Board of Supervisors

Data: The Health Services Agency has not developed and deployed analytic, data-driven reports to address the financial challenges in managing the Behavioral Health and Substance Use Disorder services, despite recommendations from accreditation reviews. Data driven tools and regular reporting are required for the County to manage High-Cost Beneficiaries as well as all Behavioral Health and Substance Use Disorder clients. __ AGREE X PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): Santa Cruz County Behavioral Health Division (BHD) has been actively working to understand and address service patterns among high-cost beneficiaries, particularly in the Adult Mental Health system. This includes close monitoring of individuals in residential settings, collaboration with providers to ensure appropriate documentation, and regular case reviews to identify opportunities for step-down care. While most efforts have focused on residential care, BHD recognizes the need to expand data analysis to outpatient clients with recurring or intensive service patterns, as well as to psychiatric inpatient services. The division has also implemented a dedicated team to address the needs of unhoused individuals who more frequently utilize crisis services. These strategies demonstrate ongoing progress, though additional work remains to broaden and deepen data-driven approaches. Required Response from the Santa Cruz County Board of Supervisors High-Cost Beneficiaries Due by September 24, 2025

Administrative: The Jury finds that many programs, such as the Focus Intervention Team, Integrated Housing And Recovery Team, 24/7 Mobile Crisis Response Team, and Enhanced Care Management, provide critical services to High-Cost Beneficiaries. Although they have overlapping goals there is little to no coordination for tracking clients that receive services from one or more of these programs. The lack of coordination leads to higher costs in an era of shrinking resources. __ AGREE __ PARTIALLY DISAGREE X DISAGREE Response explanation (required for a response other than Agree): Multiple mechanisms ensure coordination among programs serving high-cost beneficiaries, including case conferences, electronic messaging, and shared access to the Behavioral Health Electronic Health Record (EHR). Adult Mental Health (AMH) and Crisis and Access leadership meet weekly, and both coordinate regularly with providers such as Encompass, local board-and-care homes, and Telecare (CSP and PHF). These practices ensure client needs are addressed without duplication. Enhanced Care Management (ECM) operates as an adjunctive, not duplicative, service under the Managed Care Plan, and AMH coordinates with ECM providers for alignment. To further strengthen coordination, the County is pursuing several data- sharing initiatives, including piloting a new EHR, developing a Countywide cross- departmental system, and working with CCAH and SCHIO to establish a closed-loop referral ecosystem. Required Response from the Santa Cruz County Board of Supervisors High-Cost Beneficiaries Due by September 24, 2025

Clinical: Santa Cruz County does not have a Level of Care Tool to track and manage High-Cost Beneficiaries. The Central California Alliance for Health does have a Level of Care Tool to track and manage High-Cost Beneficiaries. The parties are partners in the delivery of services and their resources could be leveraged to create a unified Level of Care tool. __ AGREE X PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): Since January 1, 2023, the State has required the use of the Screening and Transition of Care Tools for Medi-Cal Mental Health Services to ensure timely and coordinated services between specialty and non-specialty mental health providers. Both the Central California Alliance for Health (CCAH) and the County Behavioral Health Division (BHD) utilize these tools. However, the factors driving high costs differ significantly between Managed Care Plans (MCPs), which focus on physical health needs, and Behavioral Health Plans (BHPs), which serve individuals with higher-level behavioral health needs. For this reason, a single, unified tool to track high-cost beneficiaries across MCPs and BHPs would not be functional. Within BHD, additional tools are already in use or under consideration. For adults, the Level of Care Utilization System (LOCUS) is being evaluated as a possible standard for level-of-care determinations. Currently, Adult Mental Health uses the Adult Needs and Strengths Assessment (ANSA) to assess needs, impairment, and treatment progress. Children’s Behavioral Health and contracted providers use the Intensive Support Services (ISS) Screening Tool and regularly assess for eligibility for services such as Intensive Care Coordination, Intensive Home-Based Services, Therapeutic Foster Care, and Therapeutic Behavioral Services. Required Response from the Santa Cruz County Board of Supervisors High-Cost Beneficiaries Due by September 24, 2025

