Santa Barbara County Board of Supervisors Response to the Santa Barbara County Grand Jury 2018-2019 Report “Children

R1

That the Board of Supervisors direct the Department of Behavioral Wellness to pursue the establishment of a licensed Crisis Stabilization Unit that can accommodate adults, children and youth in Santa Maria. The Recommendation will not be implemented. The Department of Behavioral Wellness will not be implementing a Crisis Stabilization Unit (CSU), as a CSU is not the best model for Santa Barbara County needs due to both the length of stay limitations well as services allowed within a CSU and fiscal sustainability considerations. There are several models for crisis stabilization for youth other than a CSU. The Department is working to implement an alternative model of crisis stabilization beds by developing agreements with Short Term Residential Therapeutic Programs (STRTP) for crisis stabilization beds. The Department of Behavioral Wellness (the “Department” or “Behavioral Wellness”) has just credentialed the first Short Term Residential Therapeutic Programs (STRTP) within the County. As they are just beginning in this new role, it will take up to one year until the Department will be ready to provide crisis stabilization beds to accommodate children and youth in Santa Maria. It is anticipated that more STRTPs will also become credentialed and be able to offer crisis stabilization services. There are no Crisis Stabilization Units (CSU) for children and youth in Santa Barbara County. Operation of a Child and Youth CSU is only one model of providing crisis stabilization beds. As example, Ventura County recently opened a CSU for children and youth and have consistently found the unit to be underutilized. Behavioral Wellness recognizes the need for crisis stabilization beds within the children’s crisis service system and is actively working to develop crisis stabilization beds as a part of the service system which will provide alternatives to psychiatric hospitalizations for children and youth. Several group homes are presently converting to Short Term Residential Therapeutic Programs (STRTPs) and are exploring in the development of crisis stabilization beds as an option within their program. Crisis stabilization beds are a critical component to divert youth from higher levels of care, deliver essential screening and treatment, and provide timely intervention. Short term crisis residential models are uniquely designed to meet these needs. Current literature shows that crisis residential care is effective at reducing symptoms and functioning at lower cost than traditional inpatient care. Attachment A

R2

That the Board of Supervisors direct the Department of Behavioral Wellness to explore partnerships with community agencies to sponsor and maintain licensed Temporary Shelter Care Facilities for children and youth in Santa Barbara County. The recommendation has not yet been implemented, but will be implemented in the future, by October of 2020. The Department is currently working in partnership with the County Department of Social Services to develop a Request For Proposals for Therapeutic Foster Care which will be issued in October 2019. These services are reimbursable through Medi-Cal. The Therapeutic Foster Care model (California Welfare and Institutions Code (WIC) Section 18358) provides intensive and comprehensive treatment for youth. Therapeutic Foster Care is designed to provide an alternative to higher level group home care by placing youth in a specialized foster home where an individualized treatment program is provided with foster parents who are carefully matched for each child.

R3a

That the Board of Supervisors direct the Department of Behavioral Wellness to establish and implement measurable response times, and to track and evaluate the efficacy of their crisis response services. The Recommendation has been implemented. While components of this finding may have been valid at the time the investigation was conducted, it is no longer accurate. Since the investigation was conducted, the Access Screening Team has been co-located to a centralized location and has expanded staffing. In addition, in December of 2018, Behavioral Wellness launched the Drug Medi-Cal Organized Delivery System (DMC-ODS) and again expanded staffing on the 24/7 Access Line to assure adequate staffing to respond to the increase in calls to the Access line to request authorizations for Drug Medi-Cal Organized Delivery System requests in addition to the existing requests for crisis and specialty mental health services. Behavioral Wellness actively monitors data which reflects length of time in which callers are on hold. Attachment A While SAFTY can be called 24 hours a day, 7 days a week at an independent phone number, SAFTY is also accessed through calling the Behavioral Wellness 24/7 Access Line (referenced above). Beginning in FY 18-19, SAFTY began tracking data on timeliness in response which includes time of call received, time SAFTY left the office to respond to the field location and the time SAFTY arrived to the field location. Given recent increases in SAFTY direct care staffing and transition to Behavioral Wellness Mobile Crisis responding to calls after hours, the capacity of SAFTY to respond in a timely manner has increased steadily. The current Department data collection system in addition to the data system for Access Line calls allows for the tracking and evaluation of the efficacy of crisis response services. Our data tracking system capacity has expanded significantly in the last two years since the centralization of the Access Line.

R3b

That the Board of Supervisors direct the Department of Behavioral Wellness to require its contracted partner SAFTY to respond in the field for face-to-face evaluations more quickly and frequently. The Recommendation has been implemented. Behavioral Wellness met with Casa Pacifica (contractor for the SAFTY program) in the summer of 2018 to address this concern. As a result of this conversation, SAFTY has increased direct care staffing in the field to improve response time as well as the ability to respond in person rather than over the phone. These changes have been reflected in the contractual agreement between Casa Pacifica and the Department. The Department reviews program data routinely to assure this staffing change remains effective. Training on the model of in-person response is embedded in all training for new staff. Face to face evaluations on calls received have doubled between FY 17-18 and FY 18-19

R4

That the Board of Supervisors direct the Department of Behavioral Wellness to require the crisis response staff of their contracted partner, SAFTY, to receive more training to acquire the authority to write 5585 holds independently and in a timely manner. The Recommendation has been implemented. While this finding may have been valid at the time the investigation was conducted, it is no longer accurate. The recommended training for SAFTY was completed in December of 2018. While the time taken to hospitalize a youth on a 5585 hold takes longer than would be the case for adults, Casa Pacifica has embedded training on actions which can expedite this process. The trainings include shortening the length of call time to a supervisor for consult aiming for Attachment A supervisor consult time over the phone being less than a minute and streamlining reporting during this process. In addition, with system program developments such as the Children’s Crisis Triage Program in the North County (with plans to expand to South County), SAFTY is no longer in the emergency rooms allowing greater attention to field based needs and reducing wait times for youth in emergency rooms.

R5

That the Board of Supervisors direct the Department of Behavioral Wellness to design and implement a computerized record of the 5585 holds that are written, where the children are hospitalized out of County, their length of stay in each facility, and the cost of their treatment. This Recommendation has been implemented. The Department began compiling this data through the Quality Care Management Department in 2014. Behavioral Wellness tracks the data referenced, including the number of children on 5585 holds hospitalized out of County, their location, length of stay in each facility, and the cost of their treatment. This data can be made available to the Grand Jury if still desired.

R6a

That the Board of Supervisors direct the Department of Behavioral Wellness to evaluate the efficacy of the new Crisis Triage Program by keeping statistics on the number of children served and process outcomes. Attachment A The Recommendation has been implemented. The Children’s Crisis Triage Program began in January 2019. As this is a grant funded program, evaluation of efficacy, outcome measurement and data tracking is required. The first quarter of services showed positive outcome data with 61 crisis evaluations having occurred in emergency departments, nearly 25% of hold rescinded with a safety plan in place and hospitalization avoided. Of the children evaluated in the emergency room, over 30% were existing Behavioral Wellness clients; 20% were not known to Behavioral Wellness, but had cases opened to the Department and connected with services; and 17% of the children had private insurance and were able to be linked back to their private insurance services for follow up.

R6b

That the Board of Supervisors direct the Department of Behavioral Wellness to continue to pursue the full implementation of the Children's Triage Program in South County. This Recommendation will not be implemented as it not warranted as the Department began implementation of a modified model for children’s triage in August of 2019. Cottage Health was originally planned to be the location for the South County Children’s Crisis Triage team (mirroring the model in mid- and North County emergency rooms). While the Department of Behavioral Wellness continues to work in collaboration with Cottage Health for these services, Cottage Health has modified the way in which these services will be provided and are currently offering the services through one of their own staff who works in close communication and collaboration with Behavioral Wellness. Cottage Health worked collaboratively with Behavioral Wellness on the development of this program model. A Memorandum of Understanding is being developed with Cottage Health to define their role in this model and to define the parameters of data collection so as to compare data to the Children’s Crisis Triage Teams in the other two regions. As such, the services are currently active in South County, with a modified model. The Department is also working to expand the Children’s Crisis Triage Program to be available in all regions of the county. Several strategies have been implemented subsequent to the Children’s Triage grant submission that warrant modifications in the original approach. Cottage Health and the Children’s Crisis Triage Program staff will be working collaboratively to coordinate care for all youth and family experiencing a mental health crisis that requires intervention in Cottage Health’s Santa Barbara emergency department.

R6c

That the Board of Supervisors direct the Department of Behavioral Wellness to integrate the funding of the Children's Triage Program into the Department of Behavioral Wellness budget on an ongoing basis. This Recommendation requires further analysis. The Department of Behavioral Wellness has a positive history of sustainability of grant-funded programs. The Department has every intent of working to sustain a Children’s Crisis Triage program after the end of the 3-year grant funding period. The analysis of the ability to sustain funding will be taking place during the period of the grant life and exploring other funding options, which arise over time. The Board of Supervisors considers funding for all programs during the County Budget process which occurs in June each year. Attachment A

R7

That the Board of Supervisors direct the Department of Behavioral Wellness to design, post and keep current an on-line dashboard that provides comprehensive contact information on mental health services and community resources for children and youth in all geographic areas of Santa Barbara County, and publicize this resource to the community at large. This Recommendation has been implemented. Information on resources for children and youth is publicized on the Behavioral Wellness website (below), shared in monthly Director’s Reports, shared at monthly outreach events/resource tables, shared through public speaking engagements and trainings, and shared through the school system with students, parents and teachers. Additionally, information on the Behavioral Wellness Access Line is shared frequently through media outlets. The Department of Behavioral Wellness website: www.countyofsb.org/behavioral-wellness How to contact us: www.countyofsb.org/behavioral-wellness/contacts.sbc Children’s Services Home Page: www.countyofsb.org/behavioral-wellness/child-home.sbc Behavioral Health Services for Children: www.countyofsb.org/behavioral-wellness/childrenservices.sbc Attachment A