. Several of our permanent Staff Psychiatrist and MH Nurse Practitioner positions remain unfilled due to recruitment challenges. However, the department has recently hired three psychiatrists (filling 2.50 FTE of the 6.0 FTE positions allocated). The balance of all required psychiatry services are being performed at this time with contracted Locum Tenens (temporary) psychiatrists.

R7

If psychiatric positions continue to be difficult to staff, the county should implement options to improve recruitment such as student loan repayment programs and use of telepsychiatry. Response: This recommendation includes two separate components: 1) utilization of student loan repayment programs, and 2) use of telepsychiatry. The recommended option of student loan repayment programs has already been implemented. Loan repayment programs are currently available through both State (MHSA/Mental Health Loan Assumption Program) and Federal (Health Resources and Services Administration/National Health Service Corps) resources. The use of telepsychiatry will not be implemented because it is not warranted at this time. Telepsychiatry has been analyzed and budgets for equipment, licenses, etc. have been developed. We are delaying issuance of a Request for Proposals (RFP) at this time as we have recently hired three psychiatrists and are in discussions with two more. If additional staff psychiatry positions are not filled through the current process we will proceed with other options, including the use of telepsychiatry.

R8

The county, whether by clinic staff, interns, temporary or part-time employees, should institute contact with those clients awaiting appointments to decrease the number of no-shows who prevent the scheduling of another client. This could also determine if the severity of the individual's condition has improved/stabilized/worsened and if the client has transportation. Response: This recommendation has been partially implemented, and the remainder of the recommendation requires further analysis. Individuals are contacted via telephone the day prior to their assessment appointment with a reminder. Reminder calls started 10/20/14. Recent analysis indicates the reduction of "failure to show" after reminder calls were initiated is approximately 3%. A similar study conducted in 2009 showed a similar reduction rate of 2% failure to show after phone reminders were initiated. However, further analysis is required to determine the cost/benefit consequences of adding the staff resources necessary to gather the additional information suggested, as in the severity of the individual's condition and if there are other barriers complicating the individual's ability to keep the scheduled appointment. Solutions to any barriers, such as assistance with transportation or mobile intake appointments, will require further cost analysis as well. This analysis will be completed by December, 2015.