Administrative: Santa Cruz County programs and resources for High- Cost Beneficiaries, and all Health Services Agency behavioral health and substance use disorder services, are siloed and fragmented across HSA departments and contract providers. For example, clinical, financial, and operational benchmarks are not being used to report the cost of services and track patient acuity. As new programs are being developed, the financial, operational, and administrative targets are not established in advance or integrated into operations. County and Alliance collaboration and coordination can pave the way to overcome fragmentation. __ AGREE X PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): The siloed design of health care delivery systems is primarily the result of state and federal mandates, funding streams, and oversight from multiple agencies, which constrain how local services can be structured. At the local level, however, the Health Services Agency (HSA) and Central California Alliance for Health (CCAH) actively work to strengthen coordination. For example, the Behavioral Health Division (BHD)— which operates the County’s Mental Health Plan and Drug Medi-Cal Organized Delivery System—partners with CCAH to improve follow-up care after inpatient hospitalizations and emergency department visits, helping reduce costs for high-need beneficiaries. BHD also incorporates clinical, financial, and operational benchmarks into its provider contracts and emphasizes collaboration with agency partners. Regular coordination occurs with the Sheriff’s Office, Jail, Adult Protective Services, Public Guardian, Housing for Health, Child Welfare/Family and Children’s Services, Juvenile Probation, County Office of Education, and the San Andreas Regional Center to ensure services are aligned across systems. Required Response from the Santa Cruz County Board of Supervisors High-Cost Beneficiaries Due by September 24, 2025

Data, Clinical & Administrative: The Central California Alliance for Health (Alliance) has substantial financial reserves, and Santa Cruz County has seats on the governing board of the Alliance. Clinical, financial and operational collaboration between these agencies, who are both insurers and providers, needs to be better coordinated and integrated at all levels to improve treatment and outcomes for all clients. __ AGREE __ PARTIALLY DISAGREE X DISAGREE Response explanation (required for a response other than Agree): The Behavioral Health Division (BHD) operates the Mental Health Plan (MHP) and the Drug Medi-Cal Organized Delivery System (DMC-ODS), while the Central California Alliance for Health (CCAH) administers the Medi-Cal Managed Care Plan (MCP). Each of these plans is subject to distinct state requirements, mandates, and oversight, which limits the possibility of full integration. However, collaboration between the plans is required and actively occurs to support continuity of care for shared clients. BHD and CCAH hold regularly scheduled meetings for both the MHP and DMC-ODS to coordinate care, resolve complex cases, and ensure communication across systems. In addition, BHD and CCAH are developing a process for BHD to invoice CCAH for inpatient costs attributable to medical conditions. Historically, BHD has assumed these costs to prevent vulnerable clients from losing placements, which would increase their risk of homelessness and worsening health. Required Response from the Santa Cruz County Board of Supervisors High-Cost Beneficiaries Due by September 24, 2025

Administrative: The Jury finds that the Serving Communities Health Information Organization and the Mental Health Advisory Board partnerships with Santa Cruz County could be better leveraged to have greater impact on Behavioral Health. Failure to leverage these partnerships results in missed opportunities to coordinate programs and services. __ AGREE __ PARTIALLY DISAGREE X DISAGREE Response explanation (required for a response other than Agree): The Behavioral Health Division (BHD) engages in multiple coordination efforts with both the Serving Communities Health Information Organization (SCHIO) and the Behavioral Health Advisory Board (BHAB). BHD leverages SCHIO for data collaboration on required Healthcare Effectiveness Data and Information Set (HEDIS) measures for both the Mental Health Plan (MHP) and the Drug Medi-Cal Organized Delivery System (DMC-ODS), specifically follow-up after hospitalization for substance use challenges (FUA) and for mental health challenges (FUM). BHD also maintains an active partnership with the BHAB, participating in monthly board meetings and collaborating on community priorities. Within its advisory role, BHAB supports BHD in raising community awareness and advancing opportunities to strengthen the behavioral health system of care. Required Response from the Santa Cruz County Board of Supervisors High-Cost Beneficiaries Due by September 24, 2025

Compassion: Throughout the Grand Jury investigation, the Jury found that the staff and leadership of the Health Services Agency, Santa Cruz County Sheriff’s Office, and the Central California Alliance for Health are compassionate in the treatment of people experiencing behavioral health or substance use disorder. Patients are treated with dignity and respect, despite sometimes difficult conditions. X AGREE __ PARTIALLY DISAGREE __ DISAGREE Response explanation (required for a response other than Agree): Required Response from the Santa Cruz County Board of Supervisors High-Cost Beneficiaries Due by September 24, 2